AccountId: 011433970860
ContactId: 4d0728cf-e3b9-4c27-8c69-52b8963a9363
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 991190 ms
Total Talk Time (AGENT): 154487 ms
Total Talk Time (CUSTOMER): 797466 ms
Interruptions: 6
Overall Sentiment: AGENT=1.1, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/4d0728cf-e3b9-4c27-8c69-52b8963a9363_20250530T20:50_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and my company um is offering your coverage.
[CUSTOMER][NEUTRAL] I have a question. I'm confused, which is saying a lot considering I worked in insurance for 15 years.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I'm looking at what is covered and it says inpatient benefits of 3000 or $51,500 whichever plan you choose obviously and then outpatient is the same amount, is that, does that mean you pay.
[CUSTOMER][NEUTRAL] A combined of 6000 or.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, that's where I'm confused.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Do we have $3000 allowance? OK, which plan is it? I apologize. It's Medlink Medlink 9 gap insurance.
[AGENT][NEUTRAL] No, you're fine.
[AGENT][NEUTRAL] OK, do you have a group number?
[CUSTOMER][NEUTRAL] Well, we haven't signed up yet. We're signing up now. I'm not a member yet. I'm trying to choose which coverage I want to use. I do I want to go with the 3000 or do I wanna go with 5000 coverage from you guys? I mean, I'm getting the insurance. It's just which level am I getting because I'm confused as to when it says inpatient because we tried to get another um gap insurance policy.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] However, we didn't have enough employees that would enroll, which is crazy. Now we probably would because.
[CUSTOMER][NEUTRAL] I mean we've been advocating for and now we explained it to the guy who explained it didn't explain it well anyway, that being said, they covered a combined inpatient, outpatient whatever the copay was.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, to get both inpatient or outpatient, the maximum of $5000 per year.
[CUSTOMER][MIXED] OK, but that was combined, but yours is saying that it's separate.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The inpatient benefit maximum is 3000 and outpatient benefit maximum is 3000.
[AGENT][NEUTRAL] Yes, ma'am. Some of
[CUSTOMER][NEUTRAL] Is that correct or?
[AGENT][NEUTRAL] Some of our policies do have it to where separate like total for inpatient, total for outpatient, but then they have some that are combined. So unless it says combined benefit for inpatient or outpatient of.
[AGENT][NEUTRAL] Uh, the amount, then that's combined, but if it's showing a separate, like this much for inpatient, this much for outpatient, those are two separate benefits.
[CUSTOMER][NEUTRAL] Now what does it mean by maximum of 9000 per calendar year?
[AGENT][NEUTRAL] Uh, that could be for family.
[CUSTOMER][POSITIVE] Oh, for all covered, that's for all covered for, yeah, all, yeah, if I had two dependents, that would be, uh, I, I answered myself as I read it, the complete sentence. OK, so well.
[AGENT][NEUTRAL] No, you're fine.
[CUSTOMER][NEUTRAL] So let me give you a let's let's give us an um.
[CUSTOMER][NEUTRAL] A scenario here here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] If I were to go into the hospital.
[CUSTOMER][NEUTRAL] And I've not met any, you know, I've not had any anything prior.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] And my hospital stay is $10,000.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let's, yeah, 10,000, so you guys are gonna pay the maximum of 3000 towards that.
[CUSTOMER][NEUTRAL] Inpatient bill correct?
[AGENT][NEUTRAL] Not necessarily towards the inpatient bill, but the way the Metlink policy works is uh based on what the primary applies towards deductible, co-pay or co-insurance up to that max benefit.
[CUSTOMER][NEUTRAL] Right, it's not
[AGENT][NEUTRAL] So if the primary, if
[CUSTOMER][NEUTRAL] Right, my co-insurance.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] I'm sorry, let's say the bill is $5000. My max out of pocket is 60.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I'm gonna have to pay 20% of anything up to.
[CUSTOMER][NEUTRAL] $6000.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] If I
[CUSTOMER][NEUTRAL] If I
[CUSTOMER][NEUTRAL] You will pay the maximum you will pay on a hospital visit, which God knows you'll be lucky if you can go in the hospital and come out for under 6000. But let, but let's say the bill is 20,000, which is
[CUSTOMER][NEUTRAL] More likely than not, you are still, and my 20% exceeds $3000 you're still going to pay only $3000 correct?
[AGENT][POSITIVE] Correct, yes, ma'am.
[CUSTOMER][NEUTRAL] That's, that's what I was afraid of. I mean, that's what I, OK. That's the reason cause my best friend, um, and I, and English is not her first language, and
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I told her to go with 5000.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Because our maximum out of pocket is 6.
[CUSTOMER][NEUTRAL] And that would
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] They mostly pay out the 20% of 1000, yeah, $1000 that's.
