AccountId: 011433970860
ContactId: 6e8c734a-8fed-4cc1-8960-1cc308bba5cf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 984349 ms
Total Talk Time (AGENT): 263094 ms
Total Talk Time (CUSTOMER): 433867 ms
Interruptions: 7
Overall Sentiment: AGENT=1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/6e8c734a-8fed-4cc1-8960-1cc308bba5cf_20250428T19:05_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] calling APL, this is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Um, I need to do an, a phone appeal. Um, my social is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, uh, what was your name, please? I'm sorry.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] I'm sorry, that was [PII]?
[CUSTOMER][NEUTRAL] Yes, [PII]
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Got you thank you and then uh [PII], if I could, can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][POSITIVE] Oh, you call back if you get disconnected? Well, that's lovely to know.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Sometimes I don't get that lucky. Um [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[AGENT][NEUTRAL] OK, and then [PII], just gonna verify some information really quick. Uh, can I get your date of birth, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. Last thing I need is the email address that we've got on file for you uh it looks like it is a Gmail account.
[CUSTOMER][NEUTRAL] OK, it's either [PII] or [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, bear with me just a moment. I'm sorry.
[AGENT][NEUTRAL] Yes, it was the [PII]. Thank you so much for verifying all of that. OK, so it looks like you um currently don't have any active policies with us, but you did have, uh, 4, which policy was this in regard to? You have a short term disability?
[CUSTOMER][NEUTRAL] The short term, the short-term disability.
[AGENT][NEUTRAL] Visibility. Got it. OK, give me just a moment, let me get that pulled up here.
[CUSTOMER][NEUTRAL] Yeah, you probably can't see it because they've already uh did a decision and they have rejected it, so I'm just needing to do a phone appeal.
[AGENT][NEUTRAL] OK, so for appeals I can't do that over the phone um there is, so I'm sorry, let's uh back up just a little bit so that I understand what's going on um so the claim has already been filed, uh, denied and you're just simply wanting to appeal that decision, is that correct?
[CUSTOMER][POSITIVE] Correct, correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Bear with me just a moment. I'm just gonna get this pulled up real quick.
[AGENT][NEUTRAL] OK, so it looks like it denied as.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Oh, the current, uh, condition being preexisting.
[CUSTOMER][NEUTRAL] Yes. Now, as far as the current condition, they are saying that they are denying I think it was, I think it said narcolepsy and something else, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Narcolepsy, they might have said sleep apnea too or something. I forget. But anyway, so the reason why I want to appeal it is because the reason why I'm seeing the doctor is to undergo testing to see what's wrong with me. My prior conditions is not what I'm being treated for.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you're filing for disability for something else, is that right?
[CUSTOMER][NEGATIVE] No, no, no, no, no. They denied my claim based on prior existing condition. There's no current diagnosis that is related to my past condition. There is no diagnosis whatsoever, which is why I'm undergoing testing. Whatever they made the decision based upon what they saw in my medical records, that is not what I'm being treated for. That is not what I'm being tested for.
[AGENT][NEUTRAL] Sure, OK, OK, so let's do this, [PII], if you don't mind, um, I'm I just kind of see surface level, so I might just, uh, put you on a brief hold if you're OK and reach out to our claims specialist that way they can kind of go in actually look at what was recovered and provide further information regarding that um I can tell you as far as um appeals though and of course you know it would uh definitely be beneficial if you had additional information what this is in regard to.
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Oh, I understand, I understand.
[CUSTOMER][POSITIVE] Great
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, so that would be.
[CUSTOMER][NEGATIVE] Yeah. It's just, it's just as simple as them telling me, so you're telling me that you have a diagnosis and my doctor doesn't have a diagnosis. That's, that's the simple, that's cut and dry right there. So, you can't deny me for something that's related to a past condition when I don't have a diagnosis for whatever it is that's going wrong with me. It's not related to my past history because the past history stuff has already been eliminated. I already have a treatment plan for that. So we're dealing with some extra, yeah.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Right, so.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, and again that's what that's definitely something that just might need a second look, you know, um, so [PII], if you don't mind, I'm just gonna put you on a brief hold, uh, while I reach out to them. I'll get right back with you, OK?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Alright thank you one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], it's [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you [PII]?
[AGENT][NEUTRAL] Doing all right thank you. I've got a member I'm gonna have to transfer to you um she's calling regarding a disability claim, and she's uh I guess it was determined that she had a preexisting condition so it denied, um, and she is very confused as to why that was or doesn't believe it to be relevant to what she's going through currently, um, so I'm not quite sure what to do with it.
[CUSTOMER][NEUTRAL] OK, what's the policy number?
[AGENT][NEUTRAL] It is 256-966-8.
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, [PII], that is a lot of pieces of mail to look through.
[AGENT][POSITIVE] I saw, I looked at all, I was like, oh my gosh.
[CUSTOMER][NEUTRAL] Yeah, that's like 123456789 1011, 12.
[CUSTOMER][NEUTRAL] Let's see if there's like a medical director or something because that's gonna be.
[CUSTOMER][NEUTRAL] The quickest way medical record request, medical director review that's gonna be the quickest way to see what's going on.
