AccountId: 011433970860
ContactId: 7af7a29c-3c76-4e2e-ae74-e154f91df368
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1247459 ms
Total Talk Time (AGENT): 623346 ms
Total Talk Time (CUSTOMER): 158094 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/7af7a29c-3c76-4e2e-ae74-e154f91df368_20250121T17:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], um, I need to speak with someone about my claim not being processed due to payment or something like that.
[AGENT][POSITIVE] Sure, I'd be happy to help you with that claim inquiry. Can I have your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And Ms. [PII], can I please have a callback number in case we get disconnected please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and Miss [PII], do you have your policy number handy or need me to look it up?
[CUSTOMER][NEUTRAL] Um, yeah, I don't know the policy number.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Just give me one moment please.
[AGENT][NEUTRAL] Are you in a safe place you could provide your social security number and I can look you up like that.
[CUSTOMER][NEUTRAL] Yes, [PII] I'm I'm sorry [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And I'm gonna have you verify some information if you don't mind, please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, and the mailing address please.
[CUSTOMER][NEUTRAL] Welcome.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, and that last piece of verification, your email address please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And um was the claim for yourself or for uh another family member?
[CUSTOMER][NEUTRAL] For my son.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just bear with me for one moment.
[AGENT][NEUTRAL] This is for [PII], is that right?
[CUSTOMER][NEUTRAL] [PII], yeah.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] It looks like it's pending uh.
[AGENT][NEUTRAL] Bear with me for just one moment while I check some information.
[AGENT][NEUTRAL] It looks like I have it under the hospital indemnity for a service date of [PII], is that right?
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] OK, it looks like I've got an internal, uh, excuse me, a pending code for premium.
[AGENT][NEUTRAL] Um, because it's the January data service, we, um, didn't have the premium posted as of yet, um.
[CUSTOMER][NEUTRAL] So that's the issue that I have. I mean my payments are automatically drafted from my bank account, so.
[AGENT][NEUTRAL] I'm not
[CUSTOMER][NEUTRAL] Uh, when it's due, it's paid and it's automatically drafted, so I don't understand what they mean by premium.
[AGENT][NEUTRAL] Yeah, let me check and see um.
[CUSTOMER][NEUTRAL] And, and I also have a question um once you're done checking whatever it is.
[AGENT][NEUTRAL] And it also looks like let me just check some information here because I think.
[AGENT][NEUTRAL] So I'm looking at the claim um and so when you say it was deducted so you're is it's your your payroll deduction is that what you mean?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] No, it's automatically draft I pay it myself and it's drafted from my bank account every month.
[AGENT][NEUTRAL] Oh, I see. OK, so you're a self pay, yeah, let me check on that. Uh, my apologies, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I believe my draft date is maybe the [PII] of every month. I'm not sure. And I mean, if it needs to change, because this is like the 2nd time that they've like held processing a claim because of payment.
[CUSTOMER][NEUTRAL] But if it was an issue with the date I chose, then it's been that way for a year now.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well, I'm actually looking at some additional information um that tells me that we could have uh processed through this claim.
[AGENT][NEUTRAL] Now, um, the adjuster that uh has the claim pending is not in the office today she will be back tomorrow, so what I can do is send a message to her and let her know that this claim can be uh processed through and finalized um because you do have um.
[AGENT][NEUTRAL] You do have what we call a grace period that's built into your policy so I'm not certain why the claim was ended, um, because we do show I do show that it could be eligible so um like I said, what I can do is send a message and, and, and request her to go ahead and process through this claim um because I don't see, um, I don't see what she saw as the you know, I can't.
[AGENT][NEUTRAL] I can't speak on that unfortunately um because I believe that the claim should be eligible to be processed through um so I can send a message and request that she uh go ahead and get the claim processed and like I said she'll be back in the office tomorrow, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you said you had another question?
[CUSTOMER][NEUTRAL] So my son had a heart transplant.
[CUSTOMER][NEUTRAL] And he is currently in rejection, so I, which, you know, means his body is now rejecting the heart. I don't know if that is considered to be as major organ failure or
[AGENT][POSITIVE] I'm sorry to hear that.
[CUSTOMER][NEUTRAL] Um, like I don't know what they're reviewing, like what she's has it pending as or what she's has it pending paying for, like, how do I find that out and what information would I need to provide?
[AGENT][NEUTRAL] So the for this particular claim we're speaking of, is that right?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, because I'm looking at it actually looks like we, we, that first claim form was on a wellness claim form and it showed a chest X-ray. So that's what I'm looking at now. So now I'm.
[AGENT][NEUTRAL] So he was seen in the emergency room. I'm not.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let me look at that information.
[AGENT][NEUTRAL] And so the chest X-ray was part of the emergency room visit, is that correct?
[AGENT][NEUTRAL] This was all done on [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So right now it looks like it's pending under that um physician fee. Um let me look at this other claim form just bear with me for one moment because it looks like we received a couple different mail. So he had an EKG and a chest X-ray in addition to the emergency room visit, is that right?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so unfortunately, the chest X-ray um and the electrocardiogram are not covered under the hospital indemnity. Um, however, it would be covered for the um emergency room visit.
[AGENT][NEUTRAL] And I don't believe you had, so this is the new calendar year, so.
[AGENT][NEUTRAL] Let me just check on that.
[AGENT][NEUTRAL] OK, so it looks like it should be eligible for that emergency room care under that particular benefit under your hospital indemnity. Um, however, like I said, the EKG and chest X-ray are not uh covered under the um benefit plan.
