AccountId: 011433970860
ContactId: b67cb1be-b4d6-406a-a728-19dd41723c40
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 741099 ms
Total Talk Time (AGENT): 184813 ms
Total Talk Time (CUSTOMER): 275400 ms
Interruptions: 4
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/17/b67cb1be-b4d6-406a-a728-19dd41723c40_20250217T14:32_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Hey, [PII], it's [PII]. Happy Monday. Yay. Yay.
[AGENT][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] I have an insured on the line. It's gonna take a little bit more research um to assist him. He's frustrated.
[CUSTOMER][NEUTRAL] I've got policy number 228.
[CUSTOMER][NEUTRAL] 3755
[CUSTOMER][NEUTRAL] [PII], I've verified all of his information.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Uh, we went over the denial of the claim, and he says that he's called several times. He got hurt on the job, hurt his back, went to the ER, went to urgent care, he's been to physical therapy.
[CUSTOMER][NEUTRAL] And we're trying every way we can to find not to pay the claim. We went over the fact, well, I told him that the accident policy pays due to a bodily injury.
[CUSTOMER][NEUTRAL] Due to an accident.
[CUSTOMER][NEUTRAL] And I said, according to the new cause I did review the new claim, it, and I said, it does say back pain, but it doesn't say what caused the back pain. And I said, we need that accident, diagnosis or reason. He could say, well, I'll tell y'all what it is. I say we need medical anyway. Can you look at this with him and just make sure we don't have anything from the ER or anything with the
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me glance and see what we got. Let's see.
[CUSTOMER][NEGATIVE] And he's very frustrating. I mean, I get it.
[AGENT][NEUTRAL] Trying to see if any of this information.
[AGENT][NEUTRAL] indicate any bodily injury. So far, I'm not seeing anything. I see this is like physical therapy notes or something, most recent mail.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] See, let me keep glancing.
[CUSTOMER][NEUTRAL] Yeah, I never saw anything due to an accident.
[AGENT][NEUTRAL] This is what workers can follow-ups.
[AGENT][NEUTRAL] Yeah, none of this is seeing an injury or anything. It's just saying back pain, which that's not bodily injury. They all got the same diagnosis code on the end of these work comp.
[AGENT][NEUTRAL] Documents
[CUSTOMER][NEUTRAL] And he said he went to the emergency room. And if he told them why he hurt, why his back is hurt and what caused it, you know, we should be able to get documentation for that, right?
[AGENT][NEUTRAL] Look at this
[AGENT][NEUTRAL] Yeah, if you can provide us with some additional information, let me see what he previously sent in.
[CUSTOMER][NEUTRAL] And that's what he keeps saying all we're trying to do is keep asking for more stuff and more stuff.
[CUSTOMER][NEUTRAL] And trying to find a way to not pay the claim. And I, I do understand his frustration.
[AGENT][NEUTRAL] So what he sent, OK, he sent the bill which it has a diagnosis code. I'm just wanna make sure he didn't send the records on this other mail real quick.
[AGENT][NEUTRAL] To make sure looks like we only got the bill so far for the ER and then his workers' comp stuff.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, I mean, you can send it to me. I'm pretty much tell him the same thing that the polyphonic covers due to bodily injury. Um he can submit additional information.
[AGENT][NEUTRAL] Um, supporting documents that indicate an injury.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] bodily injury did occur or he can also submit in an appeal is what I'm gonna tell him.
[AGENT][NEUTRAL] If you disagree with the decision.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, if, maybe if you could get, do we have the ER medical notes?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No, just only the bill.
[AGENT][NEUTRAL] I just see we only have the hospital bill and it has the diagnosis code, low back pain. That's where we originally got the diagnosis code from.
[CUSTOMER][NEGATIVE] Yeah, I should have told him that low back pain can be caused from an illness or, you know, but because this is an accident policy, you know, it has to be due to an accident, an injury caused by an, anyway, uh.
[CUSTOMER][POSITIVE] Anyway, can, if you can talk to him, I think that'll make him feel good.
