AccountId: 011433970860
ContactId: ad732621-53a5-42d7-877c-f3c8b0abf077
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 974229 ms
Total Talk Time (AGENT): 339411 ms
Total Talk Time (CUSTOMER): 453359 ms
Interruptions: 4
Overall Sentiment: AGENT=1.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/ad732621-53a5-42d7-877c-f3c8b0abf077_20250107T19:21_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] So I'm calling in regards to check the status on my uh accidental insurance claim.
[AGENT][NEUTRAL] OK, yeah, I can check a claim for you. I'm sorry, what was your name?
[CUSTOMER][NEUTRAL] I'm [PII].
[AGENT][NEUTRAL] OK, and [PII], can I get a good call back number from you really quick in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] All right, thank you. Do you have your policy number?
[CUSTOMER][NEUTRAL] Yes, it's gonna be 991306.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Alright, just gonna verify some information. [PII], can I get your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then can I get your mailing address?
[CUSTOMER][NEUTRAL] It's gonna be [PII].
[AGENT][NEUTRAL] Perfect. Last thing I need is the email address that we've got on file for you. It looks like it might be through an organization.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, ma'am, it's gonna be uh [PII].
[AGENT][POSITIVE] Perfect alrighty thank you so much for verifying that information.
[AGENT][NEUTRAL] OK, so let's see.
[AGENT][NEUTRAL] So we got two claims submitted on [PII]. Does that sound right to you?
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] OK, one moment please.
[AGENT][POSITIVE] Bear with me just a moment, [PII]. I appreciate your patience. It's going a little bit slow today.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] No problem.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, um, was this claim for data service, um, [PII], uh, at Methodist Hospital, is that right?
[CUSTOMER][NEUTRAL] Yes, and uh this new paperwork, yeah, I resubmitted uh uh more paperwork cause the first time, uh, the, the claim was closed and uh so I sent more information, more detailed information on my client.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I see. OK, got you. All right, yeah, sorry about that confusion there. OK, just a moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK [PII], if you don't mind I'm gonna put you on a brief hold and reach out to our uh claims specialist so they can take a look at this for me and see where it's at Give me just a moment.
[CUSTOMER][POSITIVE] OK, ma'am, no problem.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Uh-huh. You are on hold.
[CUSTOMER][POSITIVE] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] Doing all right, thank you. Um, wanting some help, uh, regarding an accident claim. I've got the insured on the line. Uh, he submitted a claim originally, stated it needed more information. He said he received or he did send that information. When I look at that claim though, it just says miscellaneous correspondence from insured and or provider. I'm not quite sure.
[CUSTOMER][NEUTRAL] OK, what is that policy number? Let me take a look.
[AGENT][NEUTRAL] Sure it is 991306.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, give me just a second here.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, that's the 354-600-03?
[AGENT][NEUTRAL] Yes, um, and I did, I did see that it referenced it said educational claim and I saw the original claim, um.
[AGENT][NEUTRAL] But he said that this one was supposed to be that additional information we needed.
[CUSTOMER][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] OK, he sent an appeal.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Did he send the information we needed or did he just send.
[CUSTOMER][NEGATIVE] Um, because page 2 states, I, [PII] am disputing my denied accidental insurance claim. I went to the ER because I accidentally slipped on water in the shower that caused me to land and hurt.
[CUSTOMER][NEUTRAL] My left knee and twist my back awkwardly. I'm sending more detailed information on the accidental slip and fall that I had on [PII].
[CUSTOMER][NEUTRAL] So he sent an appeal, um, the claim number 3514276. Let's take a look here.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Which, that one, it states no accidental bodily injury.
[CUSTOMER][NEUTRAL] OK, so let's see.
[CUSTOMER][NEGATIVE] Uh sorry, I'm sick as a dog.
[AGENT][NEUTRAL] No, no, you're fine.
[CUSTOMER][NEGATIVE] I'm just not with it today.
[AGENT][POSITIVE] Oh, it's I think everything is going around. Shoot might have to, I think they're talking about possibly another mask mandate and all that fun stuff.
[CUSTOMER][NEGATIVE] Oh God, I haven't heard that. I've been to urgent care. My primary care can't get me in. They're like full. I've been to urgent care 3 times in 5 weeks.
