AccountId: 011433970860
ContactId: cfa87157-5584-4521-930c-bd91ffc16902
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 521229 ms
Total Talk Time (AGENT): 309046 ms
Total Talk Time (CUSTOMER): 116290 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/cfa87157-5584-4521-930c-bd91ffc16902_20250401T16:43_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. I was calling about my, oh, I was calling about my insurance with you guys.
[AGENT][NEUTRAL] Hi [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh if my claim was denied.
[AGENT][NEUTRAL] OK, I can help you look into that, [PII]. Do you mind if I go ahead and get a good callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah it's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Wonderful, thank you. And what's the policy number we want to look at today, sir?
[CUSTOMER][NEUTRAL] 2521406
[AGENT][NEUTRAL] 6 perfect give me just a second to get that pulled up real quick.
[AGENT][NEUTRAL] How's your week going so far?
[CUSTOMER][NEUTRAL] Um, just running around trying to get my hip. I had a hip replacement.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, that's where I'm at, laid up.
[AGENT][POSITIVE] Goodness. Well, I'm sorry you're going through it right now.
[AGENT][NEUTRAL] All right. And then I do have that policy loaded. If you don't mind just verifying for me, please, sir, um, your date of birth?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Wonderful, thank you. And if you could verify for me as well, I'm sorry, we're almost done, but just the email, phone number and mailing address on file.
[CUSTOMER][NEUTRAL] It's uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the address is [PII].
[AGENT][POSITIVE] Perfect, wonderful and then it looks like I have a different phone number than the one you gave me as a call back. Would you be able to verify that one with me as well?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Perfect. Thank you, thank you. I really appreciate you going through that with me. And let's see, it does look like we had a claim.
[AGENT][NEUTRAL] Process yesterday for you.
[AGENT][NEUTRAL] Let me pull it up and see what it says.
[AGENT][NEUTRAL] All right, so I'm showing it says that it was, there was a pre-existing condition as defined in section 4 of your policy means disease, injury, or sickness or physical condition, or mental illness for which received treatment, incurred expense, took medication, received care or services, including diagnostic testing or related measures, or received a diagnosis or advice from a physician during the period.
[AGENT][NEUTRAL] Um, immediately before the effective date of your coverage, no disability payment will be payable if disability is caused by or resulting from a pre-existing condition. The limitation will not apply to a disability resulting from a pre-existing condition that begins after you've been covered continuously under the policy for 12 months. Based on a claim documentation, the current condition was determined to be a pre-existing condition, and therefore no benefits are payable.
[CUSTOMER][NEUTRAL] So when I bought that policy, [PII] told me I was covered right away.
[AGENT][NEUTRAL] So I think the understanding here is you'd be covered for anything new right away, but if it was pre-existing, you had a 12 month waiting period to wait through before coverage would.
[AGENT][NEUTRAL] Would take effect.
[CUSTOMER][NEUTRAL] Oh my Lord.
[CUSTOMER][NEUTRAL] And I guess uh.
[CUSTOMER][NEUTRAL] It's all black and white, I guess, right?
[CUSTOMER][NEGATIVE] No way I could just do that.
[AGENT][NEUTRAL] So you always have the right to appeal, um, that's 100% within your rights all the time and you have that right from 180 days from that claim decision which was just yesterday, so you're not even running out of time. um, so if you would like to appeal, you can state a letter of appeal, um, and mail that back to us and I can give you the mailing address information, um.
[AGENT][NEUTRAL] And if you would like, I can also email out your policy documents so you have access to um your like how the policy is worded and what they're referring to if that's something that you feel like could um give you more insight and knowledge into how that policy was written.
[CUSTOMER][NEUTRAL] I guess I'm sure I have it somewhere.
[AGENT][POSITIVE] OK, if you change your mind or if you can't find it, let us know when we can email it it's no no problem at all, OK?
[CUSTOMER][NEUTRAL] Oh my.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, uh, can, can you, can you send me a copy of that denial?
[AGENT][NEUTRAL] Yes, I can send you a copy of that denial. I can send it via email for you if you'd like.
[CUSTOMER][NEUTRAL] Got it
[CUSTOMER][POSITIVE] Yeah, that'd be perfect.
[AGENT][POSITIVE] OK, perfect. Let me get that loaded for you real quick, my friend.
[CUSTOMER][NEUTRAL] Well, can you override that decision in my favor?
[AGENT][POSITIVE] If I could do that, oh my gosh, wouldn't that be nice?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Jo
[CUSTOMER][POSITIVE] Oh my goodness.
[AGENT][NEUTRAL] Uh, I have a feeling if I had that much power within this company, I would be doing something different.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Something different.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Oh boy.
[AGENT][NEUTRAL] And it's just taking its sweet time loading but it's so close and I have that at the [PII] is that the email you want me to send it to?
[CUSTOMER][NEUTRAL] Yeah, did that [PII] her mother.
[AGENT][NEUTRAL] [PII]
[AGENT][POSITIVE] Perfect. OK, perfect.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Are you having good weather out your way?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Good. It's like dreary and gray skies where I'm at.
[AGENT][NEUTRAL] And cold. It was like 85 degrees on Sunday and then yesterday it was like 60 degrees.
[CUSTOMER][POSITIVE] Oh my goodness, big temperature swing.
[AGENT][NEUTRAL] I know it's insane.
[AGENT][NEUTRAL] I went from like, I don't know, I was ready for summer all weekend, and then it was like back to sweaters.
[CUSTOMER][NEUTRAL] Yeah, I hear you.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][POSITIVE] Alright, and I am just typing out that email for you, but it should be coming your way in just one second.
[CUSTOMER][POSITIVE] OK dear thank you so much and have a.
[AGENT][NEUTRAL] And my, yeah, I was gonna say, is there anything else I can do for you, my friend?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Alrighty well you have such a wonderful day and I really wish you the best of luck.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Uh, one second, what here, what, what's that address where we send the letter of appeal.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Oh yeah, you bet you the address is gonna be [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Our zip code here is [PII], and you would just um make it out to APL appeals.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Here and what I'll do is I'm gonna go ahead and I'm going to include that in the email I'm sending you so that way if you need it you have it as reference, OK?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Oh, that's great.
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Do you have like a uh.
[CUSTOMER][NEUTRAL] Do you have like a sample letter? What are you doing up here?
[AGENT][POSITIVE] Um, so I don't actually, but that is a wonderful question, and I can, I mean look in and see if the company could do something like that in the future, but I think all you need to do is just write that you were.
[AGENT][NEUTRAL] That you are
[AGENT][NEUTRAL] Wanting to appeal the decision and include your policy number, your name, and the claim number, the decision that you're trying to and why you are trying.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] Alright, I appreciate it thank you so much.
[AGENT][POSITIVE] Perfect and I'm about to hit send on that email for you if you need anything else just give us a call OK?
[CUSTOMER][POSITIVE] OK, I sure will thanks a lot.
[AGENT][POSITIVE] My pleasure you have such a wonderful day.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] Bye-bye.