AccountId: 011433970860
ContactId: 67d5ebdc-b324-4f70-9b27-b5cd8380b485
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 386350 ms
Total Talk Time (AGENT): 270318 ms
Total Talk Time (CUSTOMER): 132813 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/21/67d5ebdc-b324-4f70-9b27-b5cd8380b485_20250421T14:43_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] over on the care team. How's it going today?
[AGENT][POSITIVE] It's going pretty good, [PII]. How are you?
[CUSTOMER][NEUTRAL] Doing all right thanks so I've got kind of a a silly question. um I have someone on the line who uh accident policy um uh it was a fracture of their arm. I see the benefit, um, in terms of the information they need to send us, apparently he's still receiving like going to the doctor, uh, for it would we just need that initial, um, statement showing that you know it was indeed a fracture?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, what's the policy so I can kind of see what the benefits look like?
[CUSTOMER][NEUTRAL] Oh sure.
[CUSTOMER][NEUTRAL] Yeah, it's 2452637.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I guess he went to the ER, um, and then he had to go back and was hospitalized for about 4 days. And, you know, he's got continuous follow-ups and for me, I wouldn't think we would need all of that.
[CUSTOMER][NEUTRAL] Is it just a one time payment?
[AGENT][NEUTRAL] So for the fracture itself, because this is a 21. So, OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So the ER.
[AGENT][NEUTRAL] The initial, that initial would be covered. Here's the thing, because of how this policy has everything laid out, there is a possibility that everything would be needed because he went to the ER for initial treatment and if he was not there for any length of time and they sent him home, whether they casted it or whatever, then that, let me see what the how the fracture pays like does it have to be.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Fixed or does it have to be just diagnosed? Let me see that.
[AGENT][NEUTRAL] Cause I think it has to be, OK. We pay for an open reduction, which is a surgical repair, but then it's like a, usually a lesser amount if it's not a surgical repair.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Oh, I didn't know what that meant.
[AGENT][NEUTRAL] Yes, so open reduction means surgical intervention was needed. They needed to go in and fix it surgically. Close reduction means, yes, you do have a fracture, but we are able to um fix this without the need of surgical intervention. So dislocations can be done, yeah, so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, I see.
[AGENT][NEUTRAL] Every all the charges you see on the policy are gonna be for open reduction and then when you get to the bottom like specifically for um his policy it says close reduction is 50% of whatever the open reduction benefit is.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] I see. OK, that's really good to know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, so that is.
[CUSTOMER][NEUTRAL] I had no idea that's what that meant.
[AGENT][NEUTRAL] Yes, that is what that means. So if he had initial treatment in the ER, he does have an ER benefit. Um, so that would be able to be considered. Um, and then if he was diagnosed there, but no repair was done, like, did he, did, I guess I'm trying to figure out because I don't want us to pay for a closed reduction and then he got hospitalized and had to have an open reduction. Like, do we know what the hospitalization was for?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It seems like that.
[CUSTOMER][NEUTRAL] I'm not 100% so I know that he initially went to the ER after he fell, um, and then he went home and then he had to go back and he said that he stayed there for 4 days so I would imagine, you know, yeah, so that's what it sounds like to me.
[AGENT][POSITIVE] Oh wow.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK, so I would say at least the initial ER and his hospital stay information we'll need because he also has admission and confinement when due to an accident. So for sure those two as far as follow up visits, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Does he have anything for that? Sometimes they do and sometimes they don't. I don't, I mean, he has X-ray, major diagnostic exam. Like I'm sure all of that was done either in the ER while he was there. Mhm. So, I don't see what is extended treatment? Let me double check that because I don't know if that's gonna be considered like.
[CUSTOMER][NEUTRAL] Initially, yeah.
[AGENT][NEUTRAL] Follow-up visits after an accident or if that's just, let me double check our definition for that. Because if that is inclusive of follow-up visits, then I would say yes, I mean everything, you know, like get as much as you can. OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I would think so too, OK.
[AGENT][NEUTRAL] So it says extended treatment um is for each day a covered person receives chiropractic, acupuncture, or mental health services for treatment as a result of an accident. So I don't think it would cover.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] His fracture follow up and him making sure he's healing correctly. So I don't, I don't think so.
[CUSTOMER][NEUTRAL] OK, I might just err on the safe side though and go ahead and tell him to send it.
[AGENT][NEUTRAL] But if he's getting physical therapy, he has that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, I mean, there's a whole number of things that we can consider. We just don't know what those follow-ups are inclusive of and physician's office visit, even though it's not the initial, it says that we will pay.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] For each day a cover person receives treatment from a physician or medical professional in their office due to the result of an accident, treatment must occur within 30 days. So if, if he's following up regularly and it's payable up to 10 days per plane year per person.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So, it doesn't have to be initial for physician's office. So I would say yes, submit everything.
[CUSTOMER][NEUTRAL] OK, so let me ask you this.
[CUSTOMER][NEUTRAL] OK, let me ask you this then, um, because she said she has another appointment, a follow up, uh, coming up in May. Should they wait and submit all of that at once, or is it OK to submit that after?
[AGENT][NEGATIVE] Oh no.
[AGENT][NEUTRAL] Yeah, go ahead and submit all the things.
[AGENT][NEUTRAL] Now.
[CUSTOMER][NEUTRAL] OK, so they can go ahead and submit what they have now and then the follow up they can do separately.
[AGENT][POSITIVE] Yes, they can submit as they have them.
[CUSTOMER][NEUTRAL] I got it. OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Got it. OK. I really appreciate your help. I always like getting you. You are just always so informative and but really, I, I can't tell you how much I appreciate it. Thank you.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Oh,
[AGENT][POSITIVE] No problem at all, anytime, anytime if you have any more questions, OK.
[CUSTOMER][POSITIVE] All right, I will let her know. Yes, ma'am. Thank you. All right, bye.
[AGENT][NEUTRAL] OK. All right. Bye.