[AGENT][NEUTRAL] Oh man.
[AGENT][NEUTRAL] Oh, that's why I'm not looking forward to my son going back to school cause I was like, we'd be fine if we just stayed here, but he's gonna catch everything there and bring it all back here.
[CUSTOMER][NEUTRAL] Yeah, I've
[CUSTOMER][NEUTRAL] Yeah, no, I've had flu, rhinovirus 2 days prior to [PII] and then 2 weeks later, I had COVID. And then yesterday, I went back and my right lung is full, it fluid and infection, and it's, I'm wheezing and then now I just have a viral infection. And let me tell you what, this right here that I have beats everything I've ever had in my life.
[AGENT][POSITIVE] Oh my gosh.
[AGENT][POSITIVE] And you're still working. You are a superhero. What are you doing?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] I've woke my husband up the past two nights crying because I'm hurting so bad.
[AGENT][POSITIVE] Oh my gosh, girl, you need to take care of yourself.
[CUSTOMER][NEUTRAL] Oh, OK, so on page 4 of this information that he sent, it states that the chief complaint is back pain and left knee pain, so there's no bodily injury. So that's why this appeal that he sent in, which states to state that he's disputing the denial. So the appeal was still denied. It was upheld. The original decision was upheld.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I guess I was more confused why it didn't state that.
[AGENT][NEUTRAL] It was just his correspondence, but OK, I appreciate you looking at that for me. I'll go ahead and let him know and that was just simply because there, it was just pain. Like there wasn't actually an injury.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] A bodily injury, yes, ma'am. This is a bodily injury accidental policy. So there's no bodily injury. Um, the diagnosis code, like I said, um, I wanna say page 4, it clearly states back pain and left knee pain. It does not state, um.
[AGENT][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That there's bodily injury done.
[AGENT][POSITIVE] Got it. OK, I will let him know thank you so much take care of yourself. I hope you feel better soon.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Thank you. Mm bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.
[AGENT][POSITIVE] All right, [PII], I'm so sorry about that wait. Are you still with me?
[CUSTOMER][NEUTRAL] Yes, ma'am, I'm here.
[AGENT][NEUTRAL] OK, so, um, I did get with the claim specialist, so, um, I did see in the original claim that it was stating that there was no bodily injury and therefore we weren't able to make a claim.
[AGENT][NEUTRAL] Um, and so I didn't realize what you had sent was an appeal. Um, so essentially the claim denial did, um, it was upheld as there was no bodily injury. Um, pain does not count for bodily injury under this policy, so it's still not something we would be able to cover.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, well, it was an accident, ma'am, and uh it's clearly states on there it was a knee injury and, uh, that's what they wanted. They wanted more detailed information on the injury because originally they said that they showed nothing about an accident that that occurred on the original, um, paperwork that I submitted so they wanted, they wanted to.
[AGENT][NEUTRAL] Right. It's more the lack of the bodily injury, whereas pain is not going to be considered that. Sorry, go ahead.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Well, I mean, it it was a knee spray that's, it clearly shows the, the stuff that I sent the second time around for uh the uh [PII]. Uh, it states all that, it's all the doctor's position notes and everything.
[AGENT][NEUTRAL] OK, OK, um, let me put you back on that hold [PII], um, and I'll get right back with you, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, this is [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you Ka?
[AGENT][NEUTRAL] Doing all right, thank you. I actually just got off with [PII] um the same insured, um, I think he's gonna have to talk to y'all though he's um.
[AGENT][NEUTRAL] Essentially he filed a claim for an accident. We denied it as there was no bodily injury. He sent in an appeal with all kinds of information stating that it was, and from what [PII] told me was essentially that decision was upheld, that it was not a bodily injury for his policy, and so he's arguing with me about that, so I'm not quite sure.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, what's the policy?
[AGENT][NEUTRAL] It is 991306.
[AGENT][NEUTRAL] Sorry to dump this on you.
[CUSTOMER][NEUTRAL] No, it's OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You're not being mean or anything, just, you know.
[CUSTOMER][NEUTRAL] Yeah, just
[AGENT][NEGATIVE] Yeah, [PII].
[CUSTOMER][NEUTRAL] It's yeah and these um these accident policies like.