[CUSTOMER][NEUTRAL] Cause her diagnosis, it looks like her the.
[CUSTOMER][NEUTRAL] Policy are part of the thing, uh, obstructive sleep apnea.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then.
[AGENT][NEUTRAL] I think she said like narcolepsy or something like that. Yeah.
[CUSTOMER][NEUTRAL] Uh, narcolepsy. Mhm.
[CUSTOMER][NEUTRAL] So the.
[CUSTOMER][NEUTRAL] Question to the um.
[CUSTOMER][NEUTRAL] To the medical director is, you know, obviously we're trying to determine if the insurer's disability is preexisting, so they gave a timeline stating when she was treated.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um for obstructive, let's say insured was treated on [PII] and [PII] for obstructive sleep apnea and narcolepsy, um, and then they put definition of preexisting in your medical opinion, do you agree that the disability is preexisting based on the policy language, um, because she was claiming disability in January, so she was treated for this a year prior.
[CUSTOMER][NEUTRAL] To her disability, it looks like. And the definition.
[AGENT][NEUTRAL] Right. So according to her,
[AGENT][NEUTRAL] Yeah. According to her, and this is what I, I don't know that it's just that she doesn't understand, but I, I'm not gonna try to pretend that I understand. Um, but she's saying that she's still being like undergoing diagnosis. And that's where I got confused cause how are you, how are you gonna apply for this if you don't know what you have? I don't think it works that way. Um, so that's where she's not, yeah, I know. And that's why I was like, I'm, I'm just not going to touch this one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it doesn't.
[CUSTOMER][NEUTRAL] Yeah, um, let's see.
[CUSTOMER][NEUTRAL] OK, so no disability benefit will be payable if disability is caused by or resulting from a pre-existing condition and begins before you've been continuously covered under the policy for 12 months.
[CUSTOMER][NEUTRAL] Um, so, basically, our definition is that a disease, injury, sickness, physical condition, or mental illness for which you have experienced any of the following treatment, incurred expenses, took medication, received care services, including diagnostic testing or related measures, or received a diagnosis or advice from a physician.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEGATIVE] And then it says during the 12 month period immediately before the effective date. Hey, give me just one second, my husband locked himself out of the house.
[CUSTOMER][NEUTRAL] So give me just a second.
[AGENT][NEUTRAL] OK
[AGENT][POSITIVE] Good.
[CUSTOMER][NEUTRAL] Just getting the front door was open. He got a self in, OK.
[AGENT][POSITIVE] You're good.
[CUSTOMER][NEUTRAL] OK, so the term preexisting condition will also include conditions which are related to such disease, injury sickness, physical condition or mental illness.
[CUSTOMER][NEUTRAL] So the issue based off what I'm seeing is that what we've received she is.
[CUSTOMER][NEUTRAL] I'm just gonna review briefly.
[CUSTOMER][NEUTRAL] Medical records from [PII] because that's the 12 months prior to her disability.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, and based on the medical records, she's been receiving.
[CUSTOMER][NEUTRAL] The the issue is that the preexisting definition includes advice from a physician, treatment, medication, diagnostic procedures, so she's already been in the process of receiving this information prior to ever claiming.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] That's interesting. OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Would you mind explaining that to her?
[CUSTOMER][NEUTRAL] Yeah, so I will, no, yeah, I will still talk to her about it, but just kind of like a heads up for you like I think it's because it does include them.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] I appreciate it.
[AGENT][NEUTRAL] No, yeah, I didn't know about like even them just asking about it that does make sense, but I don't know why I never thought about that.
[CUSTOMER][NEUTRAL] Right, so, you know, when you are under the assumption that you've had that like, like if you receive a cancer diagnosis and you are being treated for cancer, um, we're going to do a pre-existing because did you have a mammogram, you know, two months ago and thought that you were gonna have, you know, they were suspicious of breast breast cancer and now you've got this policy and now you're getting treatment.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So that's one of the, because if you were receiving any type of treatment, any diagnostic, anything, then that is going to.
[CUSTOMER][NEUTRAL] Essentially follow up under preexisting so that I think it's the problem because she's been receiving even if she doesn't have a for sure mhm.
[AGENT][POSITIVE] Right, yeah, that makes sense.
[AGENT][NEUTRAL] Yeah, and I think that's what she's not understanding, yeah.
[CUSTOMER][NEGATIVE] And it's unfortunate. I mean it sucks because it's like.
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] But now I, I think I might have this and it's like I'm aware but.
[AGENT][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] It does look suspicious on paper though, so I understand that.
[CUSTOMER][NEUTRAL] Yeah, so
[CUSTOMER][NEUTRAL] It, it does because, you know, she's been treated since.
[CUSTOMER][NEUTRAL] Um, [PII], March and June, but her effective date on her policy is November.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So that's the issue.
[AGENT][POSITIVE] Well, I sure again, once again I appreciate you breaking that down and helping me understand.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] Of course. No problem, no problem.
[AGENT][POSITIVE] Because that's really good to know. All right, are you ready for Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes, I am.
[AGENT][POSITIVE] All right, all right well thanks [PII]. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] You're welcome you too.
[AGENT][NEUTRAL] OK, bye.
[CUSTOMER][NEUTRAL] Bye.