AccountId: 011433970860
ContactId: 5ffc42a5-d1f0-4fa8-a06f-299ac6b05a5d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1145660 ms
Total Talk Time (AGENT): 515929 ms
Total Talk Time (CUSTOMER): 511614 ms
Interruptions: 19
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/5ffc42a5-d1f0-4fa8-a06f-299ac6b05a5d_20250227T21:47_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. With whom am I speaking to? How may I help you?
[CUSTOMER][NEUTRAL] Yes, uh, Ms. [PII], this is [PII], um, so I'm actually calling about my claim.
[AGENT][NEUTRAL] OK, what's your policy number?
[CUSTOMER][NEGATIVE] Uh, it's cancer, yes, sir.
[CUSTOMER][NEGATIVE] Oh shucks, um.
[CUSTOMER][NEUTRAL] Hold on, I only because I called, uh, what do you call this, the employee retention benefits, yes please.
[AGENT][POSITIVE] I can look it up. What is a good, what is a good, what is a good call back number for you in case we get disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, one moment, and give me one moment to get to a screen where I can look up your policy and then I'll have you verify some information and then I'll be able to assist you after that point. Give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] Thank you for your patience. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what's your social security number?
[CUSTOMER][NEUTRAL] Uh, it's uh [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. Uh, no, that does not come up for a [PII]. Um, you can repeat that, please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. It's [PII].
[CUSTOMER][NEUTRAL] 575333
[AGENT][NEUTRAL] OK. All right, now that came up that time, one moment, OK?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm sure.
[AGENT][NEUTRAL] Alright, and what is your date of birth followed by your uh mailing address?
[CUSTOMER][NEUTRAL] Uh, it's [PII]. Address would be [PII].
[AGENT][NEUTRAL] Thank you and you don't have an email address on file so that's fine. Alright, so I can give you your policy number before I assist you with your claim question.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you need a policy number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yeah, sure.
[AGENT][NEUTRAL] 249.
[CUSTOMER][NEUTRAL] and
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 1733.
[CUSTOMER][NEUTRAL] So let me repeat that. It's 2491733.
[AGENT][NEUTRAL] Yes, that is correct. And what is your your claims question today? What question do you have?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, I'm actually waiting for the, uh, pay for, uh, the cancer.
[AGENT][NEUTRAL] OK, let me take a look at that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Looks like they finished processing on that and give me one second.
[CUSTOMER][NEUTRAL] Yeah, I'm just wondering like
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, so it looks like that claim was denied on the [PII] a couple of days ago and you should be receiving an EOB in the mail, and the reason it was denied is because it was determined to be a pre-existing condition and preexisting conditions are not covered under the policy.
[CUSTOMER][NEUTRAL] It residency and like
[CUSTOMER][NEUTRAL] Why is it preexisting condition? Like I believe I signed up like [PII], I mean, I'm on [PII].
[AGENT][NEUTRAL] Yep, you signed up [PII], but you, you, you signed up [PII], but because this policy was not in effect for one year, the preexisting time frame would be [PII]. So if you were seen from [PII], that is considered preexisting and we requested those medical records and that's what they found. So for the condition that you were filing for, that's considered preexisting.
[CUSTOMER][NEUTRAL] And then I was told.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] How is it possible that I, I, I only had a biopsy on [PII]?
[AGENT][NEUTRAL] OK. Well, you have the right to an appeal, so you can appeal it and you can send in the question that you just asked. You just state that you're appealing to the same, uh, you can upload it to your, your, well, I don't know if you mailed this claim form or if you faxed it.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] But however you sent the claim form, you could file an appeal, OK? And you just need to state why you're appealing it. And as you're stating, you're saying uh you didn't have a biopsy until what date you said, then that's yes, ma'am. So you have to peel it at this point, OK?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh, how do I, do I have the form for appeal or something?
[AGENT][NEUTRAL] No, there's not a form. You'll just write it up.
[AGENT][POSITIVE] And you'll just say you're appealing.
[CUSTOMER][NEGATIVE] Oh, in the first place, why do I have to appeal when it, you know, it's just, uh, I'm just talking to my, you know, my mind like I don't understand how you guys do it cause I signed up uh [PII] and then I decided to have, um, not decided but, you know, I had the biopsy, uh, I think [PII]. So I already signed up before the, the biopsy took place.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So how come they
[AGENT][NEUTRAL] It, it does, it doesn't. So here's what you have to do. I see that they requested um they they sent you a form to fill out with the doctors you have seen. So you need to fill that out and return that as well, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] I, I, I already returned it. I already sent that. Yes, everything, everything.
[AGENT][NEUTRAL] You already returned that? OK, so yes, so they reviewed that, so yeah, they reviewed that information, ma'am, and what happens is.
[AGENT][NEUTRAL] You just, just because you had a biopsy on [PII], you present it to the doctor according to those medical records that they got from that doctor. You went to that doctor before [PII], which is the effective date of your policy regarding that issue. So because you were seen for that issue, that is considered preexisting. It has nothing to do with a biopsy. It says if you were consult, if you consulted a doctor or you receive medication for anything that is for the diagnosis that you're filing for.
