AccountId: 011433970860
ContactId: b7b7b2b3-10f2-4edb-b26b-390b6f522369
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1109569 ms
Total Talk Time (AGENT): 563227 ms
Total Talk Time (CUSTOMER): 496839 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/b7b7b2b3-10f2-4edb-b26b-390b6f522369_20250227T17:40_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]. How are you? This is [PII].
[AGENT][NEUTRAL] Hi [PII], how are you?
[CUSTOMER][NEUTRAL] I'm good, thank you. I have a member on the line um he's calling about a claim and he don't want to call back. Um, so, um, the policy number is 2444567.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And he's stating that he did send out the information indicating it was a bodily injury and he don't understand why it's still being denied.
[AGENT][NEUTRAL] It's for [PII].
[CUSTOMER][NEUTRAL] Mhm I remember [PII].
[AGENT][NEUTRAL] OK, and I'm gonna pull that.
[AGENT][NEUTRAL] Information up and he has been verified so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, it's fully verified. The callback number is the same one in the system.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, is that the one that appears on the screen, the [PII]? OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm [PII]. Yeah, that's it. OK, let me know when you're ready.
[AGENT][POSITIVE] Um, you can send them through. Thank you.
[CUSTOMER][POSITIVE] OK, thank you. Have a good day.
[AGENT][POSITIVE] You too thank you.
[CUSTOMER][POSITIVE] And you're welcome. Thank you for holding and being patient for him, Mr. [PII]. I got Ms. [PII] on the line. She's in the claims department. She's gonna assist you from here.
[CUSTOMER][POSITIVE] OK. Thank you have a good day bye bye.
[AGENT][NEUTRAL] Hi, good afternoon, Mr. [PII]. This is [PII] in the claims department. Um, I understand you had some questions in regards to a denial for your claim on the accident, uh, policy. Is that correct? OK. So let me just pull up, I'm gonna pull up that documentation if you'll bear with me for just a moment while I do that. My system's being a little slow, so it'll just take a moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, yes.
[CUSTOMER][NEUTRAL] Yes it is uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Let's try a different way.
[AGENT][NEUTRAL] OK, so it looks like we received a um CMS 1500 claim form and it looks like it was a visit on [PII] to Center Point Orthopedics.
[CUSTOMER][NEUTRAL] Yes, that was one of them, and that was sent in reference to the previous claim where I sent an MRI showing uh from the doctor of the accident, and you guys was asking me, that claim was denied because you guys was asking me for receipts. So then I sent this claim in uh Center Point in which I'm, I'm gonna send a, I was gonna send another receipt in as well. I'm waiting for it to come in the mail.
[CUSTOMER][NEGATIVE] And this one you guys are saying that I have no proof of bodily, bodily injury. I'm, I'm confused on all of this.
[AGENT][NEUTRAL] OK, sure. Let me, um.
[AGENT][NEUTRAL] I'm pulling up your claim form now. Uh, just bear with me for a moment and I'm looking at that original document, uh, the original documents that were sent in. OK. So it looks like.
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][NEUTRAL] Yes, please. OK.
[CUSTOMER][POSITIVE] Yes please, yes.
[AGENT][NEUTRAL] OK, so it looks like the original injury, the date of accident [PII], and it was your right knee that was injured, correct?
[CUSTOMER][POSITIVE] Correct, yeah, correct, meniscus tear, yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It shows it all on there and everything. And so I sent all that proof in, but then you guys said, so, well, I need receipts. So then I didn't know that till late, so I start going out, backtracking, getting receipts. One was from Center Point, and then another one's gonna be coming from the actual MRI diagnosis place, which I'm waiting for it to come in the mail.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, so what we were needing was the itemized billing. So then we see that you did send in that CMS uh for that [PII] date. That CMS is just like there, um, that's what the doctors and hospitals use to bill to insurance companies. Um, so that is sufficient documents. However, the reason why it was denied as non, uh, no bodily injury is because the diagnosis indicates that it was just pain in the knee.
