AccountId: 011433970860
ContactId: c83219bb-24f3-4fca-a0a3-b100c3d4e430
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1970800 ms
Total Talk Time (AGENT): 639380 ms
Total Talk Time (CUSTOMER): 967089 ms
Interruptions: 10
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/c83219bb-24f3-4fca-a0a3-b100c3d4e430_20250114T19:06_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, this is [PII] with Eris Group, and I am calling to um get some information on a couple of claims.
[AGENT][POSITIVE] Well, [PII], it would be my pleasure to assist you. What is a good callback number?
[CUSTOMER][NEUTRAL] Yeah, a good call back number is [PII].
[AGENT][NEUTRAL] Thank you and what is the policy number?
[CUSTOMER][NEUTRAL] So, the first policy number is
[CUSTOMER][NEUTRAL] 1 2nd, my computer.
[CUSTOMER][NEUTRAL] Here we go.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Is an accident claim and it's 02435157.
[CUSTOMER][NEUTRAL] Name on the policy is [PII].
[AGENT][NEUTRAL] Mhm. Is the claim for [PII]?
[CUSTOMER][NEUTRAL] It's for [PII], her daughter.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Getting that pulled up, [PII]. Bear with me just one second.
[AGENT][NEUTRAL] You're with the agent's office.
[CUSTOMER][NEUTRAL] Yep, broker.
[AGENT][POSITIVE] Brokers off, gotcha. Thank you, [PII].
[AGENT][NEUTRAL] I'm checking on that for [PII]. Let's see.
[AGENT][NEUTRAL] The last time we had on file was received on [PII] and processed and paid on [PII].
[CUSTOMER][NEUTRAL] And what was that one for?
[AGENT][NEUTRAL] This was
[CUSTOMER][NEUTRAL] And how much was paid?
[AGENT][NEUTRAL] For, looks like.
[AGENT][NEUTRAL] We paid $300 to the insured.
[AGENT][NEUTRAL] For 5 data service 5 1524.
[CUSTOMER][NEUTRAL] OK, but we submitted in, so [PII], I submitted some information over to her like on [PII] with some additional EOBs.
[CUSTOMER][NEUTRAL] And I mean the.
[CUSTOMER][NEGATIVE] Policyholder has not received anything regarding it because they were asking for more information.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So she got some more EOBs we sent that over and yeah she also wrote up a letter because there were certain things that she can't you know they don't even have the information they were asking for and now you're telling me you guys don't even have the stuff.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Hang on just, I'm gonna check on it for you, so bear with me.
[AGENT][NEUTRAL] And you send it directly to [PII]?
[CUSTOMER][NEGATIVE] Yep, because I can forward it to you from her if you need me to, but yeah, and I followed up with it today because I said I'm dealing with a policyholder who's now not very happy because there's been absolutely no correspondence.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Yeah, I sent it to around [PII].
[AGENT][NEUTRAL] And [PII]. OK.
[CUSTOMER][NEUTRAL] I mean, every time she sends new information.
[CUSTOMER][NEUTRAL] You guys open up a new claim even though it's for the same accident.
[CUSTOMER][NEUTRAL] Which is very strange.
[AGENT][NEUTRAL] It just opens up a new claim number. Each document that was when it's received will have a.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] We'll get a new claim number because it's just it's new documentation.
[CUSTOMER][NEUTRAL] OK, but I'm just, I'm saying like this stuff's not being, I don't know that it's all being put together then then and it's all being considered to be paid for.
[AGENT][NEUTRAL] It is what the examiners.
[CUSTOMER][NEUTRAL] Cause if you're paying one.
[AGENT][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] If you're paying one benefit.
[CUSTOMER][NEUTRAL] Then you're basically approving it as an accident claim and therefore, all other benefits regarding the accident claims should be paid.
[AGENT][NEUTRAL] Yeah, hang on just a second.
[CUSTOMER][NEUTRAL] I mean you can't, you can't, you can't say you're paying on an accident claim and then I'll decide to pick and choose what you're playing on. If it's if it's already an accident claim and you're paying, the other benefits should be being paid and they're not.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's take a look. Hang on just a second.
[AGENT][NEUTRAL] I'll tell you what I need to do.
