AccountId: 011433970860 ContactId: d0e21655-18b0-401c-9a4e-acb2b645c05a Channel: VOICE LanguageCode: en-US Total Conversation Duration: 1408390 ms Total Talk Time (AGENT): 569706 ms Total Talk Time (CUSTOMER): 578718 ms Interruptions: 0 Overall Sentiment: AGENT=0.5, CUSTOMER=0.1 Redaction Types: PII Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/d0e21655-18b0-401c-9a4e-acb2b645c05a_20250225T20:22_UTC.wav -------------------------------------------- [AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you? [CUSTOMER][NEUTRAL] Hey [PII], how are you doing? [AGENT][POSITIVE] I'm doing well. How are you? [CUSTOMER][POSITIVE] I'm not too bad. So I'm calling you because, um, the irony of my situation just generally speaking is, is palpable. [CUSTOMER][NEUTRAL] So, um, I, my wife and I had a baby, um, in January, so [PII]. [AGENT][POSITIVE] Oh, congratulations. [CUSTOMER][POSITIVE] Thanks. So I'd call, I, I intended to call you last Tuesday to figure out how my policies work because I'm a financial planner. I, I got these last July or August, and like it seemed like a good idea and [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEGATIVE] Um, so we had a baby and I had some questions about that, and I never got to make the call last week and then on Thursday, I fell and broke my ankle. So I have more. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So I have the hospital uh coverage, I guess, indemnity and then also the accident. So I'm, I'm not 100% sure the pregnancy doesn't, and it happened on accident, but it wasn't an accident. So the [CUSTOMER][NEUTRAL] My, my question though is, is, um, I, I like how do the two overlap? Can I only make [CUSTOMER][NEUTRAL] Because you know we were both hospitalized, so is it just two separate claims? Because here's the thing, I'm not gonna make the claim for if, if say you can only make one claim a year. I'm not gonna make the claim for the. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Right. [CUSTOMER][NEUTRAL] The so like I don't know what how to do this, uh, as far as like what so can you look me up like look up my coverage and then tell me like where to start and my main question is. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Yep, I sure can. [CUSTOMER][NEUTRAL] Uh, well, I'm thinking about it is, especially with the pregnancy, is there a timeline because, you know, [CUSTOMER][NEUTRAL] Uh, is the claim for my wife and the baby or just my wife since, you know, [AGENT][NEUTRAL] So there's a [CUSTOMER][NEUTRAL] Uh, because I don't know if we had [CUSTOMER][NEUTRAL] Add the baby within 30 days like you do with health insurance. [AGENT][NEUTRAL] So, let me do this first. Let me pull up your policy. There's a few things that I have to look into, but for the if you have an accident policy, then you would just file that um broken ankle under the accident policy and then everything else for your wife and the baby would be the medical policy. Um, but let me look at them both. May I have your name and a good contact number just in case we're disconnected? [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Yeah, so my name is [PII] My last name is [PII], [PII] [AGENT][NEUTRAL] Thank you for that. And [PII], may I have your policy number? Either one is fine. [CUSTOMER][NEUTRAL] Um, let me see here. [CUSTOMER][NEGATIVE] Shit [CUSTOMER][NEUTRAL] You said uh I had it set aside when they. [AGENT][NEUTRAL] And I can search the policies with your social. I don't want you to have to look for anything. [CUSTOMER][NEUTRAL] OK, yeah, I'm literally I'm sitting in the cast here, so the um [CUSTOMER][NEUTRAL] I'll give you my social it's [PII]. [CUSTOMER][NEUTRAL] [PII] [CUSTOMER][NEUTRAL] [PII]. [AGENT][NEUTRAL] OK, hold on one moment. And you're the policy holder? [CUSTOMER][NEUTRAL] Yes. [AGENT][NEUTRAL] OK, so it'll be under you. Hold on one second. [CUSTOMER][NEUTRAL] OK [AGENT][NEUTRAL] So I'm just waiting for everything to populate here. [AGENT][NEUTRAL] So that's the medical and where's the accident? [AGENT][NEUTRAL] I'm gonna do the accident um claim or, you know, policy first. I just need you to verify your date of birth, your mailing and email address on file. [CUSTOMER][NEUTRAL] The date of birth is [PII]. [CUSTOMER][NEUTRAL] And the um address is [PII] and what and on the the email is [PII]. [AGENT][NEUTRAL] Email, mhm. [AGENT][NEUTRAL] Alrighty, and thank you so much for verifying your information. So if you don't mind, I'm gonna place you on a brief hold and um pull up the actual policy for your accident