[AGENT][NEUTRAL] Yeah, you can send it to me. I'm pretty much gonna tell him the same thing and if you want to submit an appeal, if you disagree.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Alright then I appreciate it. Let me get him on the line. Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Alright, Mr. [PII], thank you for your patience. I have [PII] on the line and she has been reviewing your documents and she's going to assist you further, OK?
[CUSTOMER][POSITIVE] OK. All right. Thank you, sir. I hope you get to feeling better.
[AGENT][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Thank you. Yes.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi. So I was looking at the information that we did receive in um regarding the [PII] visit. It looks like based off the information that was submitted to us, it looks like it was due to a low back pain. Under this policy, it is an accident policy and it only covers if there was a bodily injury that incurred from this information that we have.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] It is a bodily injury.
[AGENT][NEUTRAL] is indicating a low back pain. So if you can either provide supporting documentation that indicates bodily injury or physical damage that occurred.
[CUSTOMER][NEUTRAL] It's not a low back pain, it's an injury.
[CUSTOMER][NEUTRAL] I have.
[CUSTOMER][NEGATIVE] I have. I've been to the ER. I've been to the urgent care about 3 times due to the, the injury I had at work. And then I'm now in physical therapy due to that injury.
[AGENT][NEUTRAL] OK, so low.
[CUSTOMER][NEGATIVE] What, what more proof do you guys need? It's not just, it's not just pain, it's an injury inside my body. Just because I haven't had um
[AGENT][POSITIVE] Low back pain
[CUSTOMER][NEUTRAL] I had an X-ray, but that doesn't do that, that, that does bones, that doesn't do nerves and muscles inside. Are you guys willing to pay for that? Because I'm not.
[CUSTOMER][NEGATIVE] You guys need to you need you guys need to pay for what I've been for what I already spent on that.
[CUSTOMER][NEGATIVE] I already provided the documentation from the medical bills of what I spent due to that injury. I was off work for one week. I got, I got paid by workers' comp due to that injury.
[CUSTOMER][NEGATIVE] I was off for one week, I couldn't walk, and it's, it's, it was an injury. It's not back pain, it's a, it's a lower back injury. I'm still hurting from that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So from the information that they indicated, it just says low back pain. So if it, there was an actual injury, bodily injury that did occur, you can submit that supporting documentation.
[CUSTOMER][NEGATIVE] I don't understand what you guys need.
[CUSTOMER][NEUTRAL] I need to speak to like one of your supervisors or something.
[CUSTOMER][NEGATIVE] Can you, can you put me on the phone with your supervisor, with whoever is in charge of this whole deal because it's unacceptable.
[CUSTOMER][NEUTRAL] This, this, this is, this is an injury. It's it's more than enough proof to back to, to process the, the.
[CUSTOMER][NEUTRAL] The, the claim.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I've been through ER. I've been through ERs. I've been through urgent cares more than 3 times, and I'm now doing physical therapy due to that injury. Why would I be a physical therapy, if it was just lower back pain?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Based off the information, that's what they provided to us. So if there was an act, their injury, we'll need supporting medical documentation that indicates that.
[CUSTOMER][NEGATIVE] I wouldn't. It's an injury.
[AGENT][NEUTRAL] Cause what they provide, what provided to us.
[CUSTOMER][NEUTRAL] I need to speak to whoever is in charge for you.
[AGENT][NEUTRAL] OK, sure, let me see if someone's available give me one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] The person you are trying to reach.
[AGENT][NEUTRAL] Thanks for holding Mr. [PII]. Supervisor is currently not available. I can take your number and have them give you a call back.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, no, that's, I know how that works, man. What, what exactly do you need?
[AGENT][NEUTRAL] We're
[CUSTOMER][NEGATIVE] Because I've provided everything and you guys keep declining the claim. What exactly do you need?
[AGENT][NEUTRAL] If
[AGENT][NEUTRAL] If you can provide us with medical records that indicate that bodily injury did occur.
[CUSTOMER][NEUTRAL] I provided the medical records.
[CUSTOMER][NEUTRAL] We can