[CUSTOMER][NEUTRAL] That's how we would pay additional.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] And she's like, but why [PII]? Why? Because it's da da da da da and I'm like, well, wait a minute. She had me second guessing myself. So now, no, I'm leaving mine at 5000 because it would, I would still be liable for anything beyond the 5000 still, so I still possibly might have depending on how much my bill is.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, yeah.
[CUSTOMER][NEUTRAL] Yeah, well, no, because the max, no, I'm, I'm just confusing myself talking.
[AGENT][POSITIVE] It happens, though, for sure. Yes, ma'am.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] But, uh, essentially just the the Medli policies only pick up what primary applied towards deductible copay or for co-insurance either for inpatient or outpatient.
[AGENT][NEUTRAL] So it won't it, right. Mhm.
[CUSTOMER][NEUTRAL] Exactly. For instance,
[CUSTOMER][POSITIVE] Yeah, so for instance, I, I love this. 2 years ago, I had a colonoscopy and they found a polyp.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] On my, uh, and they took it off to have it biopsied and stuff. Thank [PII] above it was not malignant.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] However, while I'm asleep under an anesthesia,
[CUSTOMER][NEUTRAL] It gets changed from preventative to.
[CUSTOMER][NEUTRAL] Now, it's because they took the biopsy, it is now, um, what do you call it? um.
[AGENT][NEUTRAL] It's considered, it would be considered a sickness since they did a biopsy.
[CUSTOMER][NEUTRAL] I, I forget the name.
[CUSTOMER][NEUTRAL] Diagnostic, diagnostic. Right. It went from being a preventative procedure to being a diagnostic procedure while I'm under anesthesia.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I'm like, great, so I come out thinking that it's been paid in full.
[CUSTOMER][NEGATIVE] Because, you know, and then, lo and behold, I get a bill and I'm freaking out and I go, oh no, they took a biopsy, so it was diagnostic. So,
[CUSTOMER][NEGATIVE] I have no say in this, you know, I don't get me started. I, you work for a good insurance company. I worked for Aetna, United Healthcare, and um, yeah, so I, it, it went against every fiber of being in my soul every day I went to work.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because I worked in prior authorization department.
[CUSTOMER][NEGATIVE] And that's heartbreaking.
[CUSTOMER][NEGATIVE] That's heartbreaking.
[AGENT][NEUTRAL] I can imagine.
[CUSTOMER][NEUTRAL] You know,
[CUSTOMER][NEUTRAL] You know, and there were agents that literally not, and I'm not joking until the um Affordable Care Act came through and people, people, I don't know if you're old enough to remember prior to that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Um, there was a maximum amount of pocket.
[CUSTOMER][NEUTRAL] That insurance companies would pay.
[AGENT][NEUTRAL] Right, yeah.
[CUSTOMER][NEUTRAL] And it was a million dollars.
[AGENT][NEUTRAL] Yeah, once you met that Max.
[CUSTOMER][NEUTRAL] And my knees.
[AGENT][NEUTRAL] No more.
[CUSTOMER][NEGATIVE] Yeah, they won't pay anything.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] And my niece, her, her mom, well, she's actually my cousin, but she's [PII] younger. Um, her daughter was in a horrific, horrific car accident at [PII].
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And the hydroplane, and they hit a tree and bounced up a tree and landed on a railroad track. And all the impact, yeah, she was in the hospital. It happened on a Sunday coming home from church. Her and her best friend, they were driving a minivan, and in the pictures, my niece sent me of it, I thought they were driving a compact car or a sedan at minimum, but it was a van.
[AGENT][POSITIVE] Oh blessed.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] I would, and, but I get a phone call that says, you need to get here if you want to see her because they don't think she's gonna make it through the night. And we lived about 4.5 hours away. I flew. She was in the hospital from Sunday, which, you know, [PII] is the first weekend in September till the Friday before [PII].
[AGENT][POSITIVE] Oh wow.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] In intensive care the entire time.
[AGENT][POSITIVE] Bless her heart, yeah.
[CUSTOMER][NEUTRAL] Her hospital bill was $1.8 million.
[AGENT][NEUTRAL] Jesus, that's a lot.
[CUSTOMER][NEGATIVE] That baby girl literally was broken from head to toe. She, she had skull fracture, collarbone, broken ribs, broken hip, um, two broken legs that had to require pins, a broken pelvic.
[CUSTOMER][NEUTRAL] And but what kept her in in ICU was that she had a cut on her butt.
[AGENT][NEUTRAL] Was it infected?
[CUSTOMER][NEGATIVE] And it was only a small lesson. It was, yeah, it was 3 inches long, and they were worried about putting her back together again cause she was like, Humpty Dumpty. And um they couldn't turn her because her legs were up in traction.
[AGENT][POSITIVE] Oh bless her heart.
[CUSTOMER][NEUTRAL] Waiting for her to stabilize so they could go in and put the pins in. And um
[CUSTOMER][NEUTRAL] It was about a week and a half, maybe before they could go in to do the surgery on her legs.