and just to check on ankle and then I can let you know what to do for that, and then we can go over to the hospital indemnity policy to see what the coverage is for your wife and baby. [CUSTOMER][POSITIVE] Got you. [CUSTOMER][POSITIVE] Cool, thank you. [AGENT][NEUTRAL] You're welcome. Hold on one moment. [CUSTOMER][NEGATIVE] You are on hold. [CUSTOMER][NEGATIVE] You are on hold. [AGENT][NEUTRAL] Hello, [PII]. [CUSTOMER][NEUTRAL] Yeah, yeah. [AGENT][POSITIVE] All right, thank you so much for holding. I apologize for that wait. So, for the ankle, did you go to the emergency room like within 72 hours of the doctor's office within 30 days? [CUSTOMER][NEUTRAL] Yeah, so I pretty much, uh, heard it at like [PII] and was at the emergency room. [CUSTOMER][NEUTRAL] Uh, by like [PII]. [AGENT][NEUTRAL] OK. So you can file for, um, you can go ahead and put your accident claim in for the ankle. So for that, um, you can use the [AGENT][NEUTRAL] Um, you weren't admitted or anything, right? [CUSTOMER][NEGATIVE] I was. I broke it. I had, yeah, I have a plate in my ankle now and. [AGENT][NEUTRAL] You were? [AGENT][NEUTRAL] Oh my God, I do too. OK, so sorry. I, um, so you actually could probably use both. So you have outpatient treatment benefits and then you have inpatient treatment benefits. So like for outpatient, um, within 72 hours of the um accident, the policy would pay up to $750 and then for the inpatient treatment for the hospital admission, [AGENT][NEUTRAL] Um, there's also $750 for that, and then I don't know, were you in there for like number of days or anything because you have hospital confinement also, which would pay up to $300 per day. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Yeah, so. [CUSTOMER][NEUTRAL] Well, so as far as the, the limited benefit group hospital indemnity, what plan level am I on? 12 or 3? [AGENT][NEUTRAL] That's different from your accident. I haven't looked at that yet. [CUSTOMER][NEUTRAL] OK, so let me. [CUSTOMER][NEUTRAL] I have I don't know which. [CUSTOMER][NEUTRAL] OK, yeah, she sent me so the accident. [CUSTOMER][NEUTRAL] OK, here, let me [CUSTOMER][NEUTRAL] Let me go the accident page. [AGENT][NEUTRAL] Now I see a level 3 on the accident. I don't, uh, let me see if I can pull up both at the same time. Hold on one second. [CUSTOMER][NEUTRAL] Teary benefits. [AGENT][NEUTRAL] Yeah, if I leave out of this, it's going, I can only do one at a time, but I do see a level 3 on accident. I. [CUSTOMER][NEUTRAL] OK [CUSTOMER][NEUTRAL] OK, OK, well that, that, that because I, I think I. [CUSTOMER][NEGATIVE] It printed the wrong thing here. [CUSTOMER][NEUTRAL] OK, so here let me. [AGENT][NEUTRAL] If you need a copy of this, I can email it to you for your accident one if you just have the other one. [CUSTOMER][NEUTRAL] Let me get to that. [CUSTOMER][NEUTRAL] Yeah, uh, it might be better because the, I, I got it. I got all the claim forms and everything from that, uh, the broker that sold it to me, that financial advisors whatever. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Um, and. [AGENT][NEUTRAL] Yeah, I'm gonna send it to you right now. Hold on one second. OK, I'm emailing it to you. [CUSTOMER][NEUTRAL] OK, so here, let me [CUSTOMER][NEUTRAL] Yeah there's no sense in me going through this out of order so let's start with what what you have in front of you since you're the. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Hold on one moment. I'm emailing this over to you now. [CUSTOMER][NEUTRAL] So we're gonna start with. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Yeah. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So what happens if. [CUSTOMER][NEUTRAL] The emergency room was, um, what if I'm at the physician's office, so like maybe it'll help me, help me if I, I walk through the timeline with you. So Thursday, I injured it and went to the emergency room. They admitted me immediately and then I was had my surgery on. [CUSTOMER][NEGATIVE] Sunday and then they discharged me on Monday. [CUSTOMER][NEUTRAL] So I was essentially in the hospital for. [CUSTOMER][NEUTRAL] Uh. [CUSTOMER][NEUTRAL] [PII], so the [PII]. [CUSTOMER][NEUTRAL] Through the [CUSTOMER][NEUTRAL] [PII]. [AGENT][NEUTRAL] So, if you were admitted on the [PII]? [AGENT][NEUTRAL] Because the confinement and all that is after admission, so that was the [PII]? [CUSTOMER][NEUTRAL] Yes. [CUSTOMER][NEUTRAL] No, no, no, sorry, sorry, I was admitted. I was admitted on the [PII]. [AGENT][NEUTRAL] The [PII]. [CUSTOMER][NEUTRAL] Yeah. [AGENT][NEUTRAL] OK. Well, yeah, because