[AGENT][NEUTRAL] There's several things I can do. I can go ahead and transfer you to our claims department, um, [PII], but they're gonna need a minute to review everything, or if you would like, I can send a message to them to review [PII]'s claims and call you back.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Well, do you have all the information? Do you have the most recent information?
[AGENT][NEUTRAL] I do. It's just gonna take me a minute to go through it.
[CUSTOMER][NEGATIVE] Cause.
[CUSTOMER][NEUTRAL] OK, so you have, you have what was sent over to [PII] on [PII].
[AGENT][NEUTRAL] No, I'm asking her if she's got that information. I don't see it on file. If you wanna send it to our care team email, then we can get it uploaded on Jayden's policy. The care team at [PII] is our direct.
[AGENT][NEUTRAL] Care team email.
[CUSTOMER][NEUTRAL] OK, what is that number?
[AGENT][NEUTRAL] It's
[CUSTOMER][NEGATIVE] What is that? I'm sorry, what is that email? I'm very frustrated now as well because [PII] did that. Well, I mean, I mean, I feel like she dropped the ball here. We sent something to her on [PII] and I understand holidays and stuff, but this is a claim that's been ongoing now since May, and this lady has jumped through a lot of hoops to try to get information just because the cops who responded didn't.
[AGENT][NEUTRAL] Email, email.
[AGENT][POSITIVE] I can hear it in your voice and I'm sorry.
[AGENT][NEUTRAL] I see that.
[CUSTOMER][NEUTRAL] Fill out an actual report. I mean, it has just been.
[CUSTOMER][NEUTRAL] It's been a lot for this group and this group is negotiating whether to keep this insurance or not and it's just not very convincing when you're dealing with this is the president's daughter's claim, so I mean and it's it's being handled like this so you know.
[AGENT][NEUTRAL] Yeah, why not
[AGENT][POSITIVE] Yeah, got you.
[AGENT][NEUTRAL] And if
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So if on that email, will you please mark that as urgent?
[CUSTOMER][NEUTRAL] I marked all I marked the ones that I sent [PII] as high importance. So what's the to who? What's what's the email address?
[AGENT][NEUTRAL] It, it's
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And [PII], and you can just send it to that email and we'll we'll get the claim documents uploaded and what I can also do, [PII], I can send a request to the claims supervisor on this.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] To please review the documents.
[AGENT][NEUTRAL] And
[AGENT][POSITIVE] um, I can even have her contact the insured and they can go over, you know, everything and see.
[AGENT][NEUTRAL] If there's a way to get this taken care of easier if they don't have those supporting documents.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEGATIVE] Well I'm gonna be real honest I mean this is the first group that we have with you guys and it's not been, I mean it's just not been very impressive at all and we have, I have asked for that before to reach out directly to her as well um but like I said I mean this is just it.
[CUSTOMER][NEUTRAL] I, I'm doing all the following up or she's doing all the following up and the pushing and the and that's not how that should go and I realized that maybe you know [PII] wasn't the right person to actually send it to but she is a contact person and a sales person for us so I would think that she could get it into the right hands then and again this is this this is a group and this is the president's daughter so if she's not impressed.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] This could not be good going forward is all I'm saying, I mean, you know, she.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yeah. Now, I can.
[CUSTOMER][NEGATIVE] She's not gonna wanna support this if she can't even get a claim paid or things paid.
[AGENT][NEUTRAL] Oh, and I can understand her frustration absolutely. I mean, she's been putting in a lot of work on this one claim.
[CUSTOMER][NEGATIVE] She has been, and that's the thing and it's like, you know, she's totally frustrated with that. I mean she does have another claim of her own and she said I don't even want to submit it into them because of everything I've had to go through with this, and that's not right. I mean, so I'm just like.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I would, I mean, I would think that.
[CUSTOMER][NEUTRAL] I, I guess that's what I felt like reaching out to [PII] that, you know, maybe she could get it going further because.
[CUSTOMER][POSITIVE] Of this lady, and it is gonna make a big difference, I mean, so.
[AGENT][NEUTRAL] Yeah, so
[CUSTOMER][NEUTRAL] I don't know what I so I'm sending it right now to the care team at [PII], right?
[AGENT][NEUTRAL] Yeah, and I'm just
[AGENT][POSITIVE] Absolutely. And I'm, I'm, I've got it open. I'm waiting for it.
