AccountId: 011433970860
ContactId: d6ebcdab-ae5f-4610-9722-1fc953de6491
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1084260 ms
Total Talk Time (AGENT): 388718 ms
Total Talk Time (CUSTOMER): 417456 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/d6ebcdab-ae5f-4610-9722-1fc953de6491_20250515T18:51_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, I'm trying to file claims for a cancer policy.
[CUSTOMER][NEUTRAL] And uh I I got some.
[AGENT][NEUTRAL] You're trying
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] I filed some claims for a a cancer policy.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm, I
[CUSTOMER][NEGATIVE] I've been diagnosed with cancer. I've been in all of the.
[CUSTOMER][NEGATIVE] Information I have so far and the claims that you, the, the information you've looked at so far, everything's been denied. Uh, does it not pay for a biopsy?
[AGENT][NEUTRAL] I would have to look at your policy, ma'am, and the claims, but I'm happy to take a look. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, it's 00455369.
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] All right. And then if I could just verify please your name and date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you, Miss [PII]. And then if you could lastly give me your physical address on file.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] All right, thank you so much. So let me.
[AGENT][NEUTRAL] Go in here and look at the last couple of claims.
[CUSTOMER][NEUTRAL] I think we send in some information that that you're not gonna that's not covered but.
[CUSTOMER][NEGATIVE] I was looking through what you've already processed and nothing got paid and, and I'm like I don't know why the biopsy wouldn't be covered.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I have the claim number for that particular one if you wanna look at it.
[AGENT][NEUTRAL] Yeah, absolutely. What was that claim number?
[CUSTOMER][NEUTRAL] It's 360-115-9.
[AGENT][NEUTRAL] OK, I do see that one it's saying non-covered, so let me.
[AGENT][NEUTRAL] Well the policy.
[CUSTOMER][NEGATIVE] Not done anything out of know is what they paid for.
[CUSTOMER][NEGATIVE] I do on that problem it's not this.
[CUSTOMER][NEUTRAL] They may have to put that one that's saying you have cases so that like.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] You know just a process.
[AGENT][NEUTRAL] OK, so let's see.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So on the surgical benefit, it says we'll pay the fee for a surgical operation or definitive cancer treatment.
[AGENT][NEUTRAL] Um, it says this benefit will not exceed the amount shown on the schedule of operations.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] So when I go down and look at the schedule of operations, I'm not seeing anything.
[AGENT][NEUTRAL] Listed.
[AGENT][NEUTRAL] So like it has abdomen, it has amputations, mouth, neck, brain, breast, chest.
[CUSTOMER][NEUTRAL] Uh it's breast cancer.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] So under breast, they list a surgical benefit for a simple mastectomy and a radical one.
[CUSTOMER][NEUTRAL] So
[AGENT][NEGATIVE] They don't list any other benefit in the policy that I see.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Whoa, whoa, wait a minute, are you saying it doesn't go, it's not gonna pay anything for breast cancer?
[AGENT][NEUTRAL] Well, it looks like it's showing that the benefit payment is only if there was a mastectomy done.
[CUSTOMER][NEGATIVE] That's not true.
[CUSTOMER][NEUTRAL] I had the same policy 14 years ago.
[CUSTOMER][NEUTRAL] And it paid for so much for radiation, it paid so much for chemo.
[CUSTOMER][NEUTRAL] Uh, it paid a lump sum.
[CUSTOMER][NEGATIVE] It paid uh so much for just about everything. So unless you changed your policy and did not notify us, that's not correct.
[AGENT][NEUTRAL] I'm just speaking on the biopsy, ma'am, um, that I just don't see, no, ma'am. I'm just saying that I don't see biopsy listed.
[CUSTOMER][NEUTRAL] 00, OK. I thought you were saying.
[CUSTOMER][NEUTRAL] OK, what is listed? What do I need to make sure I get to you?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] In regards to any sort of surgical cancer in the breast, I'm showing on this schedule of operations that the, this is just in regards to an operation that the benefit would only be paid if there was a mastectomy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's the only surgical benefit that I see for that. Now, if we wanna go.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] And look at like the radiation and chemotherapy. I'm absolutely happy to look at that as well.
