AccountId: 011433970860
ContactId: 6fdf4a82-9cfa-47f0-8252-8b8f11f91069
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 990039 ms
Total Talk Time (AGENT): 411272 ms
Total Talk Time (CUSTOMER): 387427 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/17/6fdf4a82-9cfa-47f0-8252-8b8f11f91069_20250217T14:22_UTC.wav
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[AGENT][POSITIVE] Good Morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name's [PII]. I'm just calling to get an update on my case.
[AGENT][POSITIVE] Well, it would be my pleasure to check that for you, Mr. [PII]. What is a good callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what is the policy number? Do you have that available?
[CUSTOMER][NEUTRAL] 0, 02283755.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] And what is your date of birth and current mailing address, please, sir?
[CUSTOMER][NEUTRAL] [PII] at uh [PII].
[AGENT][NEUTRAL] All right, thank you. And do you mind also verifying your email address and phone number?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] All right, I am showing that we've received a document on the [PII] and that is in line to be processed.
[CUSTOMER][NEUTRAL] It's online to be processed.
[AGENT][NEUTRAL] Yes sir, we received a new document on the [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] They have not reviewed it yet.
[CUSTOMER][NEUTRAL] You know when, when it'll be reviewed?
[AGENT][NEUTRAL] Normally takes between 7 to 10 business days.
[AGENT][NEUTRAL] Does, did you submit a new document on Friday or this
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Friday, yes, I did.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I was told they were gonna look at it that day.
[AGENT][NEUTRAL] Let me just take a quick look.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Yeah, I don't, they have not well it I don't know if they're reviewing it today or it's just not been processed.
[AGENT][NEUTRAL] But there should be.
[AGENT][NEUTRAL] It should be processed um if you wanted to call back Wednesday or Thursday and we'll be happy to check it for you or if you you have that online account on our portal once it's processed, it will have a claim number now have you, have you signed up for the text messaging for claims?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I think so. That's why I was calling today because I got a
[CUSTOMER][NEUTRAL] I got a text message from you guys.
[AGENT][NEUTRAL] It stated that we received documents.
[CUSTOMER][NEUTRAL] Well, I got a text message Saturday saying your claim is not complete, reference the following claim number.
[AGENT][NEUTRAL] Yeah, that, OK, I got you. Is that the claim number 3,563,690?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that one they would need on that, let me just take a quick look for you. Hang on just a second. Let me go further. Hang on just a quick second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So they did process the one Friday.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] They processed one claim Friday.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] But I'm checking to see.
[AGENT][NEGATIVE] They did not have any.
[AGENT][NEUTRAL] Information regarding bodily injury due to an accident on the documents that they've received. But I do see this medical history.
[CUSTOMER][NEGATIVE] Yeah, I, I, I, I that's what I did. I called them Friday and they told me they wanted that because originally they had told me they, cause I had already called, this is like the 3rd time calling, and they keep asking me for stuff.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I keep providing everything and they still are finding a way to deny the claim, so.
[AGENT][NEUTRAL] Well, according
[CUSTOMER][NEGATIVE] I'm just waiting to see what I'm just waiting to see what you guys are gonna say now that you need to try and deny it.
[AGENT][NEUTRAL] I, I understand your frustration now. We'll say that with your
[AGENT][NEUTRAL] Accident policy.
[AGENT][NEUTRAL] It only pays for bodily harm due to an accident.
[AGENT][NEUTRAL] Now, I do see, I'm looking at.
[CUSTOMER][NEUTRAL] Yeah, there it was.
[AGENT][NEUTRAL] I'm looking at your medical records. So that's what they're needing is something showing that it was due to an accident.
[AGENT][NEUTRAL] When did your accident occur?
[CUSTOMER][NEUTRAL] It happened in [PII] something.
[CUSTOMER][NEUTRAL] So it's been, it's been a while and I was, I was at the ER. I have been to the, to the urgent care follow-ups with my doctor, and I have been to physical therapy. I don't understand what you guys need in order to approve the claim. I mean, what more proof do you need than medical records and physical therapy?
[AGENT][NEUTRAL] That's that
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm. Sure.
[AGENT][NEUTRAL] So we do
[CUSTOMER][NEGATIVE] I don't understand what you guys need.