[CUSTOMER][NEUTRAL] She also wrote a letter, so, um,
[CUSTOMER][NEUTRAL] I have that letter.
[AGENT][NEUTRAL] Yeah, send that as well. We'll get it uploaded on the claim and.
[CUSTOMER][NEUTRAL] Well, the, the letters in the body of the
[AGENT][NEUTRAL] Of the email.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, if you would like, we can just escalate this to a supervisor and you can speak with the supervisor.
[CUSTOMER][NEUTRAL] I want it escalated.
[CUSTOMER][NEGATIVE] Yeah, I mean, it needs to be escalated. This is like I said, this is ridiculous and the other part, and I know it's not your fault, but the other part of it is is that, you know, like I said, you can't.
[AGENT][NEUTRAL] And, and
[AGENT][NEUTRAL] Well, the insured is the one that's, I'm sorry, I didn't mean to interrupt you, but I, it's, I feel for the insured that, that's, that's, you know, what's important and she needs to get taken care of.
[CUSTOMER][NEUTRAL] Well, right.
[CUSTOMER][NEUTRAL] Right, and uh, you know, like I said, you can't, you can't go ahead and pay on the claim and then not pay on the rest of the claim that should have benefits. I mean, if you're paying on the claim, you're acknowledging that yes, it is an injury or an accident. So if that's the case, and they've already done that with the 300, then there's other benefits that should be being paid and she shouldn't have to jump through jump through hoops to get everything taken care of.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah, let's let's see if I can get you to a supervisor and that way they can be informed and, and be on top of this. How about that?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would that be
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] Let me see who is available.
[CUSTOMER][NEUTRAL] I have another one too that I need to ask about it so I can just ask that supervisor.
[AGENT][NEUTRAL] Sure, yeah, either way I mean I can, I can check on it for you while I'm waiting for a reply to see who is available.
[CUSTOMER][NEUTRAL] Um, so the other one is on.
[CUSTOMER][NEUTRAL] Critical illness policy 243-5155. [PII].
[AGENT][NEUTRAL] And do you mind giving me that number again? I'm sorry.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] 243.
[AGENT][NEUTRAL] 243
[CUSTOMER][NEUTRAL] 5155.
[AGENT][NEUTRAL] 5155. Thank you. And [PII], what is her date of birth?
[CUSTOMER][NEGATIVE] I don't have her date of birth. This is gonna be on her child, and it's for a MS critical illness.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I do know that.
[CUSTOMER][NEUTRAL] Uh, I, I guess I don't know. Uh, we're trying to help her with this claim as well, so have you received anything on it? I believe at one point there was some documentation that you guys had said you, um, received. So I again, I, I don't know what your correspondence is like with the policy holder, but uh.
[AGENT][NEUTRAL] Is it for [PII]?
[CUSTOMER][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] Uh, it, it's her son, and he has MS.
[AGENT][NEUTRAL] It looks like, now we do have a claim for [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If it is for [PII], we did process a claim on [PII], and we are requesting the physician's portion of the claim form.
[AGENT][NEGATIVE] be returned.
[CUSTOMER][NEUTRAL] So when you say you processed you paid something on it?
[AGENT][NEUTRAL] No ma'am, it means that they have processed it. It is pending for additional information.
[AGENT][NEUTRAL] Um, we did send a letter to the insured and stating that the physician's portion of that claim form needs to be returned to our office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you email me that so I can get it to her and that's all they need is the position section.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] I can certainly email you that critical illness claim form. What is your email choice?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Let me ask you, do you, do you have Internet access? Because you can get that online as well. We do have a website and I'm just this is just for your information. I'm gonna email it regardless, but if you go to the [PII] or if you have a portal.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Account you can go to the claims and form section.
[AGENT][NEUTRAL] And it is there.
[CUSTOMER][NEUTRAL] Right, right, right, I have the critical illness form. So basically what you're saying is the physic or the physician section, you've got the claim form for him, correct? You just need the physician section.
[AGENT][NEUTRAL] Just, just additional.
[AGENT][NEUTRAL] Let's see, claim form.
[AGENT][NEUTRAL] Actually, we do need the, it says, um, I'm gonna read you the EOB. It says the enclosed claim form, so we sent through the claim form must be completed by you and your physician and returned to our office. The claim form will be used as proof of loss for your critical illness diagnosis.
