AccountId: 011433970860
ContactId: 639c36ab-fafb-47c9-8940-06d640f864d5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 287239 ms
Total Talk Time (AGENT): 134008 ms
Total Talk Time (CUSTOMER): 109131 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/639c36ab-fafb-47c9-8940-06d640f864d5_20250109T18:50_UTC.wav
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[AGENT][NEUTRAL] For calling APL, this is [PII]. With whom am I speaking and how may I help you?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Hey, [PII], it's [PII]. How are you?
[AGENT][NEUTRAL] I'm fine.
[CUSTOMER][POSITIVE] Good.
[CUSTOMER][NEUTRAL] I have an insured on the line who had called on the [PII]. She doesn't know who she spoke to. She had a note in line, but she was told that she would be getting a call back on this, on her husband's claim, and she hasn't been called, but I don't see a note by whomever she did speak to.
[CUSTOMER][NEUTRAL] And I have gone over the remark, but she, she just doesn't understand.
[CUSTOMER][NEUTRAL] The denial on this claim, it is [PII].
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] The claim is gonna be for part 2.
[CUSTOMER][NEUTRAL] And it's claim number 3547421.
[AGENT][NEUTRAL] And what's the callback number?
[CUSTOMER][NEUTRAL] Um, it is her phone number that's listed in line because this is Ms. [PII] on the phone, but it's [PII].
[AGENT][NEUTRAL] OK, you can go ahead and send her over.
[CUSTOMER][POSITIVE] All right. Thank you so much. Have a good afternoon.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yeah, you too.
[CUSTOMER][POSITIVE] Thanks.
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. Is this Miss [PII]?
[CUSTOMER][NEUTRAL] Yes, ma'am [PII], this is.
[AGENT][NEUTRAL] OK. All right. And I understand you have some questions. You say you spoke with someone?
[AGENT][NEUTRAL] But you didn't remember who and the previous rep says she doesn't see any notes where um spoke to anybody.
[CUSTOMER][NEGATIVE] She was supposed to have somebody from claims call me back, but they never did um about the denied critical illness claim.
[AGENT][NEUTRAL] OK, did she verify your name, date of birth, physical address and email?
[CUSTOMER][NEUTRAL] Yes, ma'am. She did.
[AGENT][NEUTRAL] OK, let's see, let me take a look.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Give me one second. So then I'll be able to assist you with why the claim denied. I'm just reading the notes because it is in the notes. So give me one second.
[CUSTOMER][NEUTRAL] I'm very sure.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Thank you for your patience. Verification of coverage does not guarantee the payment of a claim.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] So the claim was denied and the claim was denied on [PII] so you haven't had time to receive that denial correspondence in the mail quite yet, but the reason for denial is that it went for metal review and they determined that it did not meet the definition.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Of um this condition doesn't, is not covered under this policy based on the policy definition of the critical illness, OK, so they did not the claim, but you do have the right to appeal. If you want to appeal it, you can just send the claim in again.
[CUSTOMER][NEUTRAL] What you normally get this.
[CUSTOMER][NEUTRAL] It's still outside.
[AGENT][NEUTRAL] Put a reason, put the reason why you're appealing and any other additional documentation from a doctor.
[CUSTOMER][NEUTRAL] OK, that's fine because he had a subarachnoid hemorrhage, which is a stroke. It's a hemorrhagic stroke, not a ischemic stroke. And so that's why I'm confused as to why it's not um being paid because like uh the, in the policy, it just says for a stroke.
[AGENT][NEUTRAL] OK, so what you can do is appeal the claim and I will get documentation from the doctor that diagnosed him with the type of stroke you just mentioned, the hemorrhagic. I will have the doctor fill that information out and you could submit that with your appeal for review, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I just have to resubmit it like I'm submitting a new claim?
[AGENT][NEUTRAL] Right, we need to do a cover sheet. You need to say that you, it's an appeal. You need to say why you're appealing it and you need documentation. I will suggest you get documentation from the doctor saying what type of stroke it was, OK?
[CUSTOMER][POSITIVE] Yes ma'am, that's not a problem thank you.
[AGENT][NEUTRAL] OK. You're welcome. Anything else I can help you with, Mr. [PII]?
[CUSTOMER][NEUTRAL] That'll be all today.
[AGENT][POSITIVE] OK, thank you for calling APL. Take care, have a great day bye bye.
[CUSTOMER][NEUTRAL] You too. Bye bye.
[AGENT][NEUTRAL] Uh-huh.