[CUSTOMER][NEUTRAL] You know, it's, it's hard because we're not saying, of course, that they didn't have an accident like it's not, we're not saying you didn't fall and whatever, it's just that per your language, it, it just doesn't meet the definition.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Exactly.
[AGENT][NEUTRAL] Exactly, and again I think that's where it, it could be lost in interpretation as well, so.
[CUSTOMER][NEUTRAL] Yeah, for sure, OK, so I've got.
[CUSTOMER][NEUTRAL] All of that I've got the appeal pulled up and I've got the claim pulled up so.
[AGENT][NEUTRAL] The original, OK.
[CUSTOMER][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] Went to the ER, slipped in water, hurt his knee and twisted his back.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I think I remember going over this one with Charlotte before she responded and the biggest reason for it.
[CUSTOMER][NEUTRAL] was because everything they have is pain. They're not saying that he actually injured himself.
[AGENT][NEUTRAL] That's, yeah. That's what um [PII] told me. That's what I told him, but he said that he included doctor's notes in there for when he, he went to receive treatment. But again, um, if it was just, you know, pain medicine or something, I'm not quite sure.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Let's see, OK, um, presents do.
[CUSTOMER][NEUTRAL] For evaluation of pain in the knee and back.
[CUSTOMER][NEGATIVE] Slipped and fell.
[CUSTOMER][NEGATIVE] Uh, landed on his knee, twisted his back, did not hit his head, started having pain.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] OK, again, just pain.
[CUSTOMER][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Did a
[CUSTOMER][POSITIVE] Physical exam, no deformities.
[CUSTOMER][NEGATIVE] Doesn't mention any type of bruising.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Evaluated for acute fracture versus a sprain.
[CUSTOMER][NEUTRAL] says that they suspect his pain is secondary to a muscle spasm.
[CUSTOMER][NEUTRAL] Which again is not.
[AGENT][NEUTRAL] Right, not due to an accident, yeah.
[CUSTOMER][NEUTRAL] An accident.
[CUSTOMER][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] Believe his back pain is muscle spasm. There were no fractures. Do not believe he's having an acute spinal pathology given there's no tenderness.
[CUSTOMER][NEUTRAL] It says that I believe his left knee pain is either sprained or contusion since there's no fracture, but he did not diagnose him.
[CUSTOMER][NEUTRAL] And I remember
[CUSTOMER][NEUTRAL] Um, [PII] going over that and I said, you know, if he would have said that there was.
[AGENT][NEGATIVE] Weird.
[CUSTOMER][NEUTRAL] You know, a diagnosis of a sprain or whatever. Um,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Then I would say yeah OK let's let's go back on that and pay it um it says again patient instructions.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Acute knee pain, muscle cramps, and spasms. No mention of a sprain or a contusion. He again says, I believe your knee pain is secondary to either a mild sprain or possible contusion, but that is not, it was not confirmed. So they did not right. So they didn't diagnose it. They just said that he was having pain and cramps and spasms. So because there's not an actual diagnosis of an injury, even
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Nothing definitive. Mhm.
[CUSTOMER][NEUTRAL] You know, cause a contusion, all it is is a bruise.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] But they did not definitively diagnose him with that. The only definitive diagnosis is pain.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's just not payable now if you need I mean if if you've kind of already given that and you need me to reiterate I'm happy OK yeah I can.
[AGENT][MIXED] Yeah, I, I would really appreciate that. Yes, because again, I think [PII] kind of broke it down a bit because again, it does seem, she didn't go quite as in depth with I, I really do appreciate you walking me through that too. I mean, it's very interesting. I like learning about that stuff too. Um, but as far as, you know, yeah, it just seems like it's just pain. So I did tell him that he just kept mentioning his knee and what he submitted, so I don't want to say anything if it's not right. So that's why I'd just rather reach out to y'all.
[CUSTOMER][NEUTRAL] Yeah, of course.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, of course.
[CUSTOMER][POSITIVE] Yep, no problem at all. I will do what I can.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] I appreciate you so much. Thank you. Are you ready for him now?
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[AGENT][POSITIVE] OK thank you hope you have a great rest of your day.
[CUSTOMER][POSITIVE] You're welcome. You too.
[AGENT][NEUTRAL] Alright bye bye.
[CUSTOMER][NEUTRAL] Bye bye.