[CUSTOMER][POSITIVE] Great.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the critical uh if you've got the claim form, that's what they're needing for [PII]'s claim.
[CUSTOMER][NEUTRAL] OK, so I
[CUSTOMER][NEUTRAL] And that's 9 pages long, right?
[AGENT][NEUTRAL] Let me get that pulled up.
[AGENT][NEUTRAL] 9 pages.
[AGENT][NEUTRAL] I want to check and see cause that sounds like a lot of pain. It may be with the instructions and everything, but let me check.
[AGENT][NEUTRAL] And I'm sorry, it just takes a while to get through everything.
[AGENT][NEUTRAL] Um, yes, it is.
[CUSTOMER][NEUTRAL] OK. All right, I will get that to her.
[AGENT][NEUTRAL] And that does include the page one with the informations.
[AGENT][NEUTRAL] Information instructions as to how to file the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now if you're um if the employees have the portal they can upload those.
[AGENT][NEUTRAL] That information directly online.
[CUSTOMER][NEUTRAL] Yeah, I understand that, but a lot of times they figure they pay for the insurance, so they want somebody to help them.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And that's kind of how they feel about it so um so that's what we try to do so.
[AGENT][NEUTRAL] I'm still waiting.
[AGENT][NEUTRAL] I just want to get this resolved as quickly as possible. Let me check that email while I'm waiting to see who's available.
[AGENT][NEUTRAL] Accident claim for [PII].
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] Importing to our imaging department right now.
[CUSTOMER][NEUTRAL] Well, in the body of the email is the letter that she wrote, so you'll have to pull that from the body.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Of the email.
[AGENT][NEUTRAL] So we're getting these documents on here on the policy.
[AGENT][POSITIVE] Taking care of that right now.
[CUSTOMER][NEGATIVE] I know, but I can't even imagine trying to explain to Cassandra that.
[AGENT][NEUTRAL] It wasn't there.
[CUSTOMER][NEGATIVE] No, the forms that we sent, nobody has done anything with.
[AGENT][POSITIVE] Yeah, and I'm so sorry.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Well, [PII] consequently just.
[CUSTOMER][NEUTRAL] Uh, email me.
[AGENT][NEUTRAL] I asked her if she had that email to forward it to us.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That has been sent to our document team so they can get that uploaded on his policy.
[AGENT][NEUTRAL] On [PII]'s policy.
[CUSTOMER][NEUTRAL] Well, [PII] doesn't have a policy, but [PII] does.
[AGENT][NEUTRAL] Well, yeah, on her, on his part.
[AGENT][NEUTRAL] For his claim. I'm gonna get it out in a minute. I'm sorry. Trying to type and talk and watching.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] Look, I do apologize.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, [PII], I am going to send you to a supervisor um.
[AGENT][NEUTRAL] [PII] and.
[AGENT][NEUTRAL] She will assist you further on [PII]'s claim, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] But again, we do apologize for any inconvenience, but it has been my pleasure to assist you today.
[AGENT][POSITIVE] So if you need anything, you don't hesitate to call us back, OK?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right thank you one moment please.
[CUSTOMER][NEUTRAL] Hi, this is [PII].
[AGENT][NEUTRAL] Hey [PII], this is [PII]. Listen, I've got the [PII] from the agent's office on the line, OK? This is the owner of the group.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] What, what, what's the concern though? because what is there a specific claim or they just got questions about the policy because I don't see no pending claims out there.
[AGENT][NEUTRAL] No, it's gone
[AGENT][NEUTRAL] It's on participant for, there's pending information needed. She sent um.
[CUSTOMER][NEUTRAL] Do I got the policy right? 243-515-7?
[AGENT][POSITIVE] Yeah, it was processed and paid.
[AGENT][NEUTRAL] And then they send additional I'm just gonna kind of give you background they send additional information to [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] On [PII] and we don't have it.
[AGENT][NEGATIVE] And she said that this um insured had the customer has been the client has been jumping through hoops to get information and she's not understanding why we do a different claim number for each even though it's the same claim.
[AGENT][NEGATIVE] I did try to explain that. They're just very, very frustrated.
[AGENT][NEUTRAL] And I have just sent some additional information to EBS.
