AccountId: 011433970860
ContactId: 71dccb3d-9920-4daf-8079-0ce4239e9c75
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 479290 ms
Total Talk Time (AGENT): 316798 ms
Total Talk Time (CUSTOMER): 120060 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/24/71dccb3d-9920-4daf-8079-0ce4239e9c75_20250624T13:09_UTC.wav
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[AGENT][NEUTRAL] Morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I was calling to check on the status of my claim.
[AGENT][NEUTRAL] OK, you're the insured and you're wanting to check claim status, is that correct?
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][POSITIVE] Yes, ma'am, I can help you with that. And who am I speaking with, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, Ms. [PII], what is a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number?
[CUSTOMER][NEUTRAL] 02589560
[AGENT][NEUTRAL] Thank you. One moment while I get your information pulled up.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. And once I do get that pulled up, Miss [PII], I will have to verify several things with you first for security and also any information that is provided would be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And then I'll see your home mailing address please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Cav and love.
[CUSTOMER][NEUTRAL] Uh, sorry, then I'm
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one that you provided for me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, thank you. And lastly your email address, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Now, I can see Ms. [PII], that you had been set up in the online service center portal where you can log in for your information.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Now, over the last few weeks, there has been an update to the portal, so you will have to set up a new profile. Have you done that yet?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Yes, I set up a new profile and I just thought I see I can.
[AGENT][NEUTRAL] You did, OK.
[CUSTOMER][NEUTRAL] I can see online where it says process I think I just don't know what that means so I was just trying to call to talk with someone and hopefully get a better idea.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, no, no worries. I just wanted to make sure that you were aware that you did have to create a new profile because a lot of people, um, if you already had an existing one, you had to, you know, didn't realize they just thought there was something wrong with the system and not being able to log in. So, OK.
[CUSTOMER][NEUTRAL] Yeah, at first I didn't.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, at first I wasn't aware of that, but then someone did tell me a couple weeks ago, so I was able to at least set it up.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, good. OK. All right. So I do see that there was a claim that was went through our nightly processing actually last night. So, give me just a moment to get that pulled up. Now, I can see that this claim has been denied, Ms. [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So give me a moment to pull the remark and it's kind of long now just for your information you should be able to see this explanation of benefits with these remarks that I'm going to read to you because it is lengthy but that will probably be available in your portal this afternoon later if not for sure by tomorrow because when it's.
[AGENT][NEUTRAL] Once it goes to the overnight processing it just takes a little while for you to be able to see this, OK, so that's why you can't at the moment. Alright, so the remark again it's, it's lengthy but I'm gonna read it to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Pre-existing condition as defined in section 4 of your policy means disease, injury, sickness, physical condition, or mental illness for which received treatment, incurred expense, took medication, received care, or services including diagnostic testing or related measures, or received a diagnosis or advice from a physician.
[AGENT][NEUTRAL] During the period immediately before the effective date of your coverage. No disability will be payable if disability is caused by or resulting from a pre-existing condition.
[AGENT][NEUTRAL] The limitation will not apply to a disability resulting from a preexisting condition that begins after you have been continuously covered under the policy for 12 months. Based on the claim documentation, the current condition was determined to be a pre-existing condition and no benefits are payable.
[CUSTOMER][NEUTRAL] What, what exactly does that mean? Because I know my company, we had a different insurance, but I've been paying insurance part of my job two years ago because I know for a pregnancy, hang on one moment, I need to open my door.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] That you have to have been covered for 10 months, um, and we had to change our policy, I think in January, but I was assured that it would be.
[CUSTOMER][NEUTRAL] Covered because that is basically just like the.
[CUSTOMER][NEUTRAL] Company changed, I think, I believe, um, I'm not quite understanding why I would be denied.
[AGENT][NEUTRAL] So that is why, because any condition, you would have to be covered for 12 months under this policy.
[AGENT][NEUTRAL] For it to not be considered pre-existing if it was an existing condition that you would receive treatment for prior to your policy becoming effective and being active for 12 months.
[CUSTOMER][NEUTRAL] OK, so do I need to then, so then do I need to reach out to whoever helps with our insurance because I did not choose, I did not change our policy. It was them and I was.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Assured that it would not affect my coverage.
[AGENT][NEUTRAL] Yes ma'am, I would, you can do that, yes, now, um, that is what I would recommend. You also do have the right to file an appeal on this decision, Ms. [PII]. The appeal must be filed within 180 days from the date of the decision.
[AGENT][NEUTRAL] Um, but yes, you can also reach out to your HR department and then they can, you know, put you in contact with the agent or.
[AGENT][NEUTRAL] Whomever you would need to speak to regarding any information they have given you prior to this policy going into effect.
[AGENT][NEUTRAL] But you can see that verbiage also that I read to you in section 4 of your policy.
[AGENT][NEUTRAL] With those timelines and, and that definition.
[AGENT][NEUTRAL] And again, this explanation of benefits, you know, it should be viewable to you as well this afternoon in your portal and the remarks are always on page 2 of the explanation of benefits.
[CUSTOMER][NEUTRAL] OK, well, I guess I'll have to.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, I guess I'll have to reach out because it was not my decision to change policies and but I was assured that it would not affect coverage so clearly that was false.
[CUSTOMER][NEUTRAL] Because when is it saying my effective date is? I think it was the beginning of the year.
[AGENT][POSITIVE] Yes, ma'am, and I'm sorry.
[AGENT][NEUTRAL] Yes, ma'am. It shows that your policy went into effect. I believe it was, uh, yes, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, well then, well thank you I I guess I'll reach out to them and figure out.
[AGENT][NEUTRAL] OK. Well, is there anything else uh that I could help you with at the moment, Miss [PII]?
[CUSTOMER][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] No, I think that's it.
[AGENT][POSITIVE] OK. Well then, thank you again for calling APL and I do hope you have a very nice day.
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] Yes, ma'am. Thank you as well.
[CUSTOMER][NEUTRAL] Alright bye.
[AGENT][NEUTRAL] Bye-bye.