AccountId: 011433970860
ContactId: bb941a64-8328-45fe-8cd2-25ac63060a08
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 828469 ms
Total Talk Time (AGENT): 222708 ms
Total Talk Time (CUSTOMER): 169798 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/bb941a64-8328-45fe-8cd2-25ac63060a08_20250224T18:07_UTC.wav
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[AGENT][NEUTRAL] For calling APO, this is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you?
[AGENT][POSITIVE] I'm good. How are you doing?
[CUSTOMER][NEUTRAL] Doing all right, thank you. I've got an insured on the line. Um, he submitted a claim for a critical illness policy, um, and it denied, as it's stating that the condition doesn't fall under the definition of a critical illness. He wants to review what was submitted. He said it was a heart attack and just wanted to see if the information he submitted was sufficient.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] It's 244-437-4.
[CUSTOMER][NEUTRAL] And it is for part one.
[AGENT][POSITIVE] OK, I have the policy pulled up. Thank you.
[CUSTOMER][POSITIVE] OK, yeah, thank you, bye bye.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi, this is [PII] in the claims department. I you're calling because of the claim that denied.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And she, um, [PII] said she wanted to go over to see what was submitted for your claim.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Well, I know they had myocardial infarction on the paperwork that they had sent in, which is a heart attack.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] It it references heart attack on the policy, so I'm just confused.
[AGENT][NEUTRAL] OK, while I pull up your policy, this is a um verification of your coverage, not a guarantee for payment. I believe that is an exclusion in your policy, but I have to double check, so let me look.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Alright, so let me look at the claim form.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm going to have to um get with the processor to better understand on this um.
[AGENT][NEUTRAL] Cause I'm looking at what was submitted and.
[AGENT][NEUTRAL] And I'm looking at notes. I don't see anything um.
[AGENT][NEUTRAL] So I will have to um get with her about it. If I don't call you back, then I will have her call you back on the denial, but um.
[AGENT][NEUTRAL] And she's at lunch right now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let somebody else.
[AGENT][NEUTRAL] Hold on, let me, let me see if I can get.
[CUSTOMER][NEUTRAL] Uh, am I looking at something wrong? Look, go ahead.
[AGENT][NEUTRAL] Let me, let me get with um my supervisor. Hold on one moment.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] [PII].
[AGENT][NEUTRAL] I, I have a member on hold. Um, can you help me with his critical illness was denied?
[AGENT][NEUTRAL] Can you help me with the shade must be at lunch.
[AGENT][NEUTRAL] And I was just about to tell him I was gonna call him back. I'm sharing my screen.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] His was denied because, um, you know, I guess he didn't, it wasn't considered a heart attack.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] He said he had a heart attack.
[AGENT][NEUTRAL] Um, and that's what he was filing for the heart attack benefit.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah, and I saw that and I was like, OK, but you know, I don't know. I don't understand how, well, that's a subject for something else like I'm like, OK.
[AGENT][POSITIVE] Mm, exactly, exactly.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] A pill
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Sounds good.
[AGENT][POSITIVE] Sounds good.
[AGENT][POSITIVE] OK, sounds good to me. Thank you. Bye-bye.
[AGENT][NEUTRAL] OK. So I pulled up your form and um you may need to get with your provider cause I know you stated that you had a heart attack, but that's not what he put on your form.
[CUSTOMER][NEUTRAL] Uh, I don't have it in front of me. Can you email me that?
[AGENT][NEUTRAL] OK, I can have them um pull it for email.
[CUSTOMER][NEUTRAL] Yeah, let's see, yeah, because I, I looked, I was in a doctor's office on Tuesday and they showed it to me and I, I, I thought it said myocardial infarction.
[CUSTOMER][NEUTRAL] Because I had it this is the 2nd time they had to redo it. Well, they've won't they had to redo it once, so it's the 2nd time it's been submitted.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, cause it says, has the patient suffered a heart attack resulting in the death of a portion of the heart muscle due to a blockage of one or more coronary arteries, and he checked no.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, right, OK, I could see that because I don't think I.
[AGENT][NEUTRAL] And then it does, he checked, he did say, yes, for coronary artery disease uh for [PII], but for that benefit, you have to have a bypass, which that, you know, that wasn't the case for that. So, um, and then for heart attack, he said check no. So that's what um was filled out on the claim form.
[CUSTOMER][NEUTRAL] Yeah, I hadn't had that.
[CUSTOMER][NEUTRAL] Yeah, because it says, do you have a heart attack that resulted in death of some part of the heart, right?
[AGENT][NEUTRAL] Yeah, blockage of um muscle, portion of the heart muscle due to blockage of one or more coronary arteries.
[CUSTOMER][NEUTRAL] And that what you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Right, so I had a heart attack. I just didn't have the right kind of heart attack.
[CUSTOMER][NEUTRAL] Is that, that, that's, I mean, I had a heart attack that did not cause the things. I don't, like I said, I don't have that form. Let me see where if I may have it somewhere.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Yeah, because it said I have a blank form. I don't have the one they filled out.
[CUSTOMER][NEUTRAL] And then brain tumor.
[CUSTOMER][NEUTRAL] Yeah, that's section 816, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Has the patients suffer resulting in the death of a portion of the heart muscle due to blockage of, yeah, he said no because I didn't, I had a heart attack, but it didn't result in the death of a portion of the heart.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, that's what that's saying.
[AGENT][NEUTRAL] And see, yeah, and, and, um, if you look in your policy um that and it
[AGENT][NEUTRAL] Tells you um what the benefit for and that is what it has to happen for.
[CUSTOMER][NEUTRAL] Yeah, section 2 says heart attack $10,000.
[CUSTOMER][NEUTRAL] And then let's see new born.
[CUSTOMER][NEUTRAL] I couldn't find anything in the policy where it described what type of OK.
[AGENT][NEUTRAL] Page 15.
[CUSTOMER][NEUTRAL] Pa
[CUSTOMER][NEUTRAL] Page 15.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Uh heart attack my OK.
[CUSTOMER][NEUTRAL] OK, yeah, the death of a portion of heart muscle resulting from blockage or one or more.
[CUSTOMER][NEUTRAL] OK, clinical picture.
[CUSTOMER][NEUTRAL] All right. I'll get with the doctor on that then.
[AGENT][NEUTRAL] OK, is it?
[CUSTOMER][NEUTRAL] Because I mean none of that was provided I see that.
[CUSTOMER][NEUTRAL] But yeah.
[CUSTOMER][NEUTRAL] They're defining that. OK, let me look into that.
[AGENT][NEUTRAL] Anything else? OK, [PII], I can help you with today?
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Nope, that's it.
[AGENT][POSITIVE] All right, thank you, thank you for calling APL. Have a good day. Bye bye.
[CUSTOMER][POSITIVE] Thanks. Bye bye.