AccountId: 011433970860
ContactId: 7457e84d-e0d6-4ecb-95c9-c40bb2955250
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 826940 ms
Total Talk Time (AGENT): 313662 ms
Total Talk Time (CUSTOMER): 259578 ms
Interruptions: 2
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/7457e84d-e0d6-4ecb-95c9-c40bb2955250_20250609T18:10_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII], and I submitted a claim earlier this year, and you guys requested more information and then I just provided that and you did give me a payment, but I don't think it was enough.
[CUSTOMER][NEUTRAL] I don't think it was, so I might have gotten something confused, but I actually had two surgeries and I was expecting an anesthesia benefit payment and then I had um a full hysterectomy and it was due to cancer, so I think I only got like 300 bucks and I'm like, no, I think it needs to be more than that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, let's look at the claim. Do you have the claim number, policy number? What do we have [PII]?
[CUSTOMER][NEUTRAL] Oh, let's see here should be on something I have, right? um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] If you can't find it,
[CUSTOMER][NEUTRAL] Well I'm looking at the letter
[AGENT][NEUTRAL] I was gonna say I could.
[CUSTOMER][NEUTRAL] It's not on there.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, I probably can look at oh here we go um.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] I'm looking at my claim form so is it on here somewhere?
[AGENT][NEUTRAL] Um, if you send.
[CUSTOMER][NEUTRAL] Oh well, it asked for my social, yeah, I gave my social.
[AGENT][NEUTRAL] Oh, OK. I can look it up by that. Yeah, if you don't mind giving me that.
[CUSTOMER][NEUTRAL] Can you look it up that way?
[CUSTOMER][NEUTRAL] That's fine it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. Give me just a moment here.
[AGENT][NEUTRAL] All right, [PII], I believe I got you pulled up here. Let me just verify your last name and date of birth, please.
[CUSTOMER][NEUTRAL] OK. It's [PII], and my date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And then lastly, I just need to verify the address, uh, physical, and then your email.
[CUSTOMER][NEUTRAL] Uh, my home address is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And my email is uh.
[CUSTOMER][NEUTRAL] Well, is it my personal email or my business?
[AGENT][NEUTRAL] Looks like it's S [PII].
[CUSTOMER][NEUTRAL] Oh yeah, uh IAC that's my business.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so let's see, let me pull up the last claim process and see what it says here.
[AGENT][NEUTRAL] OK. So on the surgery portion, it looks like it does state that it paid the maximum benefit for the date of service.
[CUSTOMER][NEUTRAL] OK, what, because I had 2. I had one in December. I had a surgery in December and then I had to do surgery in January.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So I show a surgery [PII], and then there's one, it says service date was [PII].
[CUSTOMER][NEUTRAL] Yeah, that mm.
[CUSTOMER][NEUTRAL] [PII], uh, that was, that was stitches. That's different. I had an accident claim and I cut myself and I had stitches. So maybe that's what I got paid on and I didn't get paid on for the other stuff yet.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, so I don't see anything on the claim for like a January date of service.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] Just shows [PII].
[AGENT][NEUTRAL] And then there was one in September also.
[CUSTOMER][NEUTRAL] OK. Well, so you don't have one for my surgeries?
[AGENT][NEUTRAL] The only surgery dates that we, yeah, the only surgery dates that we have would just be the [PII], and [PII]. So if you had an additional
[CUSTOMER][NEUTRAL] Cause that's, that's
[CUSTOMER][NEUTRAL] Well, [PII].
[CUSTOMER][NEUTRAL] I mean that one we could, we could go with because that was um that was when they did a surgery for the biopsy and that is also a a separate claim, that's a different one, right? Um I think I saw this on here.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] Right. So when, when they did a um a biopsy for cancer, right? That, that should have been for um
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] The [PII].
[AGENT][NEUTRAL] OK. So both of the surgery dates that we have show that that was the max benefit for the date of service in regards to the surgery.
[CUSTOMER][NEUTRAL] OK, so you're not, you don't see one for January because I, I submitted one I thought for January that's when I had my.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, complete hysterectomy for cancer. So that would explain why it didn't add up to what I thought it was because I was expecting to get a payment for that and for the anesthesia. But what, can you explain what was paid for the [PII]?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So for the [PII], they paid um do you want the exact amount I can go back and look here.
[CUSTOMER][POSITIVE] Yeah, that would be good.
[AGENT][NEUTRAL] OK, right, so let's see.
[AGENT][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] Anesthesia paid for 1216 24.
[AGENT][NEUTRAL] The benefit payment shows $69.40.
[AGENT][NEUTRAL] And then the
[CUSTOMER][NEUTRAL] Why would it be so little?
