AccountId: 011433970860
ContactId: 9182649d-9648-4a51-bc03-992a4accdcfa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 997200 ms
Total Talk Time (AGENT): 491614 ms
Total Talk Time (CUSTOMER): 376766 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/29/9182649d-9648-4a51-bc03-992a4accdcfa_20250529T15:47_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], it's [PII]. I've got um an insured on the phone. His name is [PII], and he said that he is also an agent and sells our policies.
[CUSTOMER][NEUTRAL] And he is calling on policy number his own 2487523.
[CUSTOMER][POSITIVE] He's been verified the number he's calling from is a good call back number for him.
[CUSTOMER][NEUTRAL] And he's calling about claim number 3603262. I gave him the remarks.
[CUSTOMER][NEUTRAL] And he still has further questions and statements to be made.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said he was verified correct?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like a screening claim for that particular one.
[AGENT][NEUTRAL] OK, and um I'm gonna pull up that.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Uh, particular mail and you can go ahead and send them through sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much appreciate it [PII] bye bye.
[AGENT][POSITIVE] You're welcome thank you bye bye have a good day.
[AGENT][NEUTRAL] Hi Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm in the claim support, uh, I'm on the claim support team and I understand you have some questions in regards to your claim you submitted for some, it looks like some screening services.
[CUSTOMER][NEUTRAL] Yeah, so I'm a diabetic. I have A1C screenings.
[CUSTOMER][NEUTRAL] And that's a part of the policy, but yet I was basically told it was not a covered scenario.
[CUSTOMER][NEUTRAL] I get my blood drawn every 3 months.
[CUSTOMER][NEUTRAL] I'm looking at my sor uh results from Labor.
[CUSTOMER][NEUTRAL] And showing I had the A1C done 421 had one done [PII]. I had one done [PII].
[CUSTOMER][NEGATIVE] So somebody needs to tell me legitimately why APL is not paying that.
[AGENT][POSITIVE] OK, I'd be happy to let me pull up your policy and we can go over that particular uh benefit.
[CUSTOMER][NEUTRAL] Yeah, I've already looked at the screens that number.
[CUSTOMER][NEUTRAL] Yeah, it's number 2 in the, the screenings.
[AGENT][NEUTRAL] OK, just bear with me for just one moment.
[CUSTOMER][NEGATIVE] And then the other was, ma'am, I, I actually hurt my knee mowing. I stepped in a hole.
[CUSTOMER][NEUTRAL] And um hyperextended the knee and then it, it collapsed. Uh, and I'm going for an MRI tomorrow actually to see if I've got ACL MCL damage.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So I don't even understand why that was denied.
[AGENT][NEUTRAL] Well, it looks like we were asking for some additional information on that one we do need the accident claim form that gives us the details of the accident. It looks like we're asking for that claim form, but I can look at that in just one moment. I'm pulling up this uh benefit for the screening, so just bear with me for one moment.
[CUSTOMER][NEUTRAL] And as I told the young
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so under um your policy I'm not sure if you said you do have a copy of your policy that's correct and you did look at the accident.
[CUSTOMER][NEUTRAL] Yeah, I was just looking at it.
[AGENT][NEUTRAL] OK, alright, OK, so just um just to let you know it is a verification of coverage, not a guarantee of payment. What I see under the accident screen because this is an accident policy, it does need to meet that accident screening um definition. So in other words, if it's just a screening for the um A1 I believe you said A1C or your lab test that doesn't that's not considered like a screening.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, it is, it's specific to an accident screening such as like if you went in for a physical and they did, um, you know, kind of went over, you know, trip and fall and those kind of things or even wearing your seatbelt, and you know, that's can, um, part of like your exam that you have. However, laboratory tests are not part of that screening cause it doesn't screen, it's, it's specifically for screening for an accident.
[AGENT][NEGATIVE] So that benefit would not be payable for laboratory work.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Section 10 definitions accident screening.
[CUSTOMER][NEUTRAL] Any of the following tests performed on an outpatient basis. #2, hemoglobin A1C.
