AccountId: 011433970860
ContactId: c43fb4b1-64d2-40d9-a7ff-e677b8ec2f6b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 755179 ms
Total Talk Time (AGENT): 247904 ms
Total Talk Time (CUSTOMER): 191956 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/c43fb4b1-64d2-40d9-a7ff-e677b8ec2f6b_20250514T16:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi there.
[CUSTOMER][NEUTRAL] Um, I have filed a claim and it said that it was processed, but I'm not entirely sure if it was like accepted or.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, what like the status was.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, we can double check it. Do you have your policy number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I have like, the claim number, let's see.
[AGENT][POSITIVE] OK, that works too.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is 360-0539.
[AGENT][NEUTRAL] OK, let me pull that up here.
[AGENT][NEUTRAL] OK, um, on the policy, I do need to verify a few things for security. I need your first, last name and date of birth, please.
[CUSTOMER][NEUTRAL] [PII] uh [PII].
[AGENT][NEUTRAL] OK, thank you. And then what is your physical address and email address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] And then it
[AGENT][NEUTRAL] The email. Uh-huh.
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] And I do have the policy number too if you still need it.
[AGENT][NEUTRAL] No, that's OK. I got it from the, the claim. It's no, no big deal. All right, let's see, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like.
[AGENT][NEGATIVE] The claim was denied. It's showing outpatient services are not covered.
[AGENT][NEUTRAL] And then it says, this policy does not provide a benefit for surgical procedures.
[CUSTOMER][NEUTRAL] Uh, um.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So I
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] I don't know, maybe I do.
[CUSTOMER][NEUTRAL] Because I, um, I signed up for this service and I used it to, um, for the birth of my 3rd child.
[CUSTOMER][NEUTRAL] So it wasn't like a surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so there is a waiting period.
[AGENT][NEUTRAL] Let me see what that is, just a second.
[CUSTOMER][NEUTRAL] And I don't know if this would make a difference. Um, I had tried to submit.
[CUSTOMER][NEUTRAL] The claim
[CUSTOMER][NEUTRAL] And I submitted it before I had all the documents, so I think I may have submitted it twice.
[CUSTOMER][NEUTRAL] I don't know, would that make a difference?
[AGENT][NEUTRAL] No, it shouldn't. I mean.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Patient treatment.
[AGENT][NEUTRAL] So the hospital admission benefit reads, we pay the hospital admission benefit when a covered person is admitted to the hospital, confined as inpatient due to a covered injury or sickness, will not pay this benefit for outpatient treatment. So were you there for at least 18 hours?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And the document, it had me submit the um.
[CUSTOMER][NEUTRAL] Itemize itemized receipt or form whatever and I, I think it had on there my like admit date and my release date too.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So it said and then it says we will not pay benefits for lost.
[AGENT][NEUTRAL] So it looks like under the limitations and exclusions, it says we will not pay benefits that is caused by or occurs as a result of a covered person's pregnancy or childbirth during the pregnancy waiting period as shown on the certificate.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] After the pregnancy waiting period.
[AGENT][NEUTRAL] OK, so let me get somebody who's an examiner [PII] to like look at this with you because um I don't know if it was just that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] It doesn't seem like additional documentation is needed from the way I'm reading it, it's just not covered.
[AGENT][NEUTRAL] Um, but maybe they can shed some more light on some of that. So do you mind holding the line just a second?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hey, this is hey, this is [PII] over in customer care. How are you?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][POSITIVE] Doing well, [PII] thank you how are you?
[AGENT][NEUTRAL] I'm good. I have an insured on the line who has a question about a denied claim, and I was wondering if you could help her with that, please.
[CUSTOMER][NEUTRAL] Certainly, what's the policy number?
[AGENT][NEUTRAL] Her policy is 02312467.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I have a claim number.
[CUSTOMER][NEUTRAL] Let me pull that up.
[CUSTOMER][NEUTRAL] And it's for [PII].
[AGENT][NEUTRAL] Um, mhm. Um, no, it should be for [PII].
[CUSTOMER][NEUTRAL] Oh, did I put the wrong number in?
[AGENT][NEUTRAL] Yeah, let me give that to you again it's 02.
[CUSTOMER][POSITIVE] Oh, I got it. I'm sorry about that. I transposed the number my fault, my fault.
[AGENT][NEUTRAL] OK. That's OK.
[AGENT][POSITIVE] No, it's all good.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Um, and then the claim number is gonna be 360.
[CUSTOMER][NEUTRAL] And go ahead my claim number.
[AGENT][NEUTRAL] 0539.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, I did read the policy and pulled it up. It's basically for um childbirth pregnancy.
[AGENT][NEUTRAL] And I see in the limitations and exclusions like a waiting period talking about for pregnancy, but there is no waiting period on the.
[AGENT][NEUTRAL] Certificate. So I was a little confused myself and then I even asked her, I said, were you in the hospital for 18 hours? She says, yes, but the way I'm reading it, it looks like it was outpatient, not inpatient.
[CUSTOMER][NEUTRAL] OK I'm gonna pull up those documents real quick and just double check it, but that's what it looks like it looks like it was denied because if we didn't have the um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It it looks to be outpatient services so I'm gonna double check that it looks like though she.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Did indicate she was there for.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And [PII], what's her callback number?
[AGENT][NEUTRAL] Her callback is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah because it looks like these are just a professional charges that she sent in to us so it looks like probably what we're gonna need for this if she was inpatient is the hospital charges because it does show maternity care delivery however it only indicates that one date.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And so with this policy it looks like she only has like inpatient benefits so we would need that um that hospital bill that shows that you know she was confined and there's a room and board charge so if you wanna um transfer over to me I'll explain that to her.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Gotcha.
[AGENT][POSITIVE] OK, absolutely, and I will keep that in mind for next time to check that and um I can advise on that. I appreciate your help. Thank you so much.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] No problem sir and everything's been verified for her right?
[AGENT][POSITIVE] Yes, ma'am. Here she, yep, and here she comes.
[CUSTOMER][NEUTRAL] I did I already ask that? I'm sorry. OK, thank you, [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] No you're totally fine. You're welcome.
[CUSTOMER][NEUTRAL] It's been a Monday, a Wednesday, Monday.
[AGENT][NEUTRAL] I, I, I hear you, I hear you.
[AGENT][NEUTRAL] If she comes.
[CUSTOMER][POSITIVE] Have a good day sir.
[AGENT][NEUTRAL] You too.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hi [PII].
[CUSTOMER][NEUTRAL] Hi.