AccountId: 011433970860
ContactId: 8029036b-3a59-4f93-bbf0-d6c43426dcd9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1260760 ms
Total Talk Time (AGENT): 739039 ms
Total Talk Time (CUSTOMER): 387571 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/8029036b-3a59-4f93-bbf0-d6c43426dcd9_20250224T15:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. How are you doing?
[AGENT][POSITIVE] I'm good how are you [PII]?
[CUSTOMER][POSITIVE] I'm doing fine on this wonderful lovely Monday.
[CUSTOMER][POSITIVE] Hey, at least we're blessed enough to have a job, right?
[AGENT][POSITIVE] That's right. That's right.
[CUSTOMER][NEUTRAL] Listen, I've got a Mr. [PII] on the line. His policy number is 255.
[CUSTOMER][NEUTRAL] 9445
[CUSTOMER][NEUTRAL] Now he's calling to check his.
[CUSTOMER][NEUTRAL] Um, claim status.
[CUSTOMER][NEUTRAL] And we were going over and you know I was stating that we need to have something indicating that it was for an accident.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Now, he also has an accident policy and everything is, he had to have rotator cuff due to his accident.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But now his
[CUSTOMER][NEUTRAL] Accident
[CUSTOMER][NEUTRAL] Claim was denied.
[CUSTOMER][NEUTRAL] Um, wait a minute, let me make sure I'm looking this right policy um.
[CUSTOMER][NEUTRAL] It was denied as non covered the date of his accident.
[CUSTOMER][NEUTRAL] was
[CUSTOMER][POSITIVE] Wait a minute what? Hang on, I'm so sorry.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] Prior to.
[CUSTOMER][NEUTRAL] Insured's effective date, the date of the accident was [PII].
[AGENT][NEUTRAL] Hm, I don't make no sense, does it?
[CUSTOMER][NEGATIVE] No, no, no.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] That just hit me.
[AGENT][NEUTRAL] 1:15 to 1:[PII].
[AGENT][NEUTRAL] Accident occurred prior to effective day of coverage.
[CUSTOMER][NEUTRAL] Oh, the date of the date of the accident was [PII]. OK.
[CUSTOMER][NEUTRAL] I don't know why those states of service are on the claim, but anyway, that's, that's not the.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's probably just follow up.
[AGENT][NEUTRAL] Like if he had the accident in October, he probably didn't actually, I mean, that's only a couple of months between the accident and when he actually had treatment, so.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So he um, he, he knows that his accident policy is not covered.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] benefits, but he's stating, you know, when I was telling him that we would need something showing that the surgery was due to his accident.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And he said, well, it's all, we should have everything.
[CUSTOMER][NEUTRAL] He's coming, he was kind of getting a little frustrated, but then when I said, well, let's just take a deeper look, you know, he was like, thank you, you know.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So is there anything that we can use that we have?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So we deny this anesthesia not covered and then we need an itemized bill. So let me look at the accident policy and see what we have.
[CUSTOMER][NEUTRAL] All we have is a claim form.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] OK, well, let me look at what we have here on the HR.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEGATIVE] Yeah, it's just a claim form and it doesn't give us anything.
[AGENT][NEUTRAL] So, like,
[AGENT][NEUTRAL] I don't really know.
[AGENT][NEGATIVE] What we're supposed to be using for this because all he uploaded for HI was the claim form. It doesn't say.
[AGENT][NEUTRAL] Anything about like, so the thing is though, um.
[CUSTOMER][NEUTRAL] And then we
[CUSTOMER][NEUTRAL] Surgery.
[CUSTOMER][NEUTRAL] And I told, we did talk about the diagnosis code, you know, that does not indicate that it was from a, an accident. It's just showing rotator cuff, but it, and it says um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Not trauma traumatic.
[CUSTOMER][NEUTRAL] I need another pot of coffee.
[AGENT][NEUTRAL] I hear you. I hear you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So, I would say, so.
[CUSTOMER][NEUTRAL] we have
[CUSTOMER][NEUTRAL] It looks like maybe from the surgeon, the the the CMS 1500.
[AGENT][NEUTRAL] Yeah, we have, um,
[AGENT][NEUTRAL] An attending physician's statement.
[AGENT][NEUTRAL] On when he got his treatment and that, that it was due to his left rotator cuff, but there are not any diagnosis codes on that.
[AGENT][NEUTRAL] Um, and that was under the accident policy and then under the HR it's just a claim form on that one, but let me see what this one is.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, the most recent one is the CMS 1500s.
[AGENT][NEUTRAL] And it was 284.