confinement is anything over 18 consecutive hours. So from the [PII] to whenever you were discharged, so you, you're really going to be um using both of the benefit types, outpatient for when you were in the emergency room, and then it's gonna switch over to inpatient after that admission, and then you'll start, you'll use those benefits too. [CUSTOMER][NEUTRAL] So [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] So yeah, I would definitely go ahead and file that claim. Um, so to file a, well, you actually have two options. Is this the [PII]? [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So I, I was admitted on the [PII]. [CUSTOMER][NEUTRAL] And then I was discharged on the [PII]. [AGENT][NEUTRAL] Oh, so you actually have two options. So if you wanted to, you can give the the hospital a call and let them know that you have an accident policy because I doubt the bills are out already. Um, tell them that you have an accident policy and give them this policy number so that they can just go ahead and bill us once the bills come out. They'll bill your primary first. [CUSTOMER][NEUTRAL] What [CUSTOMER][NEUTRAL] I'm pretty sure that with my like I don't know that I'll have any. [CUSTOMER][NEUTRAL] Bills, so is it me, uh like, do I have, is this like a reimbursement policy or indemnity? [AGENT][NEUTRAL] Neither. [AGENT][NEUTRAL] Accident, um, so it's not a reimbursement, um, because, so it's not like a secondary policy. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] But. [CUSTOMER][NEUTRAL] So [AGENT][NEUTRAL] Go ahead. [CUSTOMER][NEUTRAL] Yeah, so here's, here's where I was going with that. No, not to interrupt, but like I think this might answer it quicker is, so my wife and I, we like we're through the deductible because of the baby being born, right? We had a $5000 deductible that's paid for, that's done. So like my [CUSTOMER][NEUTRAL] Visit other than maybe emergency room co-pay is paid for. [CUSTOMER][NEUTRAL] So if, if that's all paid for by my primary insurance, Capital Blue Cross, does this policy even like pay? Like does, do I have to be billed for this to pay out? I guess is what I'm saying. [AGENT][NEUTRAL] Mhm. You do. The bill because that's one of the things we ask for is the billing. So you have to wait for the bills to come out, um. [AGENT][NEUTRAL] So that we can see what your primary paid, we can see what's still left over, if there's any, and then if at that point, once they see there's nothing left over, then yes, it will come to you, but the examiner would see all that once they get all the paperwork. [CUSTOMER][NEUTRAL] So let's say after all that, like this my surgery and the, you know, um. [CUSTOMER][NEUTRAL] The emergency room and everything, I get a bill for $100 basically you're gonna reimburse me $100 correct? [AGENT][NEUTRAL] Mm. [AGENT][NEUTRAL] We could, but when I'm, so if you, so we're trying to eliminate you from getting the bill. So if you let them know that you have this secondary insurance, you won't get any bills. [CUSTOMER][NEUTRAL] Right. [AGENT][NEUTRAL] They're gonna go through the. [CUSTOMER][NEUTRAL] What I'm saying, there, there's some like, like you're, you're paid out so I'm trying to think of what coverage this is cause I haven't done it in a long time, but I don't know if this is the case or not. So like, [CUSTOMER][NEUTRAL] Uh, like you're, you're essentially using that for. [CUSTOMER][NEUTRAL] Um, your day to day expenses. So regardless, let's say, um, I went to the emergency room and [CUSTOMER][NEGATIVE] Um, I, but I, but net out of my pocket's $0. I'm not going to get paid $750 correct? [AGENT][NEUTRAL] It depends. That's what I'm saying. I don't, so since I'm not an examiner, I don't know what they're looking for, but now they can see all the billing and say, oh, everything's paid for and then these benefits, whatever the total is, would just be a check to you, or it could be something still left and we have to pay out and then the rest go to you. So either way it goes, you'll most likely be receiving a check. I just don't know if it's everything to you or partial. [CUSTOMER][NEUTRAL] I didn't think [CUSTOMER][NEUTRAL] OK, so then the question becomes is what is the, the timeline that I can have to send in like the explanation of benefits. [AGENT][NEUTRAL] There is no timeline. We don't have a timely filing. As long as your policy is active, you can file a claim at any time. [CUSTOMER][NEUTRAL] OK, so in essence I would have to file. [CUSTOMER][NEUTRAL] 3 claim forms, one for me for the