AccountId: 011433970860
ContactId: 6b92fa10-9207-478f-b11f-65ebeb55f68d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 863169 ms
Total Talk Time (AGENT): 356979 ms
Total Talk Time (CUSTOMER): 319917 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/6b92fa10-9207-478f-b11f-65ebeb55f68d_20250324T20:47_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I wanted to check on a claim status.
[AGENT][POSITIVE] OK, I'm happy to check on a claim for you today. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes ma'am, it is 254-890-4.
[AGENT][POSITIVE] All right, thank you so much. Let me pull this up here one moment.
[AGENT][NEUTRAL] And if I can get first name, last name on the policy and date of birth?
[CUSTOMER][NEUTRAL] Uh, my name is [PII]. Uh, the policyholder is [PII].
[CUSTOMER][NEUTRAL] Um, mine is 226 87, hers 8387.
[AGENT][NEUTRAL] Thank you, [PII], and then can you verify the address and email address we should have on file?
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] Email should be [PII].
[CUSTOMER][NEUTRAL] 12:10 at yahoo.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim you're checking on, was it under your name? Was it under [PII]'s name?
[CUSTOMER][NEUTRAL] It's in [PII]'s name.
[AGENT][NEUTRAL] OK. Let's see.
[AGENT][NEUTRAL] So I do show a claim. It looks like that was submitted online. It was done around the [PII] of this month. Does that sound right?
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] So it's OK, so it's still in progress, no decisions been made at this time, so we generally ask for about 5 to 7 days to process as far as claims go so just give it a little bit more time it looks like.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Well, the, the issue is.
[CUSTOMER][NEUTRAL] When we originally submitted everything on the, there's one that was submitted on the [PII], I believe, or the [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Um, they initially denied it.
[CUSTOMER][NEUTRAL] Saying, citing possible preexisting conditions.
[CUSTOMER][NEUTRAL] For the lump sum payment.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But we had been, she had had this policy for 2 years previous.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so that's, that's what I'm confused on, and that's what I'm trying to make sure like.
[CUSTOMER][NEUTRAL] You know,
[CUSTOMER][NEGATIVE] Uh, why, why it was told that it was denied originally.
[CUSTOMER][NEUTRAL] Uh, when it shouldn't have been since we had the policy for 2 years previous.
[CUSTOMER][NEUTRAL] And I'm trying to make sure that that's still not the case, I guess.
[AGENT][NEUTRAL] So what you submitted on the [PII], I can pull it up here, was it just additional info or was this like a whole new claim?
[CUSTOMER][NEUTRAL] I think it was, I think it was doctors' names, like the, anybody that had seen her recently or.
[CUSTOMER][NEUTRAL] Whatever.
[AGENT][NEUTRAL] OK. Let me take a look here.
[CUSTOMER][NEUTRAL] So that's what they, that's what they sent us, and it was like a form to put on like her, her doctor's name, her oncologist, all that so they could I guess contact them if they needed to.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so I see that we did get all of that and what you filled out with all of their information and all of that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't see any additional notes on the other claim originally that was denied so with the information we received for the physicians and not showing still in progress, I would venture to say that they're just reaching out and doing their legwork to make sure it's not and then that claim status on the original one.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Would then change um if a payment is sent out that would be that would be updated so um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is, is, is she still at risk of saying, of them saying it's preexisting and denying it, even though she had, um, policies previously?
[AGENT][NEUTRAL] Let me see. I don't know on this policy. I would have to check and see what they're like pre-existing clauses.
[CUSTOMER][NEUTRAL] Yeah, because
[CUSTOMER][NEGATIVE] Because that's what confused me. I think it says something like anything diagnosed within 120 days of the policy date.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um, they investigate and I'm like, OK, I get that, but.
[CUSTOMER][NEUTRAL] It doesn't list any kind of exception like if you've had previous policies because I think that would only be applicable under the first policy she had she got in [PII].
[CUSTOMER][NEUTRAL] Since you consistently had a policy with y'all going forward from that day.
[AGENT][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] Or at least that's what makes sense in my head. I mean.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] [PII] part of the street.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I go down there.
[AGENT][NEUTRAL] Yeah, so I do see that the pre-existing exclusion period is 12 months from the date as far as like having the policy.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So if we go back and look.
[CUSTOMER][NEUTRAL] I I'm pretty sure it's been the exact same policy she's had since she got it in the, she's a teacher, so she got it through the school district in [PII].
[CUSTOMER][NEUTRAL] And I guess [PII], and then she had it again and she got one at [PII] and then again in [PII].
[CUSTOMER][NEUTRAL] The only difference for 24 was she added me to it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so the only thing that I do see is, so she started the policy, the policy was originally started [PII].