[AGENT][NEUTRAL] Then that's considered preexisting.
[AGENT][NEUTRAL] And as I stated, you can appeal that. Mhm. You you just would have to appeal it, Ms. [PII]. Mhm.
[CUSTOMER][NEGATIVE] That's impossible. Yeah.
[CUSTOMER][NEUTRAL] Yeah, yeah, I'm just letting you know, like for.
[CUSTOMER][NEUTRAL] Yeah, yeah, it's just that I'm thinking like that's impossible because even the doctors, they didn't even want to do the biopsy. Yeah, at first. So how come they could tell, you know, they say like, uh, it was, I was seen for this and that. I have, the only thing is the general, you know, that my uh primary physician, that's the only doctor that I put there, that the only doctor that's, you know, uh, saw me for the 1st 2 years and then the rest, you.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] You know, which is just a regular checkup and then because I just wanted to make sure because I just reached [PII] and that's it, you know, and then, and all the tests and then all the treatments, I uh got all of those right after the biopsy because like I said, they didn't even want to do the biopsy. I insisted that, so yeah, so it's like I'm surprised like, OK, so that's why it's almost like uh almost a year now and then I'm still surprised like, OK, what's the hold up?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I spoke to the ERB representative. Yeah, last time, and she said just gonna check. Yeah, but unfortunately, when I called her office earlier, uh I was told by the other lady like uh mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You see, I just
[AGENT][NEUTRAL] I just pulled your, I just pulled your medical records, your medical records that came in and you were seeing, I'm just looking at the first page and I'm just doing this as a courtesy. I, I understand what you're saying, but according to this, they saw you on, what's the big one here? Give me one second. [PII] and your diagnosis from this visit note from the doctor is female breast cancer.
[CUSTOMER][NEUTRAL] Yeah, yeah, I understand.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So ma'am, that's preexisting.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] This was [PII]. 0, that was [PII]. OK, so that one was after, but what you have to do, you're right, that was after your effective date. So what you'll have to do is because the the individual that process this claim has gone through all these medical records that was sent in.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And it was determined that it was preexisting so you will need to just uh file an appeal, OK? And they'll take another look at it again, OK?
[CUSTOMER][NEUTRAL] I hope they didn't actually mess up the dates because when you see the dates it's all kind of the same for them you know the [PII], yeah, yeah.
[AGENT][NEUTRAL] Yeah, I, I mean, you know, we don't, we don't process claims over the phone, and I'm looking now and I'm seeing, I'm seeing some, some some notes that.
[CUSTOMER][NEUTRAL] Yes, yes, yeah, but you know, you know, you, I, I hope you also understand where I'm coming from, right?
[AGENT][NEUTRAL] I do. I do, but I see, I see.
[CUSTOMER][NEUTRAL] Yeah, like, yeah, that's why I'm just letting you know to like.
[AGENT][NEUTRAL] Mhm. But I do see that on [PII]. That's when they found that 2 centimeter oval mass on your right breast at [PII]. So, ma'am, that's prior to [PII]. So that's pre-existing. That's what made it pre-existing, OK? But you can, you can still
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But then they didn't, the doctor didn't, didn't, didn't say anything about me. I even asked them if it's something uh serious or not, and they said nothing. That's why if, if you check like after 2 years, I insisted that I, it says there like I actually requested it, not them.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, I understand, yeah.
[CUSTOMER][NEUTRAL] Yeah, so they didn't say anything. They said it's not, they didn't, they, they said like, it's not something to be worried about. I even asked them, is it uh cancer or something? They said, no, you know, you just monitor it. I even asked them like, uh, can you refer me to someone, you know, a specialist who can help me monitor it just to make sure, you know, it's not something serious in the future. They said nothing to worry about, just come back and then we'll do again, we'll do again, uh, what do you call this? The mammogram.
[CUSTOMER][NEGATIVE] So if you see there's they, they didn't mention anything that the thing is here. So that's why I'm surprised like why would they say it's preexisting when I myself didn't even know, they didn't even tell me. Yeah, so I said OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It was, yeah.
[AGENT][NEUTRAL] But they're saying in your medical records, I don't know what your doctor told you, but they're clearly saying in your medical records that they found a lump. And unfortunately, Ms. [PII], that means you saw someone for that lump where you did a biopsy in June, you saw somebody in March. You had, you had a diagnostic mammogram and I don't know what else is in those medical records, but it was determined that it's preexisting. So at this point, you would have to file an appeal, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, yeah, I understand you, but yeah, I'm just letting you know that that's what happened, like, you know, it's like a game like are they playing with me like I went to them asking, you know, to my doctors like help for that, and then now they're saying it's preexisting when that's why I have no idea. Why would they say pre existing? I mean, yeah, I have no idea that they already considering it.
[CUSTOMER][NEUTRAL] Preexisting. I thought it's just something, you know. They said it's not cancer or something. So it's like, OK. Wow. Uh wow, that's just, uh, yeah. Oh well, and I've been paying.