[AGENT][NEUTRAL] Now, with this policy, it does require that bodily injury. So we know that there was an accident, um, however, it occurred, um, isn't what is, uh, um, what we're looking for. What we're looking for is that bodily injury, um, diagnosis, and that could be a strain, a sprain, a contusion, a fracture, and in your case, where it was a meniscus tear.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, you don't, yeah, so, needing surgery to fix that is not bodily, bodily injury enough, cause it says on that document, I have a, uh, of, of, I can't think of the exact doctor's term would to use, a fatigue or flattened something in this area of the knee, and that's where it causes for surgery. And that, and I'm scheduled for surgery as well.
[CUSTOMER][NEUTRAL] And it's on that sheet of paper right on there somewhere, it shows a, uh, I can't think of the term, but it shows a flatten or a tear or, or something has in this part of it.
[AGENT][NEUTRAL] And that was in the MRI correct?
[CUSTOMER][NEUTRAL] Yes, yes, that's in the MRI, yes.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] Yes, it's kind of toward the top.
[CUSTOMER][NEUTRAL] Left top part right there, somewhere in there.
[CUSTOMER][NEUTRAL] And it was, it was diagnosed and that right there is the reason I have to. So I went to
[CUSTOMER][NEUTRAL] Back to center point, cause I had to go back to him after the MRI. So he looked at the MRI, Doctor [PII], which that's what you, I've sent in with you guys.
[CUSTOMER][NEUTRAL] And he's gone, and he said, Well, you're gonna need surgery. That's the only way you're gonna fix, fix that is surgery, and it shows that in the MRI right there.
[AGENT][NEUTRAL] OK, so this is the MRI that you had on [PII], correct?
[CUSTOMER][POSITIVE] Correct, yes, yes.
[AGENT][NEUTRAL] OK, because unfortunately, that's where it says at the top where it says the right knee, uh, MRI right knee without contrast, it tells us the technique and then it says the indication is knee pain for 6 months. So it doesn't tell us that there was an, an, you know, that was injured in an accident. It just says there was pain for 6 for 6 months.
[AGENT][NEUTRAL] So, um, that, and, and, and again, when we received the additional claim from that you submitted for the CMS, uh, the billing form that you submitted for 122 from Center Point just indicates again that it's knee pain. So what we're needing is that bodily injury diagnosis. And again, that needs to tell us that it was an, that, that the um
[AGENT][NEUTRAL] that the uh injury or that the um accident is what caused your injury to your knee. And excuse me, and then that accidental bodily injury diagnosis would um meet that, uh, that
[AGENT][NEUTRAL] Deter so we can make that correct determination, but it needs to meet that bodily injury, that threshold for being a bodily injury related to an accident because everything right now is just pointing to its knee pain.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Now, is there any documents from the orthopedic that would indicate that it was an accident?
[CUSTOMER][POSITIVE] Wow,
[CUSTOMER][NEUTRAL] You, I, I don't, I don't, I don't, I, I don't know if every, if any doctor former tell you suffers from an accident other than an actual police report. Like, like, cause if somebody's in a car accident,
[AGENT][NEUTRAL] Or related to
[CUSTOMER][NEUTRAL] Even if you go to the doctor, the doctor ain't gonna put down where the car accident caused him to have a, a, a shoulder break his shoulder. He gonna put down the broken shoulder, blah, blah, blah. You have to go get the further information before that. I, I tore that meniscus tear at an accident, uh, playing a sport. Then I went to the doctor.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I don't know. The doctor didn't see me tear it.
[AGENT][NEUTRAL] No, but they would, no, but they're gonna, what, OK, I understand what you're saying, but actually they would indicate it. So what happens is when you go to the doctor and you say, I hurt my knee playing tennis, usually they'll document that in their, in their notes because they have to document that in order for, you know, that.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] To meet that insurance claim and when the insurance claim goes and then also they do it because if they order additional tests like in this case it looks like they did an X-ray, but then of course they needed to see, they needed to get further examination which would indicate why you had to have the diagnostic test for the MRI.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] True.
[AGENT][NEUTRAL] So, again, what we're looking for is that accidental bodily injury diagnosis. And like I said, it can mean any, it can meet, as long as it meets that bodily injury. But unfortunately, pain is not um is not part of, would, would not be a payable diagnosis for that injury because it has to meet that um and what it says, what that means is, um, the, the bodily injury.