[CUSTOMER][NEGATIVE] And when they went to move her from her hospital bed to the gurney to go to surgery, the most horrific smell came out and she had developed gangrene.
[AGENT][NEUTRAL] Oh wow, bless her heart. That is horrible.
[CUSTOMER][NEUTRAL] And or not getting green or what is it that flesh eating infection, that sepsis.
[AGENT][NEUTRAL] Sepsis? Oh,
[CUSTOMER][NEGATIVE] You know, whatever it was, they ended up having to rush her to surgery on that, and they cut out probably um 6 by 8 inch area of her buttocks.
[AGENT][POSITIVE] Gracious.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And then they had to grab and they had to treat it as if she was a 3rd degree burn victim.
[CUSTOMER][NEUTRAL] And she had to be transferred once she was stable enough to go from the trauma ICU she went to the burn ICU. And the funny thing was that um because they kept her so drugged uh on morphine and everything, and she would come in and out of consciousness.
[AGENT][NEUTRAL] I can imagine. Right.
[CUSTOMER][NEUTRAL] My cousin told her like, she goes, [PII], honey.
[CUSTOMER][MIXED] You, you're out of surgery now, you're OK. She goes, but honey, they had to remove part of your booty, and she goes, my booty.
[CUSTOMER][NEGATIVE] And she goes, yeah, baby. She goes, you had a really bad infection. They had to remove part of your boot. But mommy, why couldn't they move part of my belly and leave my booty alone.
[AGENT][NEUTRAL] OK, I'll be the same, like, but.
[AGENT][NEUTRAL] It's like, yeah, can you work on the stomach, please?
[CUSTOMER][NEUTRAL] Yeah, cause she, I mean, she wasn't morbidly obese, but she did have a belly. And at [PII], you're more concerned about your belly than you are your booty. But it was hilarious. But yeah, so now, uh, OK, so I still have to do some thinking here.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] To see
[AGENT][POSITIVE] That's a lot, bless her heart. And how is she doing now?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][POSITIVE] Her, it was funny because they live in [PII] and at the time I lived in [PII], um, and they would have, she went from wheelchair to she still needs.
[CUSTOMER][NEUTRAL] I wanna say it's a hip replacement.
[CUSTOMER][NEUTRAL] Um, because of the broken hip, they, they, you can't set the hip, and everything else was a priority over the hip and she still does need that, but she went from a wheelchair to a walker to a cane to now, I just saw her about a month and a half ago and she, she kind of went, but you have to really pay attention. It's not a real obvious limp.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][MIXED] But praise God, she's doing great, but she went through so much physical therapy, so much so that the insurance company was paying to have her commute um to because she needed aqua therapy not to so that she wouldn't be putting pressure on her hip, and it was the insurance company was paying out the butt for their travel expenses and everything.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And uh so much so that they paid 60% or 80% for my niece to have an in-ground pool built in their house, built at their house.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][POSITIVE] It was cheaper for them to have a therapist come locally and help her do the water aerobics or the water therapy than having her commute like an hour or something away and paying for those doctor visits and all of that.
[CUSTOMER][NEUTRAL] I go, yeah, I go, only you could get an insurance company to pay for a pool. And the joke was we all grew up with pools and her husband would never ever allow her to get a pool.
[CUSTOMER][NEUTRAL] And you know, and I say allow because he wouldn't pay for a pool.
[CUSTOMER][NEUTRAL] And um so she was like,
[CUSTOMER][NEUTRAL] And [PII], I got my pool and I'm like, oh my God, [PII] bought [PII], what did you do? drug him? I'm like, [PII] is never, he's cheap. She goes, You're never gonna believe this. And I go, oh my God, only you would benefit from your daughter's accent. And [PII], that's mean, that's just mean. She goes, it wasn't purposely. And I'm like, and I started laughing and I'm like, I know it wasn't purposely, honey, but you know, what can I say? You got your pool.
[AGENT][NEGATIVE] No, no.
[AGENT][POSITIVE] Hey, things work out some way. Bless her heart. I, I'm hoping she continues to get better.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Yeah,
[AGENT][NEGATIVE] Cause it could have been a lot worse, so.
[CUSTOMER][POSITIVE] Yeah, she is. She actually, she, she graduated college. She got married just, I think she, a year and a half ago they they got married to her college sweetheart, and yeah, so she's, she's on them and she, and she's a good girl. She's a really good girl. But thank you, and you have a wonderful weekend and thank you for clearing this up for me.
[AGENT][NEUTRAL] A.
[AGENT][POSITIVE] Oh, that's awesome.
[AGENT][POSITIVE] You are so welcome, Ms. [PII]. Thank you so much for calling APL. Have a great weekend.
[CUSTOMER][POSITIVE] Alrighty bye bye.
[AGENT][NEUTRAL] Bye.