AccountId: 011433970860
ContactId: 62ae2204-3d81-4da7-81f5-aab9386db151
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 736380 ms
Total Talk Time (AGENT): 344535 ms
Total Talk Time (CUSTOMER): 402652 ms
Interruptions: 11
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/62ae2204-3d81-4da7-81f5-aab9386db151_20250203T21:54_UTC.wav
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[AGENT][NEUTRAL] For calling APL, this is [PII]. With whom am I speaking? How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. It's [PII]. I've got an insured on the phone and she has called several times about um this claim. Let me give you the policy number.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's 224-44360.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It's on part one [PII], and I do have his permission to speak to Ms. [PII] with his wife. He did verify the policy. The claim number is 354-436-3.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the remarks state that it's non covered service under the patient's plan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But she said that she spoke to somebody already that all they had to do was send in information from the doctor's office and she's calling. I don't see anything has been reported since [PII], but she's calling because she said the doctor did tell her he sent something in.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK, so, um, OK, so this is a critical illness policy, first of all, and we're so, no, no, you're fine. No, no, no, no, you don't. No, you don't. You got the right cue. No, you have the right cue. I'm just trying to, I have to know what kind of policy I'm dealing with. So this is critical illness and we, so it was denied stating that this condition is not covered under this policy based on the policy definition of critical illness.
[CUSTOMER][NEGATIVE] Oh goodness gracious, I got the wrong darn queue.
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[CUSTOMER][NEUTRAL] Yes. Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you can send her over, but she's gonna, yeah, she's just gonna have to appeal it and, and I mean that's, that's the, that's the decision that was made so she can appeal it, but I can let her know that.
[CUSTOMER][NEUTRAL] Right, which is what I told her. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you Ms. [PII]. I appreciate it. I think it it would help her to be able to talk to somebody besides me just so she can get it from somebody else. OK thank you bye bye.
[AGENT][NEUTRAL] Mhm. OK. You're welcome.
[AGENT][POSITIVE] OK. No worries. No problem. OK, thank you. Uh-huh, have a good one.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. Is this Miss [PII]?
[CUSTOMER][POSITIVE] It's Ms. [PII]. Thank you. Yes. How are you today?
[AGENT][NEUTRAL] Miss [PII], sorry about that. I'm good. And I understand that you're calling regarding uh the the policy for the, the claim for your spouse claim number 354-436-3. I understand he is already.
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Could you repeat that num
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] 354, go ahead, you repeat that. 354 cause I don't have my paper in front of me with that number.
[AGENT][NEUTRAL] Yeah, I, I have it. It's 354-436-3, and I understand he's already verified the policy and he's given permission for us to speak to you about this claim today. Now, uh, OK, great. So the claim denied that the condition is not covered under the critical illness policy. It does not meet the definition of being covered under the policy. At this point, you can appeal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, y'all had sent me, you had sent, I'm sorry, you had sent me a letter stating that.
[CUSTOMER][NEUTRAL] And our doctor and Doctor [PII], the neurologist, sent letters and it specified he had a brain bleed and caused a stroke. And on the policy, stroke is one of the conditions that is covered by critical illness. He is also with the neurologist, doesn't know if and when he could go back to work. Those meet critical care guidelines.
[CUSTOMER][NEUTRAL] And the stroke is specifically listed on the policy. I have it in front of me.
[AGENT][NEUTRAL] OK. All right.
[CUSTOMER][NEGATIVE] So, my doctor sent these letters in, and I don't understand how y'all could say denied when the doctors told you he did have a stroke.
[AGENT][NEGATIVE] OK. Alright, you, you finished cause I don't want to talk over you.
[CUSTOMER][NEGATIVE] I'm sorry, ma'am. I'm very upset. This is 3 months later. He has no more short-term disability. He can't go to work. We really need this money and we pay out our butt for this insurance for a year or two. I mean, my husband's [PII] and I'm [PII]. We pay almost $1000 a month for all these benefits. And then y'all people make me feel like a shame because I'm trying to claim something that's real and I give you the evidence. I'm very frustrated.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I understand, but I don't want to talk over you. I just want you to finish saying what you're saying so that I can explain what your next step is you can do.