[CUSTOMER][NEGATIVE] That doesn't seem right.
[AGENT][NEUTRAL] So the surge
[AGENT][NEUTRAL] The surgical benefit amount is 25% of the surgical benefit amount.
[AGENT][NEUTRAL] So, the max benefit on the surgical benefit is 4000. And so it would have been based off of what they sent 25% of that. Give me just a second.
[CUSTOMER][NEUTRAL] Well, that's 25% of that's a lot more than $69.
[CUSTOMER][NEUTRAL] Are you looking into it?
[AGENT][NEUTRAL] Yeah, I'm looking to see what the amount is here.
[AGENT][NEUTRAL] Of the surgical benefit amount. OK, so what do they pay on the benefit amount?
[AGENT][NEUTRAL] So on the surgery, it looks like the benefit payment was 277.60 for [PII]. That's where they're getting the 6940 for the 25% of that.
[CUSTOMER][NEUTRAL] OK, where are they getting that surgical benefit amount? Where does that come from?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So let me go into the policy and see how that's paid out exactly. Give me just a second.
[CUSTOMER][NEUTRAL] Because it's supposed to be $4000.
[CUSTOMER][NEUTRAL] And 25% of the paid surgical benefit is the anesthesia.
[CUSTOMER][NEUTRAL] Right?
[AGENT][NEUTRAL] So it pays on the anesthesia benefit. It pays 25% of whatever the benefit amount was paid for the surgical amount.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's where they were getting that number right.
[CUSTOMER][NEUTRAL] So that's where they're getting the $69. OK, OK. So uh where did they come up with $277?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] That's what I'm looking for right now.
[CUSTOMER][NEUTRAL] Cause I'll tell you what, that one surgery may max out my um.
[CUSTOMER][NEUTRAL] I mean my deductible for the year, right then, you know, like I paid over $80 for that.
[CUSTOMER][NEUTRAL] Of that stuff.
[AGENT][NEUTRAL] So it looks like it's based off of the actual procedure.
[CUSTOMER][NEUTRAL] Oh, that's if there's a bar now.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] And you said it was a hysterectomy?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me see here.
[AGENT][NEUTRAL] Cause on the surgical benefits, it lists all the surgeries covered and the percentages it pays. So I gotta figure that out here. I'm not very good at math. Give me just a second.
[CUSTOMER][POSITIVE] She was fine.
[CUSTOMER][NEUTRAL] I mean it says 50%, right?
[AGENT][NEUTRAL] No, it, well, it lists all these different surgeries that are covered and they're all different percentages.
[CUSTOMER][NEUTRAL] Right. And uh hysterectomy, radical for cancer, including lymph nodes, says 50%.
[AGENT][NEUTRAL] I see that one and then the one above it says 30.
[CUSTOMER][NEGATIVE] Well, either way, that's way off.
[AGENT][NEUTRAL] Yeah I'm wondering if it has to do with maybe the procedure code that they sent over for it.
[AGENT][NEUTRAL] Um, what I can do on this, Shannon, if you want is reach out to the examiner, have them relook at this, and then give you a call back on it, um, if you want, or I can contact somebody in claims if you don't wanna call back on it.
[AGENT][NEUTRAL] Um, because I see the same things that you do. I'm just.
[CUSTOMER][NEUTRAL] No, that's fine. Somebody can.
[CUSTOMER][NEUTRAL] Yeah, somebody can call me back that's fine.
[AGENT][NEUTRAL] OK, what's a good call back number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. [PII].
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, now in regards to the January date, I don't, I do not see anything for that, so I don't see that we ever got anything for January, so you can still, of course, submit that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I do, yes, I, I need to do that because I wonder what happened. I, I was pretty sure that I included it all at the same time, but I will, I'll go back and make sure I get that submitted.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. OK. Um.
[CUSTOMER][NEUTRAL] Um, and then let me know what you find out about that other.
[AGENT][NEUTRAL] Yeah, so I'll just put in detail like I'll I'll put a snippet of what we saw in the in the policy and just the claim number and you know um if it's something with the way it was coded um maybe you know it can be resubmitted correctly if it was an error uh for an additional payment and so yeah, somebody will call you back on that.
[CUSTOMER][NEUTRAL] Because it definitely was a full.
[CUSTOMER][POSITIVE] OK, sounds good.
[AGENT][POSITIVE] Anything else, [PII]? Yeah, no worries. Have a good day.
[CUSTOMER][POSITIVE] Thank you I appreciate it.
[CUSTOMER][NEUTRAL] No, I'll get the other one submitted too. Alright, bye bye.
[AGENT][NEUTRAL] OK.