[CUSTOMER][NEUTRAL] 7
[AGENT][NEUTRAL] That she
[CUSTOMER][NEUTRAL] Have you, OK.
[CUSTOMER][NEUTRAL] So did they, so.
[AGENT][NEUTRAL] Here I'm gonna forward you this email too.
[CUSTOMER][NEUTRAL] The information that they sent it.
[AGENT][NEUTRAL] That you can see
[CUSTOMER][NEGATIVE] OK, that's what I, um, the email that she did is she sent to [PII]. Do we know where that is? Because I can't do nothing if I don't have the information. So, um, that would be my first thing and I, I, I can definitely speak with her, but she's gonna still be frustrated with me if I don't have the information.
[AGENT][NEUTRAL] I'm, I'm getting this email to you with all the attachments.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect. OK.
[AGENT][NEUTRAL] And she also said that Ms. [PII] wrote the um
[AGENT][NEUTRAL] Letter in the body of the email which she attached in that email as well.
[AGENT][NEUTRAL] I've already kind of explained to her, you know, that it, it may have a different claim number, but.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You know, history is reviewed for each claim submission, so it's
[AGENT][NEUTRAL] Just processed as a new claim, not necessarily as a new claim.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So basically we just need to get so and you said you sent this to EBS already to ask them to upload it.
[AGENT][NEUTRAL] I did. I forwarded it to EBS and did you get the email with the documents?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, did you send me 2? You send me 2 different, is it two different or it's the same email? It just came through. OK, that's OK. No, no, no, I just didn't know if it was um.
[AGENT][NEUTRAL] I might have sent to. It's the same.
[AGENT][POSITIVE] I got in a hurry. I'm so sorry.
[CUSTOMER][NEUTRAL] No, that's OK. I just didn't know if it was like two different, like, you know how I had multiple attachments. OK, yep, I got it, so.
[AGENT][NEUTRAL] Like
[AGENT][NEUTRAL] No, it's the same. I know, girl, I get to talking and typing and uh looking and
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] So yeah so no OK that's good that we have this information so.
[CUSTOMER][NEUTRAL] I, I, that's a lot of information in the email, so I that part I don't even that, yeah, I just need to have the documents. I was trying to open it real quick in my I've been having issues with um my stuff today. Give me a second.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I know, girl, and I did ask, I did ask [PII] to upload the letter that's listed in the body of the email as well. I don't know if they can.
[CUSTOMER][NEUTRAL] Oh, go ahead.
[CUSTOMER][NEUTRAL] OK, that's fine.
[CUSTOMER][NEUTRAL] So this has
[CUSTOMER][NEUTRAL] OK, this has office. This tells me what it is, so I'll be able to, um, let me see, do they they coincide with the injury?
[AGENT][NEGATIVE] Well, see, then she was saying, you know, if it's, if, if an accident is processed then and it's claims are being paid out, then everything should be covered um for that accident. And I said under the, you know, under the guidelines of the policy, and we haven't gone over benefits or anything. Then she asked about a critical illness. I took care of that one. But I think that this may be a new group. Maybe she just doesn't know what's going on. I don't know. She's just very, very frustrated and
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] What was her name again? You said [PII].
[AGENT][NEUTRAL] Her name is [PII]. She's with the Aris group, and I've got her callback number.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] Go ahead and give it to me just in case.
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Got you OK.
[AGENT][NEUTRAL] Are you ready for this? All right. I'm gonna just take a quick moment and just let her know who you are. That way it gives you just another minute to look. How about that?
[CUSTOMER][NEUTRAL] All right, well, you can get it over to me. Yes, ma'am.
[CUSTOMER][POSITIVE] That that's perfectly fine, yes ma'am.
[AGENT][POSITIVE] Thank you, [PII]. You have a great day. Happy New Year.
[CUSTOMER][POSITIVE] You're right, thank you. Alright, yes, happy new year, alrighty.
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] Miss [PII].
[CUSTOMER][POSITIVE] Excellent, yes.
[AGENT][POSITIVE] Thank you for your patience. I do have [PII] on the line. I've come and given her a background of the situation, and I did forward her that email that you sent me, so she does have that information that she can look at quickly and kinda see what's going on.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] And she is our supervisor for this um policy and she'll be able to help you further.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] And hopefully get this taken care of for Ms. [PII] as well.