hospital, one for me for the accident, and then one for my wife and our daughter for the. [AGENT][NEUTRAL] So under the accident policy, you're only going to be filing the one claim, the outpatient and the inpatient is all together. So that'll be one claim and then it's gonna be one claim for your wife. [CUSTOMER][NEUTRAL] Right, so it's a total of 3 forms. [AGENT][NEUTRAL] Um, it's only 2, A and hospital indemnity. [CUSTOMER][NEUTRAL] That's what I'm saying. [CUSTOMER][NEUTRAL] OK, oh OK, got you, OK. [CUSTOMER][POSITIVE] OK, cool. Alright, that answers my, my question so it's just a matter of gathering all the explanation benefits for both events. [AGENT][NEUTRAL] So then [AGENT][NEUTRAL] If you want to, or you can have them bill us. [CUSTOMER][NEUTRAL] And then um [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] So that's up to, that's up to you. [CUSTOMER][NEUTRAL] Uh [CUSTOMER][NEUTRAL] OK, so I could basically just uh give. [CUSTOMER][NEUTRAL] The policy number to my doctor in the hospital for both, correct? [AGENT][NEUTRAL] Mhm. I would say to give them your policy numbers and then give them our phone number also in case they want to call us to verify the benefits or anything, we can go over that with them and tell them how to file a claim and all of that. [CUSTOMER][POSITIVE] Got you OK. [AGENT][NEUTRAL] And I'm pulling up your hospital indemnity now. I also emailed you the um your accident policy certificate with all your coverage, so you should have that. It may have went to your spam, but it's from the care team. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] And I'm pulling up the hospital indemnity uh policy now, so I can see what that coverage is. [CUSTOMER][NEGATIVE] But the point is, if there was nothing out of our pocket or otherwise out of our pocket, then nothing gets paid up through this, correct? [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] No. So like for your accident, even though you didn't pay anything, those are still your benefits. So they, they may say, OK, well, you know, insurance, your insurance paid for everything, but you still are owed the 750, so it'll just be to you. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Well, that's why I'm [CUSTOMER][NEUTRAL] Yeah [CUSTOMER][NEUTRAL] I think, I think that might. [CUSTOMER][NEUTRAL] I know, like most people might have them. [CUSTOMER][NEUTRAL] File, but maybe I'm OK doing it considering like this is kind of what I do. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So and just collecting explanation of benefits and just uh. [AGENT][NEUTRAL] Just make sure when you're, oh, I'm sorry. [CUSTOMER][NEUTRAL] The employer [CUSTOMER][NEUTRAL] Go ahead, no go ahead, just make sure. [AGENT][NEUTRAL] When you're filing, so for the accident claim, there's a um on our website, [PII]. [AGENT][NEUTRAL] Um, there's a claims and form section to the top right corner as soon as the page pops up. That's how you get the accident claim form and the um hospital indemnity claim form. On the first page of each form is the list of instructions, so it'll tell you based off of what you're filing for, this is what's needed. You're most likely going to need that explanation of benefits and the itemized billing um from the [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][POSITIVE] Got you. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] Provider. [CUSTOMER][POSITIVE] Got you. OK, cool, yeah. [AGENT][NEUTRAL] So for your hospital indemnity policy, [AGENT][NEUTRAL] Did she have to, it was just a regular birth? Did she have to have a C-section or anything? [CUSTOMER][NEUTRAL] It was C-section. [AGENT][NEUTRAL] OK, so she actually has, so you have the hospital and confinement benefit. So for hospital confinement on the hospital indemnity policy anytime over 18 hours. So that would pay $200 per day. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] There's [CUSTOMER][NEUTRAL] Now, is that OK, so here's how it broke. So [PII], my wife was there for like [CUSTOMER][NEUTRAL] 3 or 4 days, so was it Wednesday, Thursday, Saturday, but my daughter was in the NICU for a week. