AccountId: 011433970860
ContactId: 78f9e908-cd82-463c-9afb-0beeb0df8e1e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 545760 ms
Total Talk Time (AGENT): 203923 ms
Total Talk Time (CUSTOMER): 191605 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/78f9e908-cd82-463c-9afb-0beeb0df8e1e_20250221T19:18_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. Uh, I need to have a little bit more information about an explanation of benefits for policy number 02541023.
[AGENT][NEUTRAL] All right, [PII], I can assist you with that. Can I please have a callback number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Can I please have your date of birth, address, and email address, please?
[CUSTOMER][NEUTRAL] My date of birth is [PII]. Address is [PII].
[AGENT][POSITIVE] Well, thank you so much for verifying the information. And um is this on your spouse?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] I have that policy pulled up. How can I assist you today?
[CUSTOMER][NEUTRAL] On the explanation of benefits on the claim that I submitted on section 3 on the last page.
[AGENT][NEUTRAL] Alright, one moment while I pull up the explanation of benefits.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yes, section. What was the section you said?
[CUSTOMER][NEUTRAL] So it was section 3. So if you go on the very last page of that explanation of benefits, there's the little postmarks of the reason for the denial. There's 12, and 3.
[AGENT][NEUTRAL] But the specified disease?
[CUSTOMER][NEUTRAL] I'm, I'm sorry, did you, what did you say?
[AGENT][NEUTRAL] About the um, the coverage of the specified disease?
[CUSTOMER][NEUTRAL] Yeah, where it says the preexisting condition will be payable after 12 months.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Does that mean that once the policy is in effect for 12 months, I have to reapply for to get benefits?
[AGENT][NEUTRAL] OK, so let me see when this policy was effective.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] 91
[AGENT][NEGATIVE] And this was not.
[AGENT][NEUTRAL] No takeover. OK. So that means that um the diagnosis was before the effective date of this policy, which that means that we will not cover any benefits until [PII].
[CUSTOMER][NEUTRAL] OK, so what do I do on [PII]? Do I have to reapply?
[AGENT][NEUTRAL] Well that means
[CUSTOMER][NEUTRAL] They have to redo the the claim again?
[AGENT][NEUTRAL] So that means that we would not cover anything. So, um my 1 of 25.
[AGENT][NEUTRAL] If he is still receiving.
[AGENT][NEUTRAL] Um, treatment, then we will cover treatment for [PII] from [PII] on. Anything prior to [PII] would not be covered.
[CUSTOMER][NEGATIVE] So basically you guys are not going to cover anything cause when I first applied, the lady that I spoke to told me that there was a 3 month right because I told her I said he gave treatment until after [PII], but he knows before [PII], and she told me, well, that's OK because there's a 3 month rider on it.
[CUSTOMER][NEGATIVE] And that's why I applied, but now they're telling me that there's no such thing.
[AGENT][NEUTRAL] Yeah. You cannot have been diagnosed or received treatment, diagnosed or anything prior to the effective date. If you have, then that means that you will have to wait um a one year before benefits will be payable.
[CUSTOMER][NEUTRAL] And so he has to be undergoing treatment, and what does that specifically mean? Because the treatment that he's had is is is done. We're not expecting any treatment, but he still is going for checkups.
[CUSTOMER][NEUTRAL] He'll be going for checkups for the next, until he's, until he's dead. He, they told him his lifetime.
[AGENT][NEUTRAL] OK. So while I pull up your benefits, it's a verification of your coverage, not a guarantee for payment. So that means that if there's any more radiation, chemo or immunotherapy after [PII].
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Any diagnostic, uh, medical imaging after [PII].
[AGENT][NEUTRAL] Um, surgy.
[CUSTOMER][NEUTRAL] Well, diagnostic, they, he will have, he has to have a uh a PET scan every 3 months for the next 5 years.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Medical imaging, any type of surgery, anesthesia, any um
[AGENT][NEUTRAL] Transportation that's within.
[AGENT][NEUTRAL] Transportation is only covered for surgery, radiation, chemo, immunotherapy, um, any lodging, 50 miles or more, any ambulance. So all of the benefits that come with it, if he has any of those type of treatments or anything, imaging, anything after [PII] of this year will be covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And so do I have to do the whole thing again or do I just submit the imaging?
[CUSTOMER][NEUTRAL] When he gets it.
[AGENT][NEUTRAL] So, um, after that [PII], if there's any uh payable benefits, then you will submit to us the itemized billing for that.
[CUSTOMER][NEUTRAL] For the imaging. Now, does that still cover, I think there was like a one-time benefit.
[CUSTOMER][NEUTRAL] Is that, that's not going to be the case?
[CUSTOMER][NEUTRAL] After [PII].
[AGENT][NEUTRAL] You talking about the um
[AGENT][NEUTRAL] The lump sum benefit for being diagnosed with cancer?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] No, cause he was diagnosed prior to being effective. The only time that that will come into play is if he's diagnosed with another type of cancer.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] Mm, unfortunately, that's a possibility.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much.
[AGENT][NEUTRAL] Alright, is there anything else, [PII] I can help you with? Go ahead.
[CUSTOMER][NEUTRAL] And now, well,
[CUSTOMER][NEGATIVE] I was like I said, I was just confused on why she said there was a 3 month writer on that one that's not the case.
[AGENT][NEUTRAL] Um, I'm not sure.
[CUSTOMER][NEGATIVE] Cause I wouldn't have filed, I wouldn't have filed if she hadn't have said that, cause she, cause I, I had mentioned to her, I said we didn't start treatment until after, but we were diagnosed before and that was only um after I had applied for it. I didn't even know he had cancer when I applied for this policy, um.
[CUSTOMER][NEUTRAL] And she said that's OK, that's covered.
[CUSTOMER][NEUTRAL] And she specifically said 3 months.
[AGENT][NEUTRAL] And who, I mean, who are you speaking of?
[CUSTOMER][NEUTRAL] Whoever I spoke to, whoever I spoke to here at APL, the very first, very first phone call I did.
[AGENT][NEUTRAL] Yeah, the policy states you have a preexisting condition period of 12 months.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] 3 months. I'm trying to figure, look at the policy and see what 3 months is at, but.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And that
[AGENT][NEUTRAL] I'm not sure what the 3 months comes in it, but.
[AGENT][NEUTRAL] That is, you know, the certificate, um, schedule of benefits clearly states on here.
[AGENT][NEUTRAL] It's a 12 month um uh pre-existing period.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] That's great. OK.
[CUSTOMER][POSITIVE] Thank you so much. Have a good day.
[AGENT][POSITIVE] Mhm. Thank you for calling APO. Have a good day. Bye bye.