[CUSTOMER][NEUTRAL] Ma'am, I've been doing this for 32 years selling this type of policy.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] If you're telling me that you're not paying it, I'm going to the bureau.
[AGENT][NEUTRAL] OK, just bear with me.
[CUSTOMER][NEUTRAL] Because it is clear in your definitions.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Just bear with me so I can go to that part of the policy.
[CUSTOMER][NEUTRAL] Page 22 section 10.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so what I'm gonna do at this point is you are I'm seeing what you are reading to me in that section 10, and I do agree that that uh that is listed under the accident screening and the following tests on an outpatient basis that is listed there. So what I'm gonna do is, is I'm going to send this back through to have it reviewed, um, and, um.
[AGENT][NEUTRAL] If you can give us some time to have that review completed and I can give you a call back if that's OK with you at the contact number.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, the, uh, so this is my office number, ma'am. I can give you my cell number just in case because I do have to leave to pick up some meds.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, my cell number is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And and I honestly don't understand why I mean I know you told me it didn't meet the definition, but obviously there's conflicting from what your statement was to what's in the policy.
[CUSTOMER][NEUTRAL] And this is my first venture with APL and my agency.
[AGENT][NEUTRAL] Uh huh.
[CUSTOMER][NEGATIVE] And and I, I am shocked.
[AGENT][NEUTRAL] Well, and, and I do apologize. Like I said, I didn't read further under the definitions. I was reading from you from the accident screening portion of the benefit. Not all of these policies have um contain that specific definition if I can just, um, be, um, like I said, I didn't look that far into the policy and that's my fault, and I do.
[AGENT][NEUTRAL] Apologize for that, but I do see where you're reading from under the definition, so not all of these policies do have that definition in there, um, like I said, under that accident screening, um, it just gives that definition that it must be an you know, screening for an accident because it is an accident policy. So that is, um, again my, my apologies for that.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah, I, I mean, I, I get that um it it's OK and then as far as some kind of claim form I filed this online.
[CUSTOMER][NEUTRAL] And so if you guys are now asking for a claim form, why wasn't I asked for that up front uh and either the questions online or prompted to fill out a form from the online uh submission.
[AGENT][NEUTRAL] OK, so I'm gonna pull up those documents now, so just bear with me. So there are two parts to file on that claim when you're on that um portal that that does give you the option to file that wellness claim and which is a quick, you know, you answer the four questions and you file the wellness claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] However, it should have prompted you to go ahead and file under the accident. It should have prompted you to um have that uh accident claim form um as part of the process before you uploaded the documents so you're saying that it didn't give you that option?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] No ma'am, it's not no I'm very versed at this. It did not, and that's another reason why I'm, I'm a little miffed. I'm, I'm trying to be nice, honestly, ma'am, but I, I'm, I'm thoroughly pissed use the French, uh, because I can't, you know, I test things out before I take them to a client and I could see this could cost me a client.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Not only an individual person but a group and, and there would be so much more money that I would lose outside of just a small accident policy. So um yeah, I'm.
[CUSTOMER][POSITIVE] I'm, I'm very well taken back here.
[AGENT][NEUTRAL] OK, well, again, my apologies for that that's part of the process when you're on that um portal now I do know that the portal is undergoing some changes in fact it's being completely uh revamped, so I'm not sure if that was just a um a fluke. I've not heard of that before. Usually that process like I said would prompt you to go ahead and complete that claim form.
[AGENT][NEUTRAL] Before you upload the documents and like I said that those two options are there as far as filing a claim and then also for that wellness portion like you completed the claim forms for the wellness that you did send in um you know like I said those are just that those simple four questions however the other um the other claims should have prompted you to complete the accident claim form as well.
[CUSTOMER][NEUTRAL] Well, I know
[CUSTOMER][NEUTRAL] So I remember there were some questions that I answered like the date of the accident, but.
[CUSTOMER][NEUTRAL] I'm sorry, I, I, I've been doing multiple submissions for various things, uh, I know it just wasn't an uploaded documentation but in the same token I did not get prompted to fill out a claim form.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So is there any way to cut the time frame here where we could, you know, you could take my uh submission over the phone and and provide that to the auditor?
