AccountId: 011433970860
ContactId: 85f180a5-0082-4264-a9cc-2195ad100880
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1065180 ms
Total Talk Time (AGENT): 322040 ms
Total Talk Time (CUSTOMER): 569251 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/85f180a5-0082-4264-a9cc-2195ad100880_20250418T13:41_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and I'm calling because I have got a um
[CUSTOMER][NEUTRAL] Um, an explanation of the claims that I submitted. Um, I did it before and they were telling me they would still covered like the ambulance. I just had needed to provide a couple more documentation. Well, I did that after my name was changed and now they're saying, um, I guess my benefits have been exhausted for the year or something like that. I don't know if I'm claiming the right claim up underneath the right policy because I have, um, you know, 12344 different policies.
[CUSTOMER][NEGATIVE] The accident, the critical illness in the hospital, um, so I want to know, could you just look up my, you know, files and tell me or help me be able to, you know, get what is due to me if there's still any benefits left because I was told you guys were gonna pay me for the ambulance ride, but, um, I needed to provide the hospital documentation and I did that, but now it's saying that I've exhausted my benefits.
[AGENT][NEUTRAL] OK. Uh, do you have one of the policy numbers I can look up?
[CUSTOMER][NEUTRAL] So, 22.
[CUSTOMER][NEUTRAL] Let me see, 22 44 39544 395. Yeah, that's the critical, critical illness one. That's the one I'm thinking that keeps saying I'm exhausted.
[CUSTOMER][NEUTRAL] My policy, but if I'm not mistaken, I put the ambulance one up underneath the hospital addendum, but it's changed on there, so I don't know.
[AGENT][NEUTRAL] OK, uh, we can look at it and see what's going on. Um, do you have a good callback number, Ms. [PII], just in case I lose this call?
[CUSTOMER][NEUTRAL] If you can help me.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] I just need to verify a few pieces of information. Um, what is your birth date?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And then what is your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And then lastly your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh, looks like I might have a work email.
[CUSTOMER][NEUTRAL] They changed that. That's the thing. See, they, they changed it to my personal email because I wasn't able to even upload anything to the young lady did it, but it should have [PII] and she told me she did it. She updated it in the computer. I don't know if you can look back at notes the last time I called, but she told me she updated it because it had my work email.
[CUSTOMER][NEUTRAL] And I don't, I don't check my work email like that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, what is your work email?
[CUSTOMER][NEUTRAL] Um, it's maybe the [PII]. I can't remember it. I don't even use it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me get this changed.
[CUSTOMER][NEUTRAL] I don't know if it's [PII] or [PII] match my hair or something, but they told me they did that last time.
[AGENT][NEUTRAL] OK, um, maybe they did it on one account and not another one. It's possible.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, let's see. Um.
[AGENT][NEUTRAL] Let me get this changed real quick.
[CUSTOMER][NEUTRAL] But it should be rea.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And if you can't spell it back to me because it's not my full first name, it's just [PII].
[AGENT][NEUTRAL] OK, OK, so [PII], is it [PII] or just [PII]?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] And if you can make sure it's on all the accounts please.
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Sure, that's same.
[AGENT][NEUTRAL] OK, I've got that updated. OK, OK, we're talking about an ambulance claim, is that right?
[CUSTOMER][NEUTRAL] Yes, I, I found.
[CUSTOMER][NEUTRAL] I found two claims I think it was the mammogram, but they did refresh my memory. I did get the $75 for the mammogram, um, but the ambulance, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I didn't. I submitted the doctors, the ER notes, like the discharge note from the ambulance and the bill, and it's saying I'm exhausted, so I don't know if I put it under the wrong policy cause it's under the critical instead of the hospital, which that's what I thought I submitted it under.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, let's see what they got
[AGENT][NEUTRAL] Pull up your hospital, your hospital indemnity, is that the one you're referring to?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, getting this pulled up, just give me one moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] And what date was that ambulance?
[CUSTOMER][NEUTRAL] Mm, I'm driving at the moment. I, I, if I'm not mistaken, I think it was like [PII] or something like that. I uploaded the document.
[AGENT][NEUTRAL] OK, uh.
[AGENT][NEUTRAL] OK, let me find.
[CUSTOMER][NEUTRAL] Go
[AGENT][NEUTRAL] Let's see
[CUSTOMER][NEUTRAL] It was [PII].
[AGENT][NEUTRAL] OK. Uh, let me pull this up.
[CUSTOMER][NEUTRAL] Or mhm it could have been [PII].
[CUSTOMER][NEUTRAL] Oh no, I submitted, I submitted a couple of things. I'm, I'm trying to remember the date.
