AccountId: 011433970860
ContactId: a7797f85-6c0f-4be2-b14c-6a778ff7ca13
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 585320 ms
Total Talk Time (AGENT): 257927 ms
Total Talk Time (CUSTOMER): 186249 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/a7797f85-6c0f-4be2-b14c-6a778ff7ca13_20250605T14:34_UTC.wav
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[AGENT][POSITIVE] Thank you for calling. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII].
[AGENT][NEUTRAL] Hey [PII].
[CUSTOMER][NEUTRAL] I've got a um a hi I've got a lady on the phone. Her name is [PII] and she's with the broker's office.
[CUSTOMER][NEUTRAL] For, um, and I have verified the, the information. She is calling on policy number 248-0506.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] She is calling, um, so the two children have claims out there?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] That were denied as benefits were exhausted.
[CUSTOMER][NEUTRAL] That are on this policy um for.
[CUSTOMER][NEUTRAL] [PII] and [PII], which is part 2 and part 3.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] On [PII], the claim number is oh gosh, my computer's so slow um the claim number is 3605545.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] When I read the remarks to her she said that's incorrect that um nothing has been paid out so.
[CUSTOMER][POSITIVE] The benefits are not exhausted.
[CUSTOMER][NEGATIVE] And she wants to speak to somebody. She said the last time that she got transferred, she was put on hold for a very long time and nobody came to the phone.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEGATIVE] I'm gonna go back to her and let her know that I've got you on the phone and just because she got that bad experience before it's gonna be just.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yeah, that I'm getting it pulled up, yeah.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] [PII], are you there?
[AGENT][NEUTRAL] I am. I'm looking at the policy just so I can see how many are allowed.
[CUSTOMER][POSITIVE] OK, good.
[AGENT][NEUTRAL] Let's see
[CUSTOMER][NEUTRAL] Right, and I'm gonna put, I'm gonna put you on a hold for just a second. Let me adjust my um Wi Fi real quick.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you. Everything is so slow I don't understand if it's just the computer is thinking too hard or what's going on?
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] OK, so the thing is, is that this is a 21 policy and it is per plan year not calendar year.
[AGENT][NEUTRAL] So plan year is from.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Their effective day to the day before.
[AGENT][NEUTRAL] In the following year, so her plan year would be 51 of 24 through 4:30 of 25, and [PII] and [PII] both have already had a screening during that time frame, so it is maxed out, it's not calendar year, so we're not gonna pay one per [PII] and one for [PII] and etc. it's, it's the plan year time frame and that is in her policy as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, all right, um, would you mind letting her know that or do you want me to tell her?
[AGENT][NEUTRAL] Um, what, what would you be more comfortable with?
[CUSTOMER][NEGATIVE] I would be more comfortable with her hearing it from a claim specialist because that's who she had mentioned that she was supposed to talk to before.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, I can let her know.
[CUSTOMER][POSITIVE] OK, so I'm gonna release the call and let you thanks [PII]. I appreciate it bye bye.
[AGENT][POSITIVE] No problem.
[AGENT][NEUTRAL] Bye bye.
[AGENT][POSITIVE] Thank you for calling clients. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling on behalf of one of our clients, [PII] at Peas in a Pod.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so
[CUSTOMER][NEUTRAL] I filed claims on her none of them were paid out or approved or anything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And now it's saying that she's received max benefits for the plan year but she never even received any payout or claims.
[AGENT][NEUTRAL] OK, um, so I have looked at part 2 and part 3, [PII] and [PII] with um the customer care rep prior to getting you transferred just so I could make sure I knew what I knew what we were looking at and um so this policy, this particular benefit is paid by plan year not by calendar year.
[AGENT][NEUTRAL] So a plan year goes from their effective date and then goes to the day before the next effective day, so her plan year would be um and I'll actually let's see the definition of plan year should be in the policy as well in case you need to reference it.
[AGENT][NEUTRAL] Um, it is, so it is on page 19 of the policy under definitions, and it states the time period commencing on the policy effective date and ending the day before the next policy anniversary.
[AGENT][NEUTRAL] Um, and then it does that every year after, so to be a 12 month period. So when I put that, when I review the history in our system and I put in a date span of [PII], which was her effective date through [PII], we have already paid a screening for [PII], and [PII].
[AGENT][NEUTRAL] So it is maxed for the plan year so that's why they were denied that way saying and when you look at the um remark code that'll be the difference too when you're looking at it is um it doesn't say that like it's been.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Maxed for the calendar year or for that date of service it indicates um um hang on.
[AGENT][NEUTRAL] Let me get it pulled back up my system this time, so it says this benefit has been exhausted for the plan year and that's your indication that it's not gonna be like a normal like we'll pay one per 2024 per person and one in [PII] per person, yeah, so it's gonna be that we go from there to the.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That.
[CUSTOMER][NEUTRAL] So with her effective date being [PII], now her, we would be in a new plan year though.
[CUSTOMER][NEUTRAL] Now
[AGENT][POSITIVE] Yes, we can do here.
[AGENT][NEUTRAL] Mhm so her.
[AGENT][NEUTRAL] To kind of any benefit.
[CUSTOMER][NEGATIVE] I'm sorry, you're cutting out really bad. I can't hear anything.
[AGENT][NEUTRAL] Sorry, can you hear me?
[CUSTOMER][NEGATIVE] No, like it's still cutting out bad.
[AGENT][NEUTRAL] Can you hear me?
[AGENT][NEUTRAL] I'm sorry, I don't know what's going on.
[CUSTOMER][NEUTRAL] I can kind of make out what you're what you're saying.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh goodness.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Can you hear me?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEGATIVE] I can hear you. It's just, it's still cutting out.
[AGENT][NEUTRAL] OK, I'm sorry, I don't know why, um, no benefits have been used for the current plan year which is 5125 to 430 of 26, so she still has that benefit for the current plan year.
[CUSTOMER][NEUTRAL] OK, so we still we can file again and she'll be able to claim it.
[AGENT][NEUTRAL] Yes, as long as the day that is or later.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For yeah for [PII] to [PII].
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] You said 5125?
[AGENT][NEUTRAL] Ma'am.
[CUSTOMER][NEUTRAL] OK, well then I would that was all I needed.
[CUSTOMER][NEGATIVE] You're cutting out really bad. I, I don't even hear anything anymore. I'm just gonna end the call.