[CUSTOMER][NEUTRAL] Or do I physically have to to take care of a claim for?
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Yeah, we
[AGENT][NEUTRAL] Yes, unfortunately for now for certain services under the accident policy though it does require that accident claim form because that's your uh like attestation or your, you know, um your statement of, you know, what transpired. So basically what that accident claim form consists of is again asking for that accident date and then the description and then at that point is when you would send in that do supporting documentation for the claim itself.
[AGENT][NEUTRAL] So, um, unfortunately we do have to have that claim form completed.
[CUSTOMER][NEUTRAL] OK, so can you send that to me so I can get that done immediately.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] And go ahead and verify that.
[CUSTOMER][NEUTRAL] And can I go into the existing claim and attach.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Yeah, all you would need to do is go ahead and complete the claim form since we have the documents and I it doesn't appear that there's anything else being uh requested just that claim form itself again giving us those accident details so I can send that claim form to you um.
[AGENT][NEUTRAL] Via email and just go ahead and and verify I have the correct uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Email address?
[CUSTOMER][NEUTRAL] Email is a [PII]. So it's [PII].
[CUSTOMER][NEUTRAL] And [PII]
[AGENT][NEUTRAL] Got it. [PII] and I'm gonna send that claim form over to you now and um and I will also um just to let you know Mr. [PII], I'm gonna go ahead and address this information directly with my supervisor as far as the um the um.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] The claims that were denied as well as your concern about the um website not prompting you and like I said I'm not sure I'm not aware that we've had any other situations like that but it should, like I said, it should have prompted you to go ahead and complete that.
[CUSTOMER][NEUTRAL] Yeah, because I, OK, um.
[CUSTOMER][NEUTRAL] Now my next and last question to you is, given the fact that I'm going to have an MRI tomorrow.
[CUSTOMER][NEUTRAL] What is your company specifically needing for the MRI? Do you need a copy of the written results? Do you need the itemized statement? What would you be looking for in order to get that claim taken care of?
[AGENT][NEUTRAL] Um, actually, the itemized statement with the diagnosis and procedure code would be best.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then like I said, because that that way it just we know that you're having an MRI.
[AGENT][NEUTRAL] Um, you know, for that particular, uh, incident accident.
[CUSTOMER][NEUTRAL] So I can tell you I'm on your site right now and I went under my claims and just hit upload documents.
[CUSTOMER][NEGATIVE] And it asked me to select what type of plan it was and I clicked on mine and who it was for and now it's just saying upload documents and hit submit.
[CUSTOMER][NEUTRAL] So there's there's no there's no prompting of a claim form to be completed.
[AGENT][NEUTRAL] OK, well, like I said, I'm not aware that there's been any issue, but I will definitely um look into that matter because I'm not aware that that there's any issue with it other than I know, like I said, they are revamping the site. In fact, it is um they're launching a complete new site, so there could be some maybe behind the scenes that I'm not aware of and I've not been made aware of.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] But I will, um, in fact I'm actually joining a meeting shortly here and I will definitely like I said, uh, bring that up in our meeting and make sure and when I call you back uh hopefully I'll have some additional information for you um but I will give you a call back, um, and that number that you provided me that cell phone [PII], um, if I'm unable to reach you, is it OK to leave a message?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes ma'am, and do you have a direct number or am I calling back into?
[CUSTOMER][NEUTRAL] A switchboard scenario.
[AGENT][NEUTRAL] I mean you could call into our customer service team if you'd like to ask for me. Uh my name is [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, all right, [PII], well I look forward to your email with the form and I'll get that completed and uploaded and uh tomorrow I'll have the hopefully the uh UB 04 for being at the hospital and and having that uh MRI done.
[AGENT][POSITIVE] OK, and that will work like I said, that will be probably the best if you have that UBO4 that gives us all the information needed.
[CUSTOMER][POSITIVE] OK all right thank you very much, ma'am.
[AGENT][POSITIVE] You're welcome, Mr. [PII], and uh thank you for your patience. I'll call you back shortly.
[AGENT][NEUTRAL] And I'm sending that claim form over to you now.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.