[AGENT][NEUTRAL] OK, so it looks like.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] I'm just looking through these claims locating it, hold on one moment.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I wish you just could call in and submit a claim with you guys. I just, it's like cause online, I've done it before, online it's like you gotta start the claim first and then go to the upload and then upload the documents, but I don't know, this time it seems so difficult and everything I submit just gets rejected. I'm just like I don't know.
[AGENT][NEUTRAL] I'm sorry about that. I don't, I hate to hear that it's frustrating.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so it looks like.
[CUSTOMER][NEUTRAL] I mean if you look at
[AGENT][NEUTRAL] Yeah, I found it. Um, this was for
[AGENT][NEUTRAL] OK, so under the hospital indemnity.
[AGENT][NEUTRAL] So your hospital indemnity plan and it's not a guarantee of payment basic outline of the policy. Um, so it's got specific benefits, it's got a hospital admission benefit, a hospital confinement, intensive care, and rehab.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, so let me see if this should go under a different policy.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Cause that's what it was filed under. So I'm wondering if, so under the hospital indemnity it's not covered, but it could be covered under your, was it, was it due to an accident? Is that what the
[AGENT][NEUTRAL] Like the diagnosis why you went up by ambulance.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, no, I was having abdomen pain and the EMS came and got me from home. They had to come take me from home, so I had to have a um X-ray and all all that stuff ultrasound or something.
[CUSTOMER][NEUTRAL] So I submitted the ER visit as well. So that's what I'm saying. I mean they told me they cover ambulance ground ambulance, and I see it in my book that they cover ground ambulance, but under what policy I don't know.
[AGENT][NEUTRAL] OK, that's what we'll figure out. I, it might be your critical illness or
[AGENT][NEUTRAL] Uh, group accident. So let me see which one. It's, it's not under the hospital indemnity, so let me see which one it is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And that's why I say it's a little frustrating because even if I'm not sure which policy it went up under or qualify under, I would think, you know, if someone, you know, if I was to handle it and I said, OK, this person submitted this ambulance, but it's not covered on the hospital, but they have a group critical group. OK, let me switch it over. I'm just thinking that's what would have been done automatically, you know, they see I have 4 different policies, you know, but it's almost like
[CUSTOMER][NEUTRAL] No, we'll deny it and if you submit it correctly, we'll probably approve it because they never told me they don't cover for ambulance, they just told me I need to submit my um documentation from the hospital of saying why did I go to the hospital.
[CUSTOMER][NEUTRAL] And I did that.
[AGENT][NEUTRAL] OK, so under your, and again, not a guarantee, just a basic outline, this is under your
[AGENT][NEUTRAL] Group critical illness.
[AGENT][POSITIVE] It is a covered benefit. Um, looks like it covers.
[AGENT][NEUTRAL] By ground, it covers 150.
[AGENT][NEUTRAL] But for this, it's gonna have to be, let's see, I'm trying to see. This, this is very specific on the diagnosis that it has to be.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So you could have taken it around ambulance, but it has to be like maybe a car accident or uh something like that. Is that what it's saying? I gotta have a qualifying, qualifying emergency situation.
[AGENT][NEUTRAL] it has to be considered a.
[AGENT][NEUTRAL] Yeah, there's a list of covered conditions. There's several, several conditions, but they're typically like catastrophic conditions are very, you know,
[AGENT][NEUTRAL] Like a heart attack, um, brain tumor, uh, Parkinson's disease, Addison's disease.
[AGENT][NEUTRAL] Coronary artery disease. So it's
[CUSTOMER][NEUTRAL] So you have had one of those things happen in order for your ambulance to be covered.
[AGENT][NEUTRAL] Correct. So because it's a critical illness.
[AGENT][NEUTRAL] The benefits that are underneath it and let me make sure look at the.
[CUSTOMER][NEUTRAL] I pretty critical.
[CUSTOMER][NEUTRAL] It has to be a critical reason.
[CUSTOMER][NEUTRAL] Cause I mean on my doctor's note, I have to get a CAT scan and all that stuff and it acts like I mean even if I got a CAT scan, I submitted documentation and I have to get a, I mean an ultrasound or, you know, and it's like, OK, does benefits cover for any of that?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, for this specific policy.
[CUSTOMER][NEUTRAL] Do you see the documents from the hospital?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] For the ambulance?
[CUSTOMER][NEUTRAL] Yeah, so the goes up on the critical, but the test that I had done at the ER, if I wanted to be um paid for those benefits, with those benefits, I would have had to submit those documentations on the hospitalization, under the hospital.