[CUSTOMER][NEUTRAL] OK. I'm calm now. I just need to know if you did get the letters that from Doctor [PII], Doctor [PII], the, that were sending after I sent you records.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] When
[AGENT][NEUTRAL] When was, do you know what date they sent that? Was it like a week ago or?
[CUSTOMER][NEUTRAL] Mm, no, it was right before [PII] and that's why I really didn't push it because the holidays.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, I do see that. Let me, let me look at one of them. Let me take a look at one of them, but I wanna say we did receive it.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK, [PII] said it was around [PII], he thinks, uh, Doctor [PII] or we sent the letter.
[AGENT][NEUTRAL] Yeah, we received them.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We received them and the claim went for um as you're stating your doctor's saying that it was a stroke, but we have a a medical review board that looks at that and unfortunately, they denied the claim as not meeting the definition. So, um, at this point, uh Ms. [PII], all you can do is file an appeal. Now, file your appeal.
[CUSTOMER][NEUTRAL] Well, I need to do that.
[AGENT][NEUTRAL] Mhm. So you would just draft up a letter and just say what exactly what you said to me that this was a stroke. The doctor said it was a stroke, and attach those doctor's letters to your appeal, OK? Make sure you put on just, you could just do a, you know, cover letter. You can write it in your handwriting and just say appeal and put the claim number I gave you.
[AGENT][NEUTRAL] All right. And why you are appealing because you feel like this was a stroke, that's what the doctor said and it meets the definition of the critical illness policy.
[CUSTOMER][NEUTRAL] OK, and uh.
[CUSTOMER][NEUTRAL] The other thing is that uh
[CUSTOMER][NEUTRAL] Hold on a second. We also had uh healthcare, I mean, for the hospital visit and everything, and you gave us some money, and you're also, I'm appealing on that too, because he was not inebriated. He had drunk earlier that night, and it does not matter, and accidents an accident. And so they're trying to tell me that I owe them money. No, y'all owe me money. We paid the policy in accidents and accidents.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] So yes, you will have to appeal that. Yes, ma'am. Two separate appeals. Yes, ma'am. One for the accident policy. And do you have that policy number?
[CUSTOMER][NEGATIVE] I have to file two appeals.
[CUSTOMER][NEUTRAL] Uh, I probably do in my other papers, but if you could give it to me since you're right there.
[AGENT][NEUTRAL] I sure can. 244-426-1.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And that's the accident, and I can appeal that.
[CUSTOMER][NEUTRAL] And then I have to write a separate letter and
[CUSTOMER][NEGATIVE] For the other. Oh my [PII]. How long does it take to get benefits like this? I mean, how many times y'all gonna deny me?
[CUSTOMER][NEGATIVE] Before, seriously, I'm not trying to be smart with you, ma'am.
[AGENT][NEGATIVE] Man, I, I don't, I, I don't, yeah, I don't have the answer to that, unfortunately.
[CUSTOMER][NEUTRAL] I know you can't say specific things, but is this not, is this the normal way it goes?
[AGENT][NEUTRAL] It always goes to the medical review and you know, um they look at the medical records that was sent in and then that medical review board makes a determination as to whether it meets the policy definition, but you have a right to appeal their decision.
[CUSTOMER][NEUTRAL] Are you
[CUSTOMER][NEUTRAL] And they did get the one from Doctor [PII] stating that he had a warn Degaur would have been like the
[CUSTOMER][NEGATIVE] The 1st, 2nd week in December. They got that letter too and they're still denying it.
[AGENT][NEUTRAL] Yes. Yes.
[CUSTOMER][NEUTRAL] And it said stroke in the letter.
[AGENT][NEUTRAL] Let me take a look let's see, let me take a look.
[CUSTOMER][POSITIVE] Uh, I'm pretty, I don't see how they can deny that.
[AGENT][NEUTRAL] I'm seeing that we had, we received 3 pieces of documents on the [PII] and he's saying around the [PII] and [PII] so let's see.