[AGENT][POSITIVE] Sure, I understand that. So I do see that it's showing that it's lower back pain.
[AGENT][NEUTRAL] But it doesn't say what caused the back pain. It says um sciatica.
[CUSTOMER][NEGATIVE] It's an injury at work.
[AGENT][NEUTRAL] It says acute midline.
[CUSTOMER][NEGATIVE] No, it shows the, the, the physical therapy, it goes for that because uh it was hurt. I got hurt at work and it was a lower back in it was a lower back injury, it was a lower back injury that turned into more pain on my leg.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And that hurts. I've had my lower back hurt. I'm so sorry you're going through that cause that is painful. I got thrown from a horse and I had trouble with my back for like months and it hurts so bad. I'm so sorry you're going through that.
[CUSTOMER][NEUTRAL] All because of the injury.
[AGENT][NEUTRAL] Um, but I'm still looking through the documents looking for.
[AGENT][NEUTRAL] Um, lower back pain due to a fall or what type of accident caused the lower back pain?
[CUSTOMER][NEUTRAL] Ma'am, the accident happened at work while I was at working regarding of what caused it does not matter if I got hurt at work and I got injured at work.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Regardless of what it was, that's not what I was told when I got, when I purchased the insurance. I, I was told that it was gonna cover injuries, uh, cuts or whatever, that there was, there was no, no, they never told me it was gonna be this complicated. You guys are reaching, trying to find any reason to try and deny it. You're looking for something specific, I'm telling you what it was. I'm telling you how the accident happened and what, and what I'm paying.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] And what I'm going through with the hospital and urgent care and physical therapy and you guys are still not accepting the fact that I got hurt at work. I don't understand. What are you guys like?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] No, it
[AGENT][NEUTRAL] I, I'll tell you what I'm gonna do, Mr. [PII]. Let me get you to an examiner that an accident adjudicator, OK? And let them look at this and take down your notes and everything, OK?
[CUSTOMER][NEGATIVE] Yes, please do what you need to do because this is very frustrating with you guys. You guys are trying to, you guys are, are, are, you know.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Yeah, and uh yes, sir.
[CUSTOMER][NEGATIVE] You guys are trying to not, you're not trying to process the claim, and at this point I'm 3 weeks in trying to do this.
[AGENT][POSITIVE] Yeah, and I understand you need that assistance too.
[CUSTOMER][NEUTRAL] And you guys keep keep every day.
[CUSTOMER][NEUTRAL] Exactly. You, you, if you understand that you got in your back, you should know what kind of stuff I'm dealing with right now, like.
[AGENT][NEGATIVE] I do. I do completely and it's, it's not fun. And then you, uh, for me, I couldn't work and I wasn't getting paid. And yes, it's very frustrating and very scary cause you don't know what you're gonna do. So I get it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Well, what sucks is that, what sucks is that you have the proof, you have the medical records, you have the ER visits, you have the medical, the physical therapy history, and then you guys are still asking, did you actually hurt yourself? What, what, what do you mean? What are you guys talking about?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I was also
[CUSTOMER][NEUTRAL] Yes, I heard myself, so.
[AGENT][NEUTRAL] Yeah, I was also checking to see if you had any other coverage, you know, with us, but the accident. Uh, let me, let's get you to an adjudicator and see if they can do anything further, OK, without documentation or if they can locate the document that that injury report is on. Do you mind holding one moment?
[CUSTOMER][NEUTRAL] Do your part, I mean.
[CUSTOMER][NEUTRAL] No no.
[AGENT][NEUTRAL] All right, thank you. One moment, please.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I help you?
[AGENT][POSITIVE] Hey, [PII], it's [PII]. Happy Monday. Ya. Yay.
[CUSTOMER][NEUTRAL] Hey.
[AGENT][NEGATIVE] I have an insured on the line. It's gonna take a little bit more research um to assist him. He's frustrated. I've got policy number 228.
[AGENT][NEUTRAL] 3755.
[AGENT][NEUTRAL] [PII] I verified all of his information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Uh, we went over the denial of the claim, and he says that he's called several times. He got hurt on the job, hurt his back, went to the ER, went to urgent care, he's been to physical therapy.