[AGENT][NEUTRAL] So there are certain uh.
[AGENT][NEUTRAL] Diagnostic testing uh benefits that may or may not be covered based on your policy. However, um, there are major diagnostic tests and then there's some additional follow up, uh, advanced study tests, but EKG and chest X-ray are not part of that diagnostic testing benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So again, it would be eligible for that emergency room um visit, and he wasn't admitted to the hospital, is that right? It's just an outpatient emergency room visit?
[CUSTOMER][NEUTRAL] Yeah, because they said there's nothing more they can do, so they didn't admit them.
[AGENT][POSITIVE] I'm sorry to hear that.
[AGENT][NEUTRAL] Yeah because this policy would, like I said, if it it was an event of a hospitalization, then those benefits may be able to be reviewed, but based on um the uh notes from the emergency room, it looks like it's, it would just be fall under that emergency department or emergency room visit.
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, um.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Did you have any additional questions?
[CUSTOMER][NEUTRAL] Well, um, again, he's in rejection and so I, I don't know what information I would need to provide, um, and is that considered major organ failure.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] So unless he's hospitalized, I don't see anything under that hospital indemnity, but let me check under um under some your additional policy so bear with me for just a moment.
[AGENT][NEUTRAL] I'm gonna look at your um additional policy so bear with me for just a moment while I do that. I have to go under each one individually so may take a couple minutes here.
[CUSTOMER][NEUTRAL] Yeah, I think that's under critical illness if I'm not mistaken, um.
[AGENT][NEUTRAL] That's what I'm reviewing now.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so under um I pulled up your critical illness, so I'll read you what's in the policy just to let you know it is a verification of the coverage, not a guarantee of payment. So it states under the um critical illness under the major organ failure. Um, it states that failure or loss of one or more of the following organs, liver, heart, lung, or pancreas, for which a surgeon, uh, I'm sorry, a physician recommends a surgical transplant of a human organ.
[AGENT][NEUTRAL] The definition does not include transplants involving nonhuman organs. The surgical requirement is waived if the covered person is too ill to go undergo surgery, but surgery or replacement under the United Network of organ share and the you know list would otherwise be recommended due to organ failure, um.
[AGENT][NEUTRAL] So what um
[AGENT][NEUTRAL] And did we have a previous claim um for the?
[AGENT][NEUTRAL] Organ failure?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Or no, OK, alright, there's a lot of claims here, so I just wasn't sure. I thought I would just ask you. So what you'd wanna do then is go ahead and provide, um, you could uh complete that critical illness claim form.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, it looks like you do have an active, um, online service, uh, account, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you would wanna go ahead and complete that claim form and then include um.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So under that critical illness, uh, I believe, let me pull up, let me pull up a claim form.
[AGENT][NEUTRAL] So you wanna go ahead and provide like that um proof of loss so what that would consist of is um.
[AGENT][NEUTRAL] Either some billing documents or um some medical records that would indicate what's going on with the um.
[AGENT][NEUTRAL] We need that proof of loss.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So that would be like I said any um billing or medical record documentation that shows um what's going on with the um actual.
[AGENT][NEUTRAL] Um, you know, services that are needed or with that illness. So, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You wanna complete that critical illness claim form that will be out there on the SharePoints, uh, I'm sorry, on the um Internet on the online service portal that claim form will be um listed out there for you. Let me just pull one of them up.
[AGENT][NEUTRAL] OK, so on that um instruction page on that first page, um, it does give you it tells you to complete the, uh, statement of the insured, um, and then you want to complete section G on the claim form and then you'd want the following uh benefits require supporting documentation, um, for services covered under your plan, um, that would be like the attending physician statement.
[AGENT][NEUTRAL] Um, you may, it, it also states that you may, uh, for a first time diagnosis or additional diagnosis or recurrent depending on your specific plan. So this would be that initial, um, and then like I said, you'd wanna complete, have the physician complete that statement on that critical illness form. It does ask the information about the insured and then about the patient, and then it asks about the critical illness or condition. You'll wanna fill out that section.
[AGENT][NEUTRAL] Um, and then on the, uh, let's see, there's an authorization page and then there's attending physician, uh, statement that can be used in lieu of that, um.
[AGENT][NEUTRAL] Proof of loss, meaning that billing. So if you don't really necessarily have anything cause you said he wasn't hospitalized, but you know, what's going on with this it would require them that uh a pending physician statement to let us know um exactly what uh what the diagnosis and prognosis is.
[CUSTOMER][POSITIVE] Got you.
[AGENT][POSITIVE] And I'm really sorry to hear about that. That's, it's a scary situation. My you know, my sympathies for you.
[AGENT][NEUTRAL] Did you have any additional questions, Ms. [PII]?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Um, no, that, that's it.
[AGENT][NEUTRAL] OK, and like I said, I will go ahead and send a request over to the adjuster. Like I said, she'll be in the office tomorrow and we'll have her, um, you know, reexamine that claim, uh, that you sent in for that emergency room visit and we'll get that processed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and my apologies I'm not sure why uh.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Like I said, I'm not certain as to why it was pended it should've looks like it should have been processed through, but we'll get it taken care of.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] OK, you're welcome, Miss [PII]. Thank you for calling APL and good luck with your son's, uh.
[AGENT][NEUTRAL] Prognosis.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You have a great day and thank you so much for calling APL.
[CUSTOMER][NEUTRAL] You as well.
[AGENT][POSITIVE] Bye bye thank you.