AccountId: 011433970860
ContactId: 7a44e3e4-d6a5-48f5-af99-fa010266dba6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 875969 ms
Total Talk Time (AGENT): 495869 ms
Total Talk Time (CUSTOMER): 278571 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/7a44e3e4-d6a5-48f5-af99-fa010266dba6_20250519T21:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[AGENT][POSITIVE] Doing well [PII] thank you how are you?
[CUSTOMER][NEUTRAL] Doing alright thank you. I've got a member on the line who was calling regarding a claim that denied um it is an HI claim and just simply saying it's not a covered loss um she's a little bit, um, irritated uh just kind of wants further information.
[AGENT][NEUTRAL] Sure, what's the policy number [PII]?
[CUSTOMER][NEUTRAL] That is 02560925.
[AGENT][NEUTRAL] OK, just one moment.
[CUSTOMER][NEUTRAL] Yeah, I've got that claim number as well.
[AGENT][NEUTRAL] And is that
[AGENT][NEUTRAL] Uh, OK, go ahead with that callback number.
[CUSTOMER][NEUTRAL] Oh yeah that's uh 443-629.
[CUSTOMER][NEUTRAL] 683 7.
[AGENT][NEUTRAL] OK, and that's for.
[CUSTOMER][NEUTRAL] And it's that claim number ending in uh yeah Kavia um it's the one ending in 9581.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And everything's been verified?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And it's [PII], is that right?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, I can take it from here.
[CUSTOMER][POSITIVE] All right, I appreciate your help thank you.
[AGENT][POSITIVE] You're welcome. Have a good day Kay thank you.
[CUSTOMER][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][NEUTRAL] Hello, Mr. uh Mrs. [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Hi Ms. [PII], my name is [PII]. I'm in the uh claim support team and I understand you had some questions in regards to your claim, uh, that we process for advanced radiology, is that right?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Yes, ma'am.
[AGENT][NEUTRAL] And the date of service was October, uh, looks like [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, and it looks like um they were for some uh screening services uh for your mammogram, is that right?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like the claim denied due to the services aren't covered under this plan. Now, um, are you familiar at all with your plan that you have with us, uh, with the, with this, uh, limited medical, uh, hospital indemnity plan?
[CUSTOMER][NEUTRAL] No, when, when I took the when I took the insurance, ma'am, I was told that I wanted the exactly same coverage that I had earlier, so he said that's what it is. So I was told that's the reason I went for that service, otherwise I wouldn't have gone for that service.
[CUSTOMER][NEUTRAL] The person who told me the who who who gave me that plan is like he said it covers 100% every any every service of mammogram and every service of the, you know, um, further examination.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's the reason and now.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Yeah, well, I'm sorry that you were given, you were, you were given information that's conflicting here um but unfortunately this plan does not allow that screening mammogram under this hospital indemnity plan. Now just give me one moment, I'm gonna look up your policy. Do you know if you signed up for um any additional uh.
[CUSTOMER][NEUTRAL] It does.
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Plans other than this plan that you have with the limited indemnity insurance?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] That's it. I told him that when I took the service, I told him I want 100% no copays, nothing, everything he said that's what it covers, ma'am. That's what he said exactly what you have covers exactly what you have is what he said.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I didn't take anything because he told me that it covers everything.
[AGENT][NEUTRAL] OK, well.
[CUSTOMER][NEGATIVE] Just to send the policy, people are so, so ill informed and they they try to give you misinformation that is so misleading and you know.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Otherwise I would have signed up for some additional additional things so he said I don't need anything.
[AGENT][NEUTRAL] OK, well, again, I'm, I'm sorry that you were given uh information that wasn't accurate for this policy though unfortunately it doesn't have any screening benefits, um, so this service that wasn't covered under the plan due to the fact that it doesn't cover screening services, uh, for, uh, items such as mammograms. It doesn't cover it under this plan, um.
[AGENT][NEUTRAL] Now,
[CUSTOMER][NEUTRAL] Oh my [PII], he said everything is covered. That's the reason.
[AGENT][NEUTRAL] And I don't
[AGENT][NEUTRAL] Yeah, well.
[CUSTOMER][NEUTRAL] And that's the reason I took that. I just uh.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Yeah, I'm not showing any screening benefit under your plan, and I don't show any other plan with us, um, so that's why I was asking if you had a different, uh, an, an additional plan that you might have signed up for in addition to this hospital indemnity because this hospital indemnity plan is very limited in the services that are covered, you know, would cover you in the event of an uh hospitalization or surgery.
[CUSTOMER][NEUTRAL] No.
[AGENT][MIXED] Um, and it has some additional benefits for outpatient, but unfortunately it doesn't cover any kind of screening.
[CUSTOMER][NEUTRAL] OK, so what am I supposed to be doing, man?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] That is well that's a lot for me, you know, it's one of one my one paycheck goes for it. I can't. How can I pay the bills, rest of my bills.
[AGENT][NEUTRAL] Well, I mean you might be able to work um something out with that provider of services that you saw as a you know possibly um letting them know that the car that there's not that this service isn't covered under your plan perhaps they could work with you and and offer a discount because your plan didn't cover the service.
[AGENT][NEUTRAL] Um, I would try reaching out to them and see if there's something they can work with you on because unfortunately like I said, this plan doesn't allow uh screening services for that, uh, procedure.
[CUSTOMER][NEGATIVE] But it said appeal. You can appeal that's what they said even if I appeal, it doesn't work.
