AccountId: 011433970860
ContactId: ab8f7e71-0711-4f90-847c-5d300073de04
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 330079 ms
Total Talk Time (AGENT): 225299 ms
Total Talk Time (CUSTOMER): 76987 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/ab8f7e71-0711-4f90-847c-5d300073de04_20250109T19:00_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEGATIVE] Yes ma'am, I was just calling about a claim that I had filed um it shows that it's processed and they didn't pay anything on it.
[AGENT][POSITIVE] Certainly I'd be happy to help you with that claim inquiry. Can I have your name?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] And provide me your callback number, Mr. [PII] in case we get disconnected.
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you and do you have your policy number handy?
[CUSTOMER][NEUTRAL] I, I have my claim number. Would that help?
[AGENT][NEUTRAL] They all help? Sure.
[CUSTOMER][NEUTRAL] OK, it is 354-955-5.
[AGENT][NEUTRAL] OK, thank you, just give me one moment to access that claim.
[AGENT][NEUTRAL] I'll have you verify some information and then we can take a look at it.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Go ahead and uh verify your date of birth please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and that last piece of verification your email address please.
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][POSITIVE] Thank you, thank you for verifying that information.
[AGENT][NEUTRAL] And it looks like it's for um looks like the accident date was [PII] and the date of service uh was [PII], is that right?
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] Yes, yes ma'am, that's correct.
[AGENT][NEUTRAL] OK, so it appears that um the information let me pull this up, just give me one moment and I can review.
[AGENT][NEUTRAL] The actual documents that were.
[AGENT][NEUTRAL] Submitted.
[AGENT][NEUTRAL] So it looks like the claim was denied due to there was no accidental injury diagnosis. Now, um, it does indicate here on your claim form that you injured your hand.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEGATIVE] Yes, I injured my wrist. Yes, and it was, it was all week before I could get into the doctor and it had, it was swollen. It was swollen and bruised, and by the time I got into the doctor, it was still swollen and bruised. It wasn't a lot of pain, but they did an X-ray anyway to make sure there was no fracture.
[AGENT][NEUTRAL] Trying to
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right. So they do indicate that it, um, I'm looking at the progress notes. They do indicate that it was for a fall. However, we didn't have an accidental bodily injury diagnosis. And what that means is that we're not saying it wasn't an accident, but basically, the policy does um have specific language as it must be an accidental injury diagnosis.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so the diagnosis that we're listed on the office notes don't indicate any kind of accidental injury, um.
[AGENT][NEUTRAL] And what that means is it can be a strain, a sprain, a bruise, a contusion, a fracture, you know, a sprain, but it does, it, it has to meet that criteria for that accidental bodily injury. And according to what was listed as the diagnosis codes, they didn't indicate any of that. In addition to that, sometimes um if the um documentation supports, um,
[AGENT][NEUTRAL] An accidental bodily injury, then we could also look at that information. However, it did indicate on the um X-ray that it was just for a pain after a fall injury. So we can't use that pain diagnosis even on that X-ray because like I said, it does need to meet that um accidental injury, bodily injury, excuse me.
[AGENT][NEUTRAL] And it has to be, what that means is that's just independent from any disease um or uh let's see how it's worded here. It has to be, um, it has to be a sudden unexpected, unintended event, which is independent from a disease or bodily infirmary, um, or any other excluded cause, which is why we can't use that pain.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, um, the only thing that I could suggest is possibly contacting the physician and asking them to include that, uh, bodily injury diagnosis, um, because it is not present in the uh details that were provided in the progress note.
[CUSTOMER][NEUTRAL] OK, I understand. OK. So, uh, the only, the bodily injury that I experienced was just swelling and bruising, does that qualify or not?
[AGENT][NEUTRAL] Well, if it has that, um, like I said, it can be bruising contusion that is um a swelling. Um, usually, it, it, the swelling probably is more associated with pain, but if there was bruising, contusion is a payable um accidental injury diagnosis, I should say. So it would qualify if it has, if it meets that um criteria.
[CUSTOMER][POSITIVE] OK, I understand. OK well that answered my question and thank you so much for your help.
[AGENT][POSITIVE] You're welcome, Mr. [PII], and I hope your hand's feeling better, your wrist. I hope it's feeling better.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][POSITIVE] Thank you so much. OK, thank you, ma'am.
[AGENT][POSITIVE] Thank you for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Mm bye bye.
[AGENT][NEUTRAL] Bye bye.