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] So she was in there Wednesday to Wednesday, is that a second claim? [CUSTOMER][NEUTRAL] Or is my daughter not covered because she wasn't. [AGENT][NEUTRAL] Your daughter? [CUSTOMER][NEUTRAL] Or is it all built [AGENT][NEUTRAL] The baby wouldn't be covered. The baby is not on the policy, but your wife can use the benefits. [CUSTOMER][NEUTRAL] Right. [CUSTOMER][NEUTRAL] And then is it a per like a percentage of the C-section? [AGENT][NEUTRAL] So, for the, OK, so the hospital indemnity is $200 a day and then for the first, you have a first occurrence hospital rider. So for each person, the first time that they're confined into a hospital, the policy will pay up to $2500. So you have that. [AGENT][NEUTRAL] And then there is a surgical and anesthesia benefit. The surgical um benefit is up to $6000 and then whatever the total of the surgery was, uh, anesthesia will be 25% of that, so they'll calculate that once they get the paperwork. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] I guess like one of my questions, uh, OK, so let's have in some like crazy time and space, we found the hospital that was free to us is where I was going with this. So they didn't bill us so there's, you know, no one's gonna bill you. [CUSTOMER][NEUTRAL] Right, so it's essentially paid for if it's a net zero to use the insurance company or us as the. [CUSTOMER][NEUTRAL] Insured, then that example, that surgical benefit would not pay out because there has to be, it's, it's not like a triggering event where it happened, [PII] or [PII] gets paid, it's, there has to be something that's paid up to $6000 correct? [AGENT][NEUTRAL] Something that's paid. [CUSTOMER][NEUTRAL] Because that's where in like when it comes to it, it changes so it's kind of like. [CUSTOMER][NEUTRAL] It sounds like it's more reimbursed, which is fine, uh, because indemnity typically is like if you went in for a hospital and you found a hospital that was, the bill was 100 bucks, you guys aren't gonna pay out, still pay out $2500. Do you see what I'm saying? [AGENT][NEUTRAL] Right, um, [CUSTOMER][NEUTRAL] You'd pay out the $100. [AGENT][NEUTRAL] Right, we would only pay up to that, yeah, that's why it's up to the 6000. So yes, we would only pay the 100 for in that case. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][POSITIVE] OK, so, so that answers that answers my question then. OK, great. [AGENT][NEUTRAL] Alrighty, and I was looking to see if I saw like that level 3 on, like I saw on the accident. [CUSTOMER][NEUTRAL] Um, [AGENT][NEUTRAL] But I didn't see that on hospital indemnity, on the hospital indemnity policy, um. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Is, is there only one level? [AGENT][NEUTRAL] No, there's multiple levels, but see how you [AGENT][NEUTRAL] What you sign up for? [AGENT][NEUTRAL] And what it comes over as is two different names. So, so for like example, this just says hospital indemnity insurance, but for you it might say level 234, but it doesn't show that on our end. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So I don't really know what it is. [AGENT][NEUTRAL] No, I'm just saying because it comes through the employer or, you know, the company that you use to sign up for us, they might call it specialty or um access, but to us it's hospital indemnity and then you have a product number here, but it doesn't have like a level 3 like the accident did. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Uh [CUSTOMER][NEUTRAL] OK, but if I gave you, um, a policy number you could tell me what that is? [AGENT][NEUTRAL] Mhm. Yeah, it'll pull your policy right up. [CUSTOMER][NEUTRAL] Yeah [CUSTOMER][NEUTRAL] OK, so but you could you do that with my [CUSTOMER][NEUTRAL] You already did that with my um. [CUSTOMER][NEUTRAL] Uh, let's see here. [CUSTOMER][NEUTRAL] You did that by my social like you pulled up all the, all OK. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] So, from the social, I was able to see both of your policies. Um, did you need your policy numbers? [CUSTOMER][NEUTRAL] Yeah, go ahead. [AGENT][NEUTRAL] So for, hold on, let me go back to both. [AGENT][NEUTRAL] For your hospital indemnity policy, that number is 251. [AGENT][NEUTRAL] 5658. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] Your accident is the same, it just ends in a 9. [CUSTOMER][NEUTRAL] OK, so 251-565-9, OK. [AGENT][NEUTRAL] Mhm. [CUSTOMER][POSITIVE] Fantastic. Well, thank you so much. [AGENT][POSITIVE] You're very welcome. Was there anything else I could assist you with today? [CUSTOMER][NEUTRAL] And I said, what was your name again? [AGENT][NEUTRAL] My name is [PII]. [CUSTOMER][POSITIVE] Yeah, OK, thanks [PII], I appreciate your time. OK. [AGENT][POSITIVE] You're very welcome. Well, thanks for calling APL. I hope you all have a great day. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] You too bye now. [AGENT][POSITIVE] Thank you. Bye-bye.