[AGENT][NEUTRAL] Well, you are welcome. You're always welcome to appeal, however, just so you're aware the policy doesn't have any benefit for outpatient screening services for that preventative service, so you can appeal it. I can provide you the appeal address.
[AGENT][NEUTRAL] Um, and that information, but unfortunately, like I said, the service, there is no coverage for that screening service, so you, you, um, can also try, like I said, reaching out to that provider to see if they can work with you regarding the services that aren't covered under your plan and possibly offer you a discount or some sort of uh payment uh agreement due to the plan not covering the service.
[CUSTOMER][NEUTRAL] Because that's a lot, man. That's a lot. I don't know why, because I don't know why I was told. I told him that I'm due for a mammogram before I bought this, he said, yes, you are due for a mam mammogram is included colonoscopy is included. Yeahscopy, everything is included, he said.
[AGENT][NEUTRAL] Well, again, I'm sorry you were given, uh, yeah, you were given conflicted information, but unfortunately, the plan that you were signed up with doesn't offer any of those screening services, um, for, you know, for those cancer screening like the mammogram and um those types of services that are, um, again preventive, what we consider preventative services.
[CUSTOMER][NEGATIVE] That's too bad.
[AGENT][NEUTRAL] Would you, um, would you like me to provide you the PO address?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] No, it says, uh, nothing is covered, so any of the service is not covered if it just a mammogram is not covered.
[AGENT][NEUTRAL] Well, any like they said, the pre the preventative service such as the mammogram, like I said, the policy does allow some benefits for outpatient services and then it's also an inpatient um uh plan, you know, services, some inpatient services when you're confined to the hospital and there's room and board charges, um, there is some outpatient benefits under the plan.
[AGENT][NEUTRAL] Um, as far as like uh surgery and um outpatient visits to an emergency room or urgent care facility. However, like I said, there's no screening service or preventative services that are allowed under the plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I paid 270 months. How much does the process, uh, the service that has, uh, that is with pro with the screening services cost me?
[AGENT][NEUTRAL] Um, then I wouldn't be able to answer you because you're, you're asking if there's an additional plan you could sign up for.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yeah, well, actually I don't show your, your policy is active any longer. Were you signed up through your um employer?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, no, no, I did not sign up. I bought it privately outside of my employer because because I didn't have a job that time.
[AGENT][NEUTRAL] I see, OK.
[AGENT][NEUTRAL] Well, um, yeah, the the policy is no longer active, so you would have had to when you before you cancel the policy if there was portability allowed in order to um continue coverage you would have had to elect that portability option, um, but I show that the policy is no longer active effective um [PII].
[CUSTOMER][NEUTRAL] Yes, OK.
[AGENT][NEUTRAL] Did, did you have any?
[CUSTOMER][POSITIVE] Thank you so much. So what is the next uh next uh option?
[AGENT][NEUTRAL] Well, um, Miss [PII], like I said, that you can, you, you're welcome to appeal it. However, like I said, the service is not, you know, the screening service is not covered, but I can provide you our appeals address or like I said, I could suggest contacting that provider's office.
[CUSTOMER][NEUTRAL] What is the next I have?
[AGENT][NEUTRAL] And letting them know that you selected a plan that unfortunately um you were told that it would cover these services but it didn't cover the screening. So you can ask them, like I said, if they would be willing to offer a discount to you since your insurance didn't cover the service.
[CUSTOMER][NEGATIVE] Why don't you give me at least 50%, ma'am? Why don't you pay at least 50%?
[AGENT][NEGATIVE] Unfortunately, ma'am, we can't do that because the policy doesn't, the policy benefit doesn't allow for that service. So unfortunately, it cannot be covered.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm mm mm.
[CUSTOMER][NEUTRAL] That's a lot.
[AGENT][NEUTRAL] Would you like the appeals address so you can send an appeal?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yeah, give me the IP address.
[AGENT][NEUTRAL] OK, and what you wanna um do is make sure that you mark the the request as an appeal.
[AGENT][NEUTRAL] Um, you'll wanna send any supporting documentation so if you have information, you know that you were given in regards to the service being covered, you'll wanna include that any supporting documentation and you're gonna send it to us at.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] How can I have supporting document, ma'am? I just spoke to him on the phone. I just spoke to him on the phone. I don't have any supporting documentation.
[AGENT][NEUTRAL] Pardon me?
[AGENT][NEUTRAL] OK, well I was just letting you know that if you had any you could you could send it along with your appeal request.
[AGENT][NEUTRAL] If you don't have it, you don't have it.
[CUSTOMER][NEUTRAL] I have the phone number.
[CUSTOMER][NEUTRAL] So I have the phone number of the person that I spoke to.
[CUSTOMER][NEUTRAL] Is it, will that be enough?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Well, if, well if you don't have any, again, if you don't have any uh additional information you just wouldn't include it, but you would wanna um you would wanna mark it as an appeal and then give the reason for why you're requesting the appeal.
[AGENT][NEUTRAL] And then you're gonna mail the mail that request to us at APL.
[AGENT][NEUTRAL] And it's [PII].
[CUSTOMER][NEUTRAL] OK OK.
[AGENT][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's [PII]?
[AGENT][NEUTRAL] [PII], uh-huh, and then the zip code [PII].
[CUSTOMER][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] Can you say the zip code again, ma'am?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] Can you tell the
[AGENT][NEUTRAL] [PII] and then [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you, did you have any other questions, Ms. [PII]?
[CUSTOMER][POSITIVE] That's it for now. Thank you.
[AGENT][POSITIVE] You're welcome thank you for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] Bye bye.