[CUSTOMER][NEUTRAL] One would be [PII], one would be Doctor [PII], and [PII].
[AGENT][NEUTRAL] I do see medical records from Doctor [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. And the doctor reviewed all this. He reviewed all this and, and, and, you know, they uh made a decision that basically what they're looking at, like he had a fall and it, it, you know, but as I stated, you have the right to appeal it.
[CUSTOMER][NEGATIVE] And you didn't receive them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, ma'am. I get that, but the one question I, I didn't get, maybe I misunderstood, to be patient with me is, you did not get the letter from [PII] stating that he had had a stroke.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see, all I see is medical records from Doctor [PII].
[AGENT][NEUTRAL] And let me look at this other document.
[AGENT][POSITIVE] Thank you for your patience. One moment.
[CUSTOMER][NEGATIVE] No, ma'am. You're helping me and I'm sorry I'm aggravated, but you just don't know what I've been through trying to do this. And if I haven't made 100 calls,
[AGENT][NEUTRAL] Oh, that's OK. You're fine.
[CUSTOMER][NEUTRAL] Some reason I just
[AGENT][NEUTRAL] You're fine. Let's see here. So I don't see it there.
[CUSTOMER][NEGATIVE] They don't receive the stuff from Doctor [PII].
[AGENT][NEUTRAL] Yeah, let's see, here's something from [PII] and [PII]. Let's see what this is regarding [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, [PII], I'm sorry, [PII]. I'm sorry about that. Let's see, let's see what this is though.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yes ma'am. It's OK.
[AGENT][NEUTRAL] This may just be the claim form that they originally filled out and not necessarily a letter.
[AGENT][NEUTRAL] And that's what it
[CUSTOMER][NEUTRAL] There was the first form, no, the second was a form too. They filled the one before and then we all said it wasn't enough. They needed, y'all needed more. So I went back, back to Doctor [PII] and I talked to him and I said, look, yeah, you know, I need you to fill this out. And so they did.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. Well, I don't see a letter from Doctor [PII]. I don't see a letter. So, you know, you would need to get that letter and you still at this point have to file an appeal and just send his letter in with your appeal.
[CUSTOMER][NEUTRAL] And they said they send it directly into y'all.
[CUSTOMER][NEUTRAL] OK. So I, I mean, I didn't know that you had not received it. Can I ask you something? Is there a phone number, I mean, on this, uh, this piece of paper that I have, it's got, I'm sure if I go through, I'll find it, but
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] You know, I've got your toll-free number, and I know somewhere in here I've got written, but just in case I got the wrong one, is there a um
[CUSTOMER][NEUTRAL] A number that I could fax or scan something and send it to.
[AGENT][NEUTRAL] Sure. You can fax. You can fax and let me know when you're ready. Mhm.
[CUSTOMER][NEUTRAL] OK, uh, you can fax it.
[CUSTOMER][NEUTRAL] Go ahead, ma'am.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] And I have a lot of paperwork and a lot of his records, and I only have part of them right now in front of me, so I probably have that.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But that would have been where we would have sent the stuff before.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But I'll contact the Degata and get them to send that to you all directly plus get a copy of a letter and appeal.
[AGENT][NEUTRAL] OK. Yes, ma'am.
[CUSTOMER][NEUTRAL] Because, and please notate since I spoke with you, you know, I understand I gotta send it, but yet you've spoken with me, I'm checking on it and that I will send an appeal and I will get the doctor to send that information.
[AGENT][POSITIVE] Yes, that's what I'm putting in the notes now yes ma'am.
[CUSTOMER][POSITIVE] I really appreciate your help. And um
[AGENT][NEUTRAL] You're welcome, Miss [PII] and I hope you all get it resolved. Just get that letter from that doctor that says he had a stroke and, and get that appeal in so we can get it reviewed again, OK?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] Thank you so much, ma'am. You have a very good day.
[AGENT][POSITIVE] You're welcome. You take care of yourself. Sorry for the frustration and, and have a great day. Thanks for calling APL and that's OK. Uh-huh. Bye-bye. You're welcome.
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][POSITIVE] Thank you. Alright, bye-bye.