[AGENT][NEUTRAL] OK, yeah, let me look at the, so for the hospital, you would have to be confined or an admission. Were you, were you inpatient more than 18 hours?
[CUSTOMER][NEGATIVE] No, I don't think, no, I was discharged after they treated me.
[AGENT][NEUTRAL] OK, yeah, for the hospital indemnity that has a specific parameter for the time frame, um, which is defined as 18 hours.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] But then, like I said, on the critical illness, that does have the ambulance benefit, but then it has specific illnesses that it will cover for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it has to be due to a critical illness.
[CUSTOMER][POSITIVE] Oh wow.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I got you. It's always some kind of stipulation I'll tell you. Oh man, OK.
[AGENT][POSITIVE] So sorry about that.
[CUSTOMER][NEUTRAL] It's OK. OK. So let me ask you this. Things like my wellness visit at my gynecologist, that would be submitted up on which policy?
[AGENT][NEUTRAL] That's under your critical illness. They do have a wellness benefit for health screenings, mammograms, and vaccines. Yep.
[CUSTOMER][POSITIVE] OK, good.
[CUSTOMER][NEUTRAL] OK, so this is [PII]. So I have my benefits started over because I see something about it had exhausted my benefits. So with that for [PII], they're saying I've exhausted the a benefit. Can you see that note?
[AGENT][NEUTRAL] Yeah, let me look at that.
[CUSTOMER][NEUTRAL] What are they referring to?
[CUSTOMER][NEUTRAL] Cause I haven't had my dental cleaning. I haven't had my wellness visit. I haven't had any of that. So I know when I do it, I just wanna know, you know, what do I need to submit with that. So if I go to my gynecologist, what do I just submit my results or what do I submit to be paid for it?
[AGENT][NEUTRAL] OK, so under your critical illness, it looks like we did pay for your mammogram, I paid out 75%. That was for [PII]. So your next benefit would be available in [PII], and then
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I think we what happened is we received the claim twice and it it just said denied the second time has been exhausted um so but yes so it's calendar year yeah so you're good like [PII] when you have your next mammogram that you can submit that of course um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. All right. So that kind of stuff goes on the critical illness. What about dental visit and my vision, um, my eye exam, so my dental visits and my, um, you know, when I go get an eye exam from my doctor. What is that up underneath cause it, I think I have that as well.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] I don't see a dental policy. Um, I don't see dental or vision. We actually don't do vision, but we do do dental, um, but I don't see a dental policy under here, so it might be under a different carrier.
[CUSTOMER][NEUTRAL] dental and vision.
[AGENT][NEUTRAL] Might check with your HR and if if it's through someone else maybe Delta Dental or um another different provider um but we, I just got you with group accident.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no, I do have with someone else, but I didn't know if you get like if they treat a dental, um, cleaning like your 6 month cleaning as how they would do, um, you know, your wellness for your yearly checkup with your doctor. So they don't do that, right?
[AGENT][POSITIVE] Oh, OK. No, they don't do that. That's correct.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK. OK. So, but any blood work, say if I have to get blood work or anything like that, is that covered up underneath um wellness? Is that considered like wellness like if I have to go get blood work?
[AGENT][NEUTRAL] Uh, let's see, so it will be
[AGENT][NEUTRAL] Yes, a wellness test, routine physical, any generally medically accepted screening test, uh, received. Yes, that's covered.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, on the critical. OK, I gotta remember that. I'm gonna write that on my note.
[CUSTOMER][MIXED] I don't remember that because I don't wanna be submitting it up underneath the wrong policy, so that makes it harder as well. So, OK, but I thank you for the explanation. I mean all that heck I went through trying to download those documents. I wish I had to talked to someone and that, but I don't know if you could.
[CUSTOMER][NEUTRAL] See the note, it says we do pay for ambulance, but they need the doctor's note. They're not saying that certain things were qualifying. So here I am scrambling trying to find everything. So be told it has to be a critical illness that you were transported by the ambulance for.
[AGENT][NEUTRAL] Yeah, I understand. I understand that. Yeah, that's I.
[CUSTOMER][NEUTRAL] So I get it, but I think.
[CUSTOMER][NEUTRAL] You don't make the rules.
[AGENT][MIXED] Yeah, no, I understand you'd be frustrated though. I totally get it. Yeah, I, I could have been a little bit better of a process.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yeah, but I truly thank you for the um information that you have given me, and I thank you for your time.
[AGENT][NEUTRAL] OK, anything else I can help with, Ms. [PII]?
[CUSTOMER][POSITIVE] No, that'll be all, and I really thank you. Have a blessed day.
[AGENT][POSITIVE] OK, thank you, thank you for calling APL. Have a great weekend.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] You too bye bye.