[AGENT][NEUTRAL] And we're trying every way we can to find not to pay the claim. We went over the fact, well, I told him that the accident policy pays due to a bodily injury.
[AGENT][NEUTRAL] Due to an accident.
[AGENT][NEUTRAL] And I said, according to the new cause I did review the new claims, and I said, it does say back pain, but it doesn't say what caused the back pain. And I said, we need that accident, diagnosis or reason. He keeps saying, well, I tell y'all what it is. I say we need medical anyway. Can you look at this with him and just make sure we don't have anything from the ER or anything with the
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me glance and see what we got, let's see.
[AGENT][NEGATIVE] And he's very frustrating. I mean, I get it.
[CUSTOMER][NEUTRAL] Trying to see if any of this information.
[CUSTOMER][NEUTRAL] indicate any bodily injury. So far, I'm not seeing anything. I see this is like physical therapy notes or something, most recent mail.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] See, let me keep glancing.
[AGENT][NEUTRAL] Yeah, I never saw anything due to an accident.
[CUSTOMER][NEUTRAL] This is what workers' comp follow ups.
[CUSTOMER][NEUTRAL] Yeah, none of this is seeing an injury or anything. It's just saying back pain, which that's not bodily injury. They all got the same diagnosis code on the end of these work comp.
[CUSTOMER][NEUTRAL] Documents
[AGENT][NEUTRAL] And he said he went to the emergency room, and if he told them why he hurt, why his back is hurt and what caused it, you know, we should be able to get documentation for that, right?
[CUSTOMER][NEUTRAL] Look at this
[CUSTOMER][NEUTRAL] Yeah, if you can provide us with some additional information, let me see what he previously sent in.
[AGENT][NEUTRAL] And that's what he keeps saying, all we're trying to do is keep asking for more stuff and more stuff.
[AGENT][NEUTRAL] And trying to find a way to not pay the claim. And I, I do understand his frustration.
[CUSTOMER][NEUTRAL] So what he sent, OK, he sent the bill which it has a diagnosis code. I'm just wanna make sure he didn't send no records on this other mail real quick.
[CUSTOMER][NEUTRAL] To make sure looks like we only got the bill so far for the ER and then his workers' comp stuff.
[CUSTOMER][NEUTRAL] Yeah. Yeah, I mean, you can send it to me. I'm pretty much tell him the same thing that the polyphonic covers due to bodily injury. Um he can submit additional information.
[CUSTOMER][NEUTRAL] Um, supporting documents that indicate an injury.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Bodily injury did occur or he can also submit in an appeal is what I'm gonna tell him.
[CUSTOMER][NEUTRAL] If you disagree with the decision.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, if, maybe if you could get, do we have the ER medical notes?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, just only the bill.
[CUSTOMER][NEUTRAL] I just see we only have the hospital bill and it has the diagnosis code. Low back pain. That's where we originally got the diagnosis code from.
[AGENT][NEGATIVE] Yeah, I should have told him that low back pain can be caused from an illness or, you know, but because this is an accident policy, you know, it has to be due to an accident, an injury caused by an, anyway, uh.
[AGENT][POSITIVE] Anyway, can, if you can talk to him, I think that'll make him feel good.
[CUSTOMER][NEUTRAL] Yeah, you can send it to me. I'm pretty much gonna tell him the same thing and if you want to submit an appeal if he disagree.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] All right, [PII], I appreciate it. Let me get him on the line. Thank you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] All right, Mr. [PII], thank you for your patience. I have [PII] on the line, and she has been reviewing your documents and she's going to assist you further, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] All right, thank you, sir. I hope you get to feeling better.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hello Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hi, so I was looking at the information that we did receive in um regarding the [PII] visit. It looks like based off the information that was submitted to us, it looks like it was due to a low back pain. Under this policy, it is an accident policy and it only covers if there was um bodily injury that incurred from this information that we had.
[CUSTOMER][NEUTRAL] It's indicating a low back pain. So if you can either provide supporting documentation that indicates bodily injury or physical damage that occurred.
[CUSTOMER][NEGATIVE] I have. I've been to the ER. I've been to the urgent care about 3 times due to the, the injury I had at work and then I'm now in physical therapy due to that injury. OK, what more proof do you guys need? It's not just, it's not just pain, it's an injury inside my body just because I haven't had um.