AccountId: 011433970860
ContactId: d3a4705b-3e49-4548-b098-98a23815e3f7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 491869 ms
Total Talk Time (AGENT): 250103 ms
Total Talk Time (CUSTOMER): 135638 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/d3a4705b-3e49-4548-b098-98a23815e3f7_20250519T14:01_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] I have a question regarding my benefits.
[AGENT][POSITIVE] OK, I can help you with your benefits.
[CUSTOMER][NEUTRAL] I have a uh
[CUSTOMER][NEUTRAL] I have an EOB here stating um let me give you the uh you want the reference number or the claim number?
[AGENT][NEUTRAL] Well, first, sir, can I get your name and your callback number just in case the call is disconnect.
[AGENT][NEUTRAL] Did.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. Last name is [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] My number is [PII].
[AGENT][NEUTRAL] Thank you, sir. And then what is your policy number?
[CUSTOMER][NEUTRAL] 02590580.
[AGENT][NEUTRAL] OK, let me look that up real quick, sir.
[AGENT][NEUTRAL] OK, Mr. [PII]. Can you please verify your date of birth for me, sir?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then also, will you please verify your address, phone number, and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Date of birth, you said [PII]. What uh address and what?
[AGENT][NEUTRAL] Your
[AGENT][NEUTRAL] Your email address, please?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Thank you sir and then the phone number that you gave me to call you back on if we're disconnected is that your cell?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you, Mr. [PII]. I appreciate you verifying your policy for me, and you're calling about a claim that you got an explanation of benefits on, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] And you need me to check it for you? You had some questions?
[CUSTOMER][NEGATIVE] Well, I'm, I'm not understanding how the claim is being denied. I mean, it's an $18,000 claim for an outpatient treatment, and this thing is telling me I'm not covered for outpatient treatment.
[CUSTOMER][NEGATIVE] Which I, I do not understand.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And secondly, I have, I have a uh
[AGENT][NEUTRAL] OK, sir.
[CUSTOMER][NEUTRAL] A spinal cord stimulator that's supposed to be implanted.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] And I'm wondering if that's gonna be covered.
[AGENT][NEUTRAL] OK, alright, um.
[AGENT][NEUTRAL] I can help you with your questions, sir. As far as the claim, you said you have a claim number, can I get that from you please?
[CUSTOMER][NEUTRAL] 359-9563
[AGENT][NEUTRAL] OK, let me look it up for you real quick.
[CUSTOMER][NEGATIVE] I mean, if I would have known this, I would have never.
[CUSTOMER][NEUTRAL] About this policy.
[AGENT][NEUTRAL] I understand, sir.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Now now it does have a remark on the the um denial that.
[AGENT][NEUTRAL] Benefits payable under this cer certificate are limited to those outlined on the schedule of benefits on your policy. This is not a covered loss under the plan. Therefore, no amount is payable for this.
[AGENT][NEUTRAL] Claim
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] According to the way you're.
[CUSTOMER][NEUTRAL] But I thought there was a consideration for uh repricing or whatever.
[AGENT][NEUTRAL] No sir, I don't I I have not heard that before um now what I can do sir, is I can get you some further assistance as far as how the claim is processed through a claim specialist I can transfer you to a claims specialist if you'd like to speak to somebody there.
[AGENT][NEUTRAL] And they can go over your, your claim and how it was processed, but according to the remark that I can see it's stating that it's a non.
[AGENT][NEUTRAL] Effort service under your policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So what about going forward for the spinal cord stimulator? Is that, that's gonna be outpatient. Is that also not gonna be covered?
[AGENT][NEUTRAL] Let me see if you have any outpatient benefits on on your plan.
[AGENT][NEUTRAL] OK, it's gonna be just a moment while I pull in your.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, when you have
[AGENT][NEUTRAL] OK, so for your outpatient services.
[AGENT][NEUTRAL] On this policy, therefore, and this is just to verify your benefits, it's not a guarantee of payment. There is, um, it's limited to accident and sickness treatment.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So if it was caused by an accident or sickness,
[AGENT][NEUTRAL] Then you have outpatient benefits for accident or sickness treatment for uh physical, speech or occupational therapy, physician's office visits, urgent care facility or an emergency room.
[AGENT][NEUTRAL] Now, if you have to go into the hospital for the surgery,
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] You do have an outpatient benefit for accident or sickness for surgery.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, let me tell you what that's going to be. That pays $300. It's a set amount that it'll pay.
[AGENT][NEUTRAL] Um, if you have to be admitted to, yes, sir.
[CUSTOMER][NEUTRAL] $300.
[AGENT][NEUTRAL] If you have to be admitted to the hospital.
[AGENT][NEUTRAL] You have a hospital benefit.
[AGENT][NEUTRAL] The amount of $750 that will go towards your hospital.
[AGENT][NEUTRAL] If they end up admitting you.
[CUSTOMER][NEUTRAL] It's crazy.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEGATIVE] I, I, I don't mean to sound stupid, but so you're telling me that the procedure for my spinal cord stimulator will not be covered.
[AGENT][NEUTRAL] If it's an accident or sickness.
[AGENT][NEUTRAL] The surgery benefit for outpatient is $300.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so that's all that's all I would would get.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Or if they're, or if, you know, you go in the hospital, then you have that hospital benefit.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] Which is only $700.
[AGENT][NEUTRAL] 700, yes, 750 hospital confinement.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] That won't get surgical supplies so.
[CUSTOMER][NEUTRAL] OK, I wish I had known all this. I guess it's my fault for not reading all the fine print, but uh.
[CUSTOMER][NEGATIVE] It doesn't get anything to my needs.
[AGENT][NEUTRAL] I understand, sir. OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. Is there any other questions you may have or anything else that I can help you with, Mr. [PII]?
[CUSTOMER][POSITIVE] All right, thank you.
[CUSTOMER][POSITIVE] That's it. Thank you.
[AGENT][POSITIVE] OK, well, you have a blessed day, sir, and thank you for calling APL.
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][NEUTRAL] Bye-bye.