[CUSTOMER][POSITIVE] Yep, thank you.
[AGENT][POSITIVE] And thank you, Ms. [PII]. It's been a pleasure to assist you and I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] Yup, you too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I'm one of the supervisors like Ms. [PII] just said, um, and she did, um, kind of give me some background on this, and so, um, I do know that there was some additional information that you guys were, um, submitting to us, um, for Ms. [PII], who is covered depending on the policy, but we for what.
[CUSTOMER][POSITIVE] Whatever reason we did not have that information in our system, but [PII] has um sent that information to our imaging team, and we're getting that information uploaded into our system so that we can prioritize getting that claim processed quickly and not um delaying it any further.
[CUSTOMER][NEGATIVE] OK, well, yeah, I had sent it to [PII] on [PII], so I have only I have, you know, emails that show that it was sent, um, I was sending it to her because this claim has just been sitting there, not moving. There's been a lot of frustration because there's been a lot of information asked for. I mean she's had to jump through a lot of hoops to get.
[CUSTOMER][NEGATIVE] To try to get information and it's just, you know, as I said I mean she's very frustrated with it, the time frame of it I mean that was May of last year I mean it's you know it, it appears that it paid already $300 on it, OK, so it just seems like it paid 300, but now to try to get any more benefits out of it, I mean it.
[CUSTOMER][NEUTRAL] If, if, if you're, if we're already saying which you have by paying the 300, it is in fact an accident, an injury claim, and it is, then the documentation she's providing.
[CUSTOMER][NEUTRAL] should pay more benefits and she she shouldn't have to work this hard to get a yes and no, I will say so the thing of it is any time regardless of what type of product that you have with us any time you're submitting information to receive benefits, we do require the itemized bills with diagnosis and procedure codes on them. So there, there is going to always be.
[CUSTOMER][NEUTRAL] Information that the insured has to provide um and so for this one if you know this one there was a situation where there was a car accident so initially we did request the car, um, the motor vehicle accident report we did later get documentation that showed that there wasn't necessarily report filed and so we were able to use that, um, to, um, you know, complete our file so that we can show, OK, we don't have this right, but then also.
[CUSTOMER][NEUTRAL] I was looking at um what was paid on the claim and what was requested. So some of the information that we got was like the um it was an EOB like a major medical EOB and it doesn't actually list out what services were received. And so we have to have the detailed itemized billing so that it lists out what services were received so that we know which benefits to pay.
[CUSTOMER][NEUTRAL] And so the case on this, on the last check that she got, we were able to pay benefits because based on what we got, it allowed us to pay some of the benefits and some of the information was in detailed to really know what service was rendered. And so in the absence of that, we don't have a way to be able to pay benefits. So yes, we have established that an accident took place and that benefits are payable, but in order to know which benefits are paid, we need that detailed itemized bill. Right, so and
[CUSTOMER][NEGATIVE] I, I mean I guess the other part of it is that they're coming to a certain point if you're still not getting what you need then maybe you need to reach directly out to obviously where they were treated and tell them specifically what you're looking for because you know even as a policy holder or the patient they only give you so much stuff and so you know at that point it's frustrating because they can only get what they can only get so if it still isn't the correct information.
[CUSTOMER][NEUTRAL] There's a claim that needs to be paid and that's where you need to step in and and contact them you have the information and get that information so it can process and be paid so let me look at the well it it yeah. We can definitely do that it's been frustrating the whole way around because like I said it wasn't her fault there.
[CUSTOMER][NEUTRAL] Wasn't a police report, you know, done the way the police report should have been. She had to go through all kinds of things with that just to even get something because they didn't do the police report as they should have. So why that cop made that decision again, who knows, but yeah, that's fine and it happens definitely.
[CUSTOMER][NEUTRAL] Yeah, the thing of it is that that happens, but we have no way of knowing that unless we do our due diligence and request the information that's um required. The other thing that I will tell you just, you know, for your um understanding so that the insurance also knows any time there's the.
[CUSTOMER][NEUTRAL] Getting claims to us if they're using our claim forms for that product, there's a um detailed sheet on that claim form that kind of outlines for them what information is needed. It'll tell them for each product whether it's a cancer or a disability or whatever that, you know, case may be. It lists out the items that are.