[AGENT][NEUTRAL] Accident surgery. Surgery due to a sickness is not covered.
[AGENT][NEUTRAL] It's those diagnosis code or yeah those diagnosis codes because let me see what they are exactly 75122.
[AGENT][NEGATIVE] Complete rotator cuff tear. I don't think that that would be.
[AGENT][NEGATIVE] A sickness.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I'm just confused with all this. I'm sorry.
[AGENT][NEUTRAL] No, it's fine. So.
[AGENT][NEUTRAL] I'm going to.
[AGENT][NEUTRAL] I'm gonna have this reprocessed because that I know it's an M code and a lot of times the examiners will automatically be like, oh, M codes are not accident related and a lot of times they're not. However, this one clearly indicates that it's a complete rotator cuff tear and based off of what we have under the accident policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] I'm gonna look at that again to see what that claim form looks like because I might be able to.
[AGENT][NEUTRAL] Tell them to reference that.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Because I wanna see.
[CUSTOMER][NEUTRAL] I mean, he hit his shoulder.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] My own base is so slow.
[CUSTOMER][NEGATIVE] My personal base is slow too today.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Oh my gosh. All of it, all of it is like it is Monday.
[CUSTOMER][NEUTRAL] I've been sitting here singing and.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] In my brain.
[AGENT][NEUTRAL] OK, caught himself. OK, so he fell, he caught himself, tore his rotator cuff, and then the physician.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] It's kind of
[AGENT][NEUTRAL] Says that he had a left rotator cuff tear that he was treated for.
[CUSTOMER][NEUTRAL] I mean, I know we
[CUSTOMER][NEUTRAL] And I know we have to have documentation, but it all points toward an accident to me.
[AGENT][NEUTRAL] Yeah, all it does. And a rotator cuff tear doesn't happen. That's not a wear and tear. It would say like there's a completely separate thing for wear and tear. I am gonna look though because sometimes, um.
[AGENT][NEUTRAL] The HR if.
[AGENT][NEUTRAL] I wanna make sure that it doesn't say anything about the injury having to take place prior to.
[CUSTOMER][NEUTRAL] Oh, yeah.
[AGENT][NEGATIVE] Because if so, then that's gonna be denied too and there's no.
[AGENT][NEUTRAL] There's no reason in getting him to.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Do anything else so I just wanna make sure because I sure would hate to be like, hey, we're gonna get this reprocessed and it's like, mm that's getting, we're not. We can't right, don't wanna do that. He's already feeling frustrated, so let's not do that.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Just, just trying, just get your hopes up and drop you down.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] Well, shoot, any time you go to the doctor or have any medical costs, you're already frustrated by the amount of dollars you have to spend.
[AGENT][NEUTRAL] Oh, for sure.
[CUSTOMER][NEUTRAL] Oh my [PII], it's just crazy.
[AGENT][NEUTRAL] Oh, I cannot find.
[AGENT][NEGATIVE] Oh, [PII], the, the not having these policies and on base is going to drive me absolutely insane one day.
[CUSTOMER][NEUTRAL] You and me too, girl.
[AGENT][NEUTRAL] Oh my gosh. Like it, it seems so trivial. Like, why, why, why is this a thing?
[CUSTOMER][NEGATIVE] And it's so difficult for us as well as our clients as well.
[AGENT][NEGATIVE] Yeah, yeah, I've been, I mean y'all get more calls than we do so and I've been frustrated so.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] I can only imagine.
[CUSTOMER][NEGATIVE] It's not fine.
[AGENT][NEGATIVE] No, I was telling [PII] the other day I said, look, I, I don't know the ins and outs of getting these on base or anything like that, but I truly do not understand.
[AGENT][NEUTRAL] If they're getting something, why do we not have that also?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know our last um.
[CUSTOMER][NEGATIVE] Uh, company meeting I told [PII] I said it's frustrating and I said I really don't understand why the policies aren't available prior to the effective date. I mean, me as a consumer.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I would expect it to be there.
[AGENT][NEUTRAL] At least, yeah, because if they're going to be able to.
[AGENT][NEUTRAL] Submit a claim and us process it.
[CUSTOMER][NEUTRAL] We've got to have it.
[AGENT][NEUTRAL] Both of us are doing it blindly.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You know, so I don't, I don't understand. OK, so here's something for HR.
[CUSTOMER][NEUTRAL] Hang on just a second, [PII]. I'm gonna just go back to him and tell him we're reviewing it. Please hold another moment, OK? OK, thanks.
[AGENT][NEUTRAL] Yeah, go ahead.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] He's good and he really appreciates it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um.