[AGENT][NEUTRAL] Yes. Mhm.
[AGENT][NEUTRAL] Well, go ahead and, and, and get your appeal together. Mhm. Go ahead and get your appeal together and send it in, OK?
[CUSTOMER][NEUTRAL] Uh-huh, and, uh, what's the address again for, uh, your address for the [PII], right? This is for the [PII]?
[AGENT][NEUTRAL] Yes, uh-huh, [PII].
[CUSTOMER][NEUTRAL] Because I got, yeah, [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], [PII].
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] And that is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]. So, let me repeat that. So, [PII], [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That is correct. Mhm.
[CUSTOMER][NEUTRAL] And this is, uh, to whom should I address this one? The appeal?
[AGENT][NEUTRAL] You just put it to the claims and you say appeals mhm.
[CUSTOMER][NEUTRAL] Uh, cranes and
[AGENT][NEUTRAL] And you need to make sure you're right while you're appealing. Mhm.
[CUSTOMER][NEUTRAL] OK, so it's like more of a narrative, right?
[AGENT][NEUTRAL] Uh, yes, you just gotta tell why you're appealing as you just said it to me, you feel like it's not preexisting, but you know, unfortunately the medical records say something different. So you just have to explain what you've been explaining to me and they will look at it. It's not a guarantee that the claim will be, um, that the the decision will be overturned, but they will take a look at it.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, yeah, it's just that, you know, I'm just, yeah, like, uh, surprised like if that was uh pre-existing, how come they didn't say anything from the past? Yeah, that's why I'm just letting you know like I'm really confused like why would they say that like nothing to worry, you know, for the past two years.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Until you know and then they yeah and then they didn't even recommend, you know, biopsy it was just me, yeah, and I'm really surprised like, yeah, but then this is really not good.
[AGENT][NEUTRAL] I'm not sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] Now I'm thinking of canceling everything because it's like I'm paying for nothing, yeah, and uh how do I cancel this one all my um uh if I decide.
[AGENT][NEUTRAL] I would have to put you, um.
[AGENT][POSITIVE] I will have to put you through to customer service and they will be able to assist you with that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, with that, OK. Yeah. And also, can you also check, there's another claim though, uh, the critical illness.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, let me check it one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So your cancer policy um has, let's see, let me, let me go back to it one moment. Let me look at the critical illness first and see what's going on with it. Um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right, let's take a look.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Thank you for your patience. It's just trying to locate that policy. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] What is going on with this DC [PII].
[AGENT][NEUTRAL] 21.
[AGENT][NEUTRAL] So that claim was denied as well for preexisting, so you would have to uh file an appeal. You can do that as well. I can give you that policy number. So that claim too was denied as preexisting. No, it's a different policy number 250.
[CUSTOMER][NEUTRAL] Mhm. Same, same policy number?
[CUSTOMER][NEUTRAL] OK, let me give you a 2nd. 250.
[AGENT][NEUTRAL] 981 8
[CUSTOMER][NEUTRAL] 981-82[PII]. That's critical illness.
[AGENT][NEUTRAL] Yes, and that claim was denied as well. You just, you can file an appeal for both of them, but send the appeal up under both the policy numbers.
[CUSTOMER][NEUTRAL] OK. uh OK. Uh, address it to claims and then appeal.
[AGENT][NEUTRAL] Uh-huh, that is correct. And, and you don't need to, you don't need to talk to uh customer service because both of your policies are terminated. The, the, the uh critical illness policy uh termed on [PII] and the cancer policy termed on [PII]. So they, those policies are no longer active.
[CUSTOMER][NEGATIVE] Oh wow. This is really devastating.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you don't have to worry about canceling them. I know you were saying you wanted to speak to customer service, but they're already, uh, termed, OK?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm. Uh, for this one, the APL. You, you're no longer with the ERB, right? With the employee?
[AGENT][NEUTRAL] I don't think we are. I'm not sure. I'm not sure. I don't know if you all pick someone else. I'm not sure.
[CUSTOMER][NEUTRAL] Uh, retention benefit.
[CUSTOMER][NEUTRAL] Yeah. Yeah, there's like a brokerage or something. Yeah, I think there's a brokerage and then, yeah, so with this one, yeah, critical illness, you said this was canceled [PII]?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] [PII] for critical illness.
[CUSTOMER][NEUTRAL] Uh, OK. And for the cancer, when was that canceled?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] All right. OK, thank you very much Mr. [PII].
[AGENT][POSITIVE] OK, all right, you're welcome. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I think that would be it. That it's really devastating. It's like uh my money was taken for nothing. And I was hoping it could help me, you know, during this hard time. So, yeah, I, I, I know you understand, yeah. Anyway, thank you again. Yeah, you have a good day.
[AGENT][NEUTRAL] OK, I understand. Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK. You're welcome and take care Miss [PII]. You as well. Bye-bye. Thanks for calling APO. Mhm.
[CUSTOMER][POSITIVE] Yeah, thank you.