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I do show that in [PII], the policy ended and then I showed this policy starting [PII]. Do you know if there was like a year where she elected not to have the coverage?
[CUSTOMER][NEUTRAL] Hold on, let me, let me, I have the account pulled up so on my side it shows we.
[CUSTOMER][NEUTRAL] Uh, we, I had one that started.
[CUSTOMER][NEUTRAL] 9122.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then she had one that started 9-123.
[CUSTOMER][NEUTRAL] And then I'm again 9124. I mean, it shows me three different policy numbers.
[CUSTOMER][NEUTRAL] And then it shows like the two are lapsed and then the 1 is effective.
[AGENT][NEUTRAL] Yeah, the 91231 is strange because it shows effective and paid to date the same date, 9123, 9123.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Because it shows me policy uh the one in 22 with a policy number ending in 708 and then 23, a policy number ending in 754.
[CUSTOMER][NEUTRAL] Which is still different from the one we have right now.
[AGENT][NEUTRAL] Mhm, mhm.
[AGENT][NEGATIVE] Yeah, I just don't, in 23, that policy didn't seem to have any longevity to it. It's like
[AGENT][NEUTRAL] That the policy.
[AGENT][NEUTRAL] It's like the certificate may be changed and so there was a new policy number issued ending in 9754, but it doesn't show me that that policy continued all the way up until [PII] with this current one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it should have. I mean, it it comes out of her paycheck. Like they, she sets it up at the beginning, you know, with her insurance and it just.
[CUSTOMER][NEUTRAL] Comes out
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean, I don't know if I could.
[CUSTOMER][NEUTRAL] I don't know how to get into her.
[CUSTOMER][NEUTRAL] Uh, on her end and look at that, but I'm pretty sure, I mean, we had it since then, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's the, I mean, that would be the only thing that I'm seeing that, you know, in regards to it being preexisting, obviously that date, you know, if, if I didn't see any sort of difference in dates, I, I would say, yeah, the policy started in September of 2022, the 12 months would have been September of 2023.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and then she would have been eligible for any sort of benefits at that point.
[AGENT][NEUTRAL] Does she have any sort of, do you know if there's any sort of like point of contact with the employer to.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, I could probably, she has like an online benefits.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um, portal that I could look through.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, I just don't, I just don't know her login for it.
[CUSTOMER][NEUTRAL] Um, or I'd look it up, but.
[CUSTOMER][NEUTRAL] Um, I'm pretty sure like 22 is when she came to this school district that where she's at right now and so I know everything has been the same up until this year and we changed, we went to a private health care system instead of the school insurance, but we kept like everything else through the school like the cancer policy accident policy, all that stuff.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But, um, I'd have to look at that and see on our end. But I mean, even, even though like she still didn't have, if we look at just the policy this year, this year's policy, she never had any symptoms or was never diagnosed with anything until December.
[CUSTOMER][NEUTRAL] So like
[CUSTOMER][NEUTRAL] It still wouldn't be considered preexisting. She never saw a doctor for this previously.
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] You know,
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Um, yeah, I mean the only thing that I would maybe do if you want is see if there's, you know, a way that you could find just the verification for the full [PII] year.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just for backup I guess or for.
[AGENT][NEUTRAL] Yeah, for your own, because on the claim itself really we're, you know, you're kind of in a waiting period right now because you did submit everything that was asked for and so the claims examiner now will just kind of look at it and then, you know, you have to go from there kind of unfortunately in a holding pattern, but that's, that's the only thing that I could see perhaps maybe coming about.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Just because from [PII], I don't show that there was any sort of coverage in our system.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Alright, well I'll look up that and now is there any way to speak to whoever's work investigating the claim or anything like that?
[AGENT][NEUTRAL] Um, I don't know if it will be.
[AGENT][NEUTRAL] Um, the original examiner who processed the first claim or not. Let me see.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Um, if for some reason it ends up being that it doesn't process through, um, if you call, if you have to call back [PII], then at that point we could put you in touch with either the person that did the claim or an examiner and have them.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Go over exactly if there was anything else missing. I mean, based off of the original claim, it looked like that was the only thing that we needed is what you sent in, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, well I'll give it, I'll give it a few more days and then um.
[CUSTOMER][NEUTRAL] If I don't hear anything or see anything I'll give another call back and go from there.
[AGENT][NEUTRAL] OK, did you need me to check on anything else today for you?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Alright well we appreciate you calling APL. I hope you have a nice rest of your day.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][NEUTRAL] Mhm bye bye.
[CUSTOMER][NEUTRAL] Alright bye bye.