[AGENT][NEUTRAL] So under the accident surgery, it says we will pay the applicable accident surgery benefit per day when a surgical procedure due to an injury is performed on a covered person in a hospital, hospital outpatient facility or freestanding outpatient surgery center.
[AGENT][NEUTRAL] Um, or they also have it when it's covered in a physician's office, so let me make sure.
[AGENT][NEUTRAL] OK, so injury.
[AGENT][NEUTRAL] Which is caused directly by covered accident, independent of sickness, disease, bodily infirmity, or any other calls.
[AGENT][NEUTRAL] And a covered accident occurs on or after the effective date.
[AGENT][NEUTRAL] So
[CUSTOMER][NEGATIVE] But he knows that his accidents not on the accident policy there's no benefits.
[AGENT][NEUTRAL] That's under the HR.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So under his HI that accident surgery coverage that was denied.
[AGENT][NEUTRAL] Um, the accident surgery benefit that
[AGENT][NEUTRAL] Let me see if there's anything else, took place in an outpatient surgical facility.
[AGENT][NEUTRAL] And so it's just surgery. So that would not be covered. Let me see if there's anything else on here that we might be able to cover. I know.
[CUSTOMER][NEUTRAL] Dang.
[CUSTOMER][NEUTRAL] An accident surgery benefit facility?
[AGENT][NEUTRAL] Yeah, so it occurred at an outpatient facility so literally everything about this would be covered, but it still has that definition of it has to be due to a covered accident and because covered accident is defined as happening prior to.
[AGENT][NEUTRAL] The effective date, it doesn't meet that now because we have documentation that says his accident occurred prior to, not on or after the effective date. So that's not gonna be covered under HI either.
[CUSTOMER][NEUTRAL] Oh, ding ding dong.
[AGENT][NEGATIVE] Yeah, I would have definitely sent this back.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Dang.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] With the accident occurring prior to and that language also being in, in the HR um.
[AGENT][NEGATIVE] It's not gonna be covered.
[CUSTOMER][NEUTRAL] A sugar muffin.
[AGENT][NEGATIVE] I know. It sucks pretty hard. I would say like, I, I was looking to see if there was anything else, but literally every charge is from that surgery center. So, there's not anything we can pay. We can't pay outpatient accident and sickness because
[AGENT][NEUTRAL] All of that has to take place in either an ER, an urgent care or physician's office, and that's not any of this. That's the surgery center. So it's very clearly for the surgery only. And that language is in there as well. So, his accident occurred prior to.
[CUSTOMER][NEUTRAL] OK, can you kinda, kinda go over that with him and then maybe if he had any.
[CUSTOMER][NEUTRAL] Doctor's visits or, I mean, at least he could file for that, right?
[AGENT][NEUTRAL] Yeah, he should, as long as the doctor's visits are.
[CUSTOMER][NEUTRAL] In one of those.
[AGENT][NEUTRAL] After, on or after the effective day, we would be able to consider those for accident or um sickness. Um, and then,
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] And then also he has a right to an appeal.
[AGENT][NEUTRAL] He does have a right, a right to an appeal, but I mean it's right there in the policy language which I'm sure he doesn't have, but it is in his policy language so.
[CUSTOMER][NEUTRAL] Yeah, because if it's not on base, he can't access it. He's got the portal account.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yeah, I mean, I can, I can do my best. He's not gonna like it, but I'll do my best.
[CUSTOMER][POSITIVE] Well he's really nice and he really appreciates the time we put looking into it so.
[AGENT][NEUTRAL] Yeah, of course.
[CUSTOMER][NEUTRAL] Oh, let me get him on the line and I verified all of his information.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you, [PII]. One moment. Have a good day. Thanks. One moment.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] You too.
[CUSTOMER][POSITIVE] Alright, Mr. [PII], thank you so much for your patience. I have [PII] on the line. She's been reviewing your policy benefits and the documents that we have on file, and she's going to assist you further, OK?
[CUSTOMER][POSITIVE] Yes, ma'am. Thank you. You're very welcome. You have a wonderful day and I hope that shoulder gets to feeling better.
[CUSTOMER][POSITIVE] Thank you so much. Thank you bye bye.
[AGENT][NEUTRAL] Hey, Mr. [PII], how are you?
[CUSTOMER][NEUTRAL] How you doing, ma'am? What's your name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, Ms. [PII]. How are you doing today?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][NEUTRAL] Uh, we recovering just hanging around. I got a doctor appointment today at [PII] to see how much longer it's gonna be that I can't work.
