AccountId: 011433970860
ContactId: 701b2237-bdea-4da9-b9e9-86d9f2181876
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 692010 ms
Total Talk Time (AGENT): 204268 ms
Total Talk Time (CUSTOMER): 100883 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/701b2237-bdea-4da9-b9e9-86d9f2181876_20250107T18:15_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, Er, I was calling to check on a claim that I had filed for my husband.
[AGENT][POSITIVE] OK, I'm happy to check on a claim for you today. Do you have a policy number?
[CUSTOMER][NEUTRAL] No, I can give you my social security number.
[AGENT][NEUTRAL] OK, I can look it up that way. What's that number?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, give me just one moment please. I'll take a look by that.
[AGENT][NEUTRAL] And then if I could verify your first and last name please?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Thank you, [PII]. So I did find your policy. For security, I will need to verify please your date of birth and then the address on file.
[CUSTOMER][NEUTRAL] [PII] address [PII].
[AGENT][NEUTRAL] Alright, and the Gmail account on file is the [PII] still a good email for you?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this was a claim that you had filed was, it was for [PII]?
[CUSTOMER][NEUTRAL] Yeah, for critical illness, he had a um
[CUSTOMER][NEUTRAL] A brain bleed like a stroke?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check that specific policy. I was under the uh medical plan here. One moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see here.
[AGENT][NEUTRAL] All right, so the recent claim that was submitted it looks like was it Christmas Eve?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause when I first submitted it, they said they needed more information, so I sent them more information like on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it looks like the claim was processed. It shows as of today. It looks like the claim was denied. It's saying that this condition is not covered under this plan.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so
[CUSTOMER][NEUTRAL] But it's a stroke. He had a stubbarachnoid hemorrhage.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let me look at the
[AGENT][NEUTRAL] Policy itself and see if I can find anything here. One second.
[AGENT][NEUTRAL] I'm just waiting on the policy to come up here.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so yeah, let me reach out to um somebody over in claims that processes these because I see exclusions on here but I don't see anything in regards to a stroke. I mean they would, you know.
[AGENT][NEUTRAL] Uh, the exclusions are basically anything not under, listed under the critical illness plan. If it was any sort of treatment, not medically necessary, um,
[AGENT][NEUTRAL] If treatment was received out of the [PII], but I'm assuming that's probably not the case, right?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] No, that's not the case.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. Uh, bear with me. I'm gonna place you on just a brief hold. I'll be right back with you, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you so much for your patience and waiting [PII]. So I'm going to have a claims examiner research this and see if we need additional information or if it was processed incorrectly and then they're gonna reach back out to you. Do you have a good callback number?
[CUSTOMER][NEUTRAL] Yeah, it's um [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so I've sent the claim off for research and somebody will be contacting you back. Um, it may be today, but it shouldn't be longer than 24 hours just in regards to the, uh, claim itself, and if we need additional information then they'll be able to provide you exactly what, uh, to resubmit at that time, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you need me to check on anything else for you today?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] No, it's just that I'm confused because like a subarachnoid hemorrhage, he had a subarachnoid hemorrhage and a subdural hemorrhage. Both are considered strokes. So I'm not understanding, you know, why they're not covering it. Like we were in the neuro ICU and you know, he still has some deficiencies from it. And so I'm not understanding why they're denying it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, yeah, I know definitely I get it um and I did put that all in my notes for the claims examiner so they'll have that information, um, they're gonna be better suited to explain to you exactly why and like I said maybe there's something else you can submit for a benefit payment, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] That sounds good. Thank you.
[AGENT][POSITIVE] You're welcome [PII] thanks for calling [PII]. I hope you have a good rest of your day.
[CUSTOMER][NEUTRAL] You too, ma'am and so they'll just call me back from like the [PII] number?
[AGENT][POSITIVE] Yes ma'am, they'll call you back at this [PII] yep.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome. Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.