[CUSTOMER][NEUTRAL] True, OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] will tell us that it's separate from anything else, like again, for pain or just overuse or something like that. Um, so we needed to, to, yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, I get what you're saying.
[CUSTOMER][NEUTRAL] Yeah. So when he, when I, uh, he kind of mentioned it when he was doing it, he, so he said, you must have did it when you twisted it as you was turning, playing tennis or playing the sport, and that will cause the tear. Something saying stuff like that is what you're saying. Like, uh,
[AGENT][NEUTRAL] Right, because at this point, it indicates that, like I said, it, a lot of times that, I mean, with your knee or actually any kind of injury, we, we just need something that says that it was related to that incident where you were playing tennis or, or something of that nature, but we need that diagnosis to indicate that it was bodily injury. And again, we understand that your knee hurts because
[AGENT][NEUTRAL] You were, um, playing tennis and however, that injury occurred, but it just has to meet that accidental bodily injury, meaning that, like I said, that threshold for that injury to the knee. So it can't just be pain. It has to be either it's torn or it's a bruise, a contusion, like I said, anything like that, that would indicate bodily injury.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] I guess this is, I think I'm gonna drop this accidental thing, uh, because, you know, it's not, I've been paying for this thing almost over a year now that something officially happened where I do have a tear, a meniscus tear, injury or I had that surgery. I'm paying for this and it's like, it was a waste of time cause I, I don't, I don't know, it, it wouldn't be no good, even with my wife.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] We're not trying to not pay your claim. It, yeah, we're not trying to not pay the claim. It's just that it has to meet that, um, like I said, it has to meet that criteria in order for it to be considered an accident. And it's not like we're not trying to pay it, we're, we're just needing the documentation to verify it.
[CUSTOMER][NEUTRAL] So when I said, if I was to see.
[CUSTOMER][NEUTRAL] So when I, when I have surgery on this, being that it is to that, so that wouldn't even meet it as well, because from what I'm understanding, it's still not particularly saying that it was directly from an accident from playing sports.
[AGENT][NEUTRAL] Right. And like I said, it doesn't, um, it, well, if we had that, like I said, if we have something that indicates it, like I said, a lot of times supporting documentation could include those office notes from the physician's office.
[CUSTOMER][NEUTRAL] See, yeah.
[AGENT][NEUTRAL] Or the diagnostic test that you had like the MRI to say that it was, um, you know, related to that bodily injury that occurred when you were, uh, again playing, like I said, playing tennis or whatever the the sport may be.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, or it could just be your walking and it, I mean, it happens. Excuse me. Um, you know, a lot of times these bodily injuries that, that's, but like I said, even if the doctor doesn't put that diagnosis on there, if there's something to support it, again, like office notes or diagnostic testing or something that can tell us that it was related to an accident or, you know, that accidental injury, then we would, um, you know, consider that information making our determination.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So basically, what I should have told the doctor, hey, Doc, be sure to put this down, that when I was playing tennis, I turned and it, this was the reason why the tour was. I should have particularly told him to write that down and put that in there. That's, that's it right there.
[AGENT][NEUTRAL] Well, it's, yeah, it's possible that he may have noted it, he may have noted it in your visit that it was, like I said, what happened and what occurred. So.
[CUSTOMER][NEUTRAL] Yeah, unbelievable.
[CUSTOMER][NEUTRAL] I understand. Yeah, but, uh, put yourself in my place now. If all these procedures I don't went through since it first happened from the doctor before then he sent me with the MRI. So, it's really a lost cause, because now, what, what, what it looks like I will have to do is like, like I went back and get this receipt. Now I went back the other day and got the receipt from the diagnosis.
[CUSTOMER][NEUTRAL] What you're asking me is, now I gotta go try to go back and then, doc, can you go into your computer, all your notes from when we started diagnosing my knee, when you said I could, this could happen for me the way I twist and turn it and find that note, print that note out, and then do that to me, asking the doctor to do all of that.
[CUSTOMER][NEUTRAL] Put yourself in my position of, of asking him to do that.