[AGENT][POSITIVE] Oh, goodness. I can't even imagine. I know that those surgeries can, can take some time to recover from.
[CUSTOMER][NEGATIVE] Oh, this is, this is ridiculous.
[AGENT][NEUTRAL] Well, I was reviewing everything because I see that under your accident and under your HR policy we've we've denied everything that you've submitted so I was digging into the HR um because it looks like the accident was a valid denial based off of the accident occurring prior to your effective date, so I was like OK well maybe we can pay something up under the HI so under the HI your benefits um specific to accident are.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Any type of hospital confinement if you're confined.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Accident surgery benefit either in a facility like an outpatient surgery center or in a physician's office and then you have like ER visits, urgent care visits, doctor's visits, and physical therapy.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] So I was looking at all that and.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] In the policy language, the accident surgery basically says, you know what it is we're gonna pay for this as long as it takes place in this particular situation.
[AGENT][NEUTRAL] So I made sure that we didn't have any stipulations and based off of, so it says due to a covered accident.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Um, which you obviously have an accident, you tore your rotator cuff that is known. The issue is that based off of the policy language, a covered accident, much like your accident policy has to occur on or after the effective date. So that prevents this surgery from being payable under this policy as well. However,
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If you have physical therapy that you've been going through or physician's office visits that you've been going through, those can be, let, let me clarify, let me make sure I'm telling you correctly because I wanna say those can be.
[CUSTOMER][NEUTRAL] Uh, I, yes, ma'am.
[AGENT][NEUTRAL] Um, covered, but I wanna make sure that we don't have any stipulations because I didn't deep dive on those. I was really looking at your surgery because that's what you've submitted so far and I was like, oh man, like, yeah, this is covered if it would have been just a little bit.
[AGENT][NEGATIVE] Later, which I know we don't choose that obviously you would not have chosen this.
[CUSTOMER][NEUTRAL] So you
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Yes, ma'am. So, even though the, even though the surgery is done after I was approved, that doesn't matter, it goes by the, the accident date.
[AGENT][NEUTRAL] It does so because it's due to an injury, um, the injury has to take place when your policy is effective for the treatment for that injury, yeah. So let's see, now let's look at.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Understood.
[CUSTOMER][NEUTRAL] I start I, I start physical therapy and uh
[CUSTOMER][NEUTRAL] He said the 2nd weekend of March, whatever that is.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The second week of work, I'll start physical therapy. I haven't started anything yet. I needed, he said I need a 6-week healing process before I go to any uh physical therapists.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So let's see.
[AGENT][NEUTRAL] Outpatient accident and sickness, we will pay this per day of treatment due to an injury or a cover sickness that goes right back to that language so it defines an injury.
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] And then they, uh-huh. With the policy, you know, an injury obviously is something that, you know, bodily injury is something that happens to your body without being sick, you know, or something like that. It's a true accident. And then the definition of furthermore of that is that it has to take place.
[CUSTOMER][NEUTRAL] Within the policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] On or after your effective date.
[CUSTOMER][POSITIVE] Yeah, and that's, and that's very, that's very understandable. And I thank you and that other lady so much for your help. That was very, very sweet of y'all to take that extra time to try to help me.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Of course. I, I wish so badly that that was not the case. Um, it, it bums me out a little bit that we can't help you a little bit more.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Cause I know you're just sitting back recovering.
[CUSTOMER][POSITIVE] It's OK, hopefully.
[CUSTOMER][NEGATIVE] Yeah, hopefully we don't have to speak again on these terms. I don't like getting hurt. I don't like none of this. I, I'm an act. I'm a mechanic. I'm, I'm out every day and I've been stuck in this recliner for 4 weeks and I'm going a little stir.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Oh man, I bet. Look, my dad, my dad and my brother-in-law both were truck drivers and we're on the go constantly. So the minute they both became disabled due to any number of injuries, you know, dealing with truck driving, they, they have been about to lose their mind. They keep themselves busy all the time because they can't, you know, they can't stand it. They're like, I'm not used to just sitting, I'm used to being busy, so I completely understand.
[CUSTOMER][POSITIVE] Right, well, I wanna thank y'all again so much and uh y'all y'all have been a true blessing. Even though I didn't get it, y'all could have just said you ain't got it and call somebody else, but y'all, you all really, really went actually helped me, and I appreciate that so much.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Absolutely. Well, of course, of course, and you as well and I hope you recover well.
[CUSTOMER][POSITIVE] You have a great day, ma'am.
[CUSTOMER][POSITIVE] Thank you so much bye bye.
[AGENT][POSITIVE] You're very welcome. Bye