[AGENT][NEUTRAL] Well, do you
[AGENT][NEUTRAL] I, I understand. Um, what, OK, do you have a patient portal with that physician? A lot of times those patient portals are available to you and you would be able to obtain that information um from that patient portal if the doctor, um.
[AGENT][NEUTRAL] You know, if that doctor's office has that patient portal out there. So a lot of times it's that self-service information that, you know, you could go in and look at the notes from or go into that visit from when you saw the doctor and see if that information is out there. Otherwise, my only other suggestion would be that you, you do have the right to appeal it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] And what you could do is um appeal the information and that would be that would just entail that you uh writing us and letting us know you disagree with this decision and here's the reason why and that you want the uh that you wanted to appeal it um based on the information that you're telling me that it was due, was in fact due to that injury.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And like I said, and if you can supply any supporting documentation for the appeal, um, that would be my suggestion if you don't wanna have to uh try to obtain the information from the physician.
[CUSTOMER][NEUTRAL] Now, this, now what I'm gonna do is I'm gonna, uh, reach out to this nurse just one time and I'm just gonna talk to her about it.
[CUSTOMER][NEGATIVE] And if she's not willing to cooperate and or if I can't get something, I'm gonna, I'm gonna cancel this. I'm paying $40 a week, been paying it over a year. I shouldn't have to go through all of this for this. I mean, it's a little, everything I've done is legit, proof legit. The tear is legit. I'm at the surge, the doctor can tell you I'm after surgery. Now I got to fine tune this little thread, and I'm gonna ask the nurse.
[CUSTOMER][NEGATIVE] If that's the case, can't she, you know, find [PII]'s notes within his notes? Was she willing to do that? And she probably almost going to charge me extra to even do this on top of if she even does it. And if I'm just gonna stop it right there, I'm not going to appeal, cause I, it, I shouldn't have to. This, I, I shouldn't have to. And then I'm just gonna end this service with it because
[CUSTOMER][NEUTRAL] It shouldn't be this difficult. I mean, I understand you guys have a have a job to do. I understand you guys have proof, and I've been providing that, but now it's like this extra part. It's like it's trying to make me.
[CUSTOMER][NEGATIVE] Jump through another hoop after I jumped through another hoop. I got jumped to another hoop, but, uh, I'm, I'm gonna call this nurse and I'm gonna see what she can do, and I'm just gonna leave it right there. Then I, if, if she don't help me, I ain't gonna debate it with her. I'm just gonna call and I'm gonna cancel this service with you guys and and call my, my over your payments that you guys total a loss and just leave it like that.
[CUSTOMER][NEUTRAL] So I'm gonna leave it like that.
[AGENT][NEUTRAL] All right. Well, I, again, I, my apologies, Mr. [PII], like I said, we're not trying to not pay the claim. We just have to, again, have that, have to have that documentation that it's not just pain or overuse, that it is an actual injury because it is an accident policy, it does have to meet that accidental bodily injury.
[CUSTOMER][NEUTRAL] It seems like it to me.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] Yeah. OK. Well, it's, it really does seem like you're fighting it for me. But, uh, and, and then that's causing me to add to this.
[CUSTOMER][NEGATIVE] That caused me to be off from work because I can't work on it until I'm gonna have to have surgery. So that caused me to call, uh, to file my disability claim with you guys as well. I guess so much that's, that's gonna be an issue too, because now, cause I had to file that because of it, because the type of work that I do with the pressure on my legs on that right side until I have surgery and get back going again, I can't go to work.
[AGENT][NEUTRAL] Well, the, the disability, just so you're aware, the disability policy doesn't have the same criteria as the as the accident itself. So if you are going to have surgery and you will be disabled as long as you have that um information completed on the claim form um from both your employer, yourself, and then your doctor, that's not gonna be an issue for the disability as it is for the accident. Like I said, we're just trying to verify that it was an accidental injury.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right. Well, OK. I just leave it, leave it with that. I'm gonna reach out to his nurse and let it be from there.
[AGENT][NEUTRAL] Alright, did you have, can I answer any other questions for you, Mr. [PII]?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] That, that it, you answered it all makes sense now.
[AGENT][POSITIVE] OK, thank you for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] Yeah