[CUSTOMER][NEGATIVE] Yeah, because this policy that I've got is talking about it's not giving me a list of what's paying. I'm not finding it in this policy of what it's gonna pay.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have access to email by chance? or do you want me to mail you a copy of this?
[CUSTOMER][NEUTRAL] Can you do both?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Now, uh, the copy I have.
[CUSTOMER][NEUTRAL] Uh, maybe I'm just not finding it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This says a lump sum cancer policy so it should be in there shouldn't it?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah, so it looks like the
[AGENT][NEUTRAL] Benefits schedule I'm showing from what I'm looking at in the policy is on page 6.
[CUSTOMER][NEUTRAL] OK, clients provision. Ask them how long it's gonna take for these in progress ones to go through so we know because they're the ones that it's got the paper that says you actually have.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Um, the ones that she, so I'm her daughter. I'm just helping her. I just have a question. So on her claims, some of them, you know, it said that she don't get money, that's fine, but there's some that are saying processing or in progress, and one of those is the one that has a statement.
[CUSTOMER][NEUTRAL] Like saying she has breast cancer.
[CUSTOMER][NEUTRAL] Or how long will those take to process so that we know if we need to do something different.
[AGENT][NEUTRAL] Do you have?
[AGENT][NEUTRAL] Is that the one that was submitted on, it looks like the first.
[CUSTOMER][NEUTRAL] Yes, there's um 12, it says there's 3 of them still in process or progress.
[AGENT][NEUTRAL] Yeah, huh.
[CUSTOMER][NEGATIVE] I can't click none of those.
[AGENT][NEUTRAL] Yeah, I see that.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Cause I know well from what we read, once she, y'all get the, the confirmation or you know, the thing from the doctor stating she does have it, that one will, she'll she should get something for that.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Let me see, yeah, I see the same thing it's still showing in progress.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And we can just wait. I was just curious if you knew I could turn around on it.
[AGENT][NEUTRAL] They generally say um to give it.
[AGENT][NEUTRAL] Um, like 10 business days, uh, to process anywhere from 7 to 10.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] OK, so just wait a few more days.
[AGENT][NEUTRAL] Yeah, we're about it.
[CUSTOMER][NEGATIVE] So we start stressing out.
[AGENT][NEUTRAL] Yeah, we're about at 10 days. So, um, I would maybe just give it till the beginning part of next week and then if you haven't heard anything, definitely you could check back on it.
[AGENT][NEUTRAL] Um, for the, for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So that I don't send things that you don't need.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, because I'm not understanding that this policy to explain it clear enough, uh, any chemo.
[CUSTOMER][NEUTRAL] Or any radiation you need.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, what about any medications or follow-ups or?
[CUSTOMER][NEUTRAL] I think it's just that.
[AGENT][NEUTRAL] Um, it says drugs administered. It says in or out of hospital. It says actual charges. It looks like it's the reimbursement not to exceed $25 a day. That's for drugs, um, prescription.
[CUSTOMER][NEUTRAL] So she had to go in the hospital, well, not the hospital, but like car tied twice last week to get fluid and like then what is it? Confusion, infusions and stuff. Is that stuff that we would need to submit?
[AGENT][NEUTRAL] Yeah, so I think, I wonder if that's under.
[AGENT][NEUTRAL] I wouldn't be under.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I was just kidding. You.
[CUSTOMER][NEGATIVE] Oh, they're not my favorite.
[CUSTOMER][MIXED] The flavors, it's not what I thought. to a halfway Can flavor. I know that's why I thought I like them, but I think it's because they're not very hot.
[CUSTOMER][NEUTRAL] But I'm too hot or not.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Trying to find.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] They just so.
[CUSTOMER][NEUTRAL] It's a white dog.
[CUSTOMER][NEUTRAL] Just like got to go there.
[CUSTOMER][NEUTRAL] I I'm telling you I think.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] I like.
[AGENT][NEUTRAL] Let me see what they request um.
[AGENT][NEUTRAL] I'm looking to see what they request for any.
[AGENT][NEUTRAL] OK. So if you're gonna file any claims for, are you wanting to file them for like prescriptions or is it just for like medication that was received while in the hospital?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Both. I wasn't in the hospital.
[AGENT][NEUTRAL] OK. So, for prescriptions, um, they ask for a copy of the prescription when filing the claim for medications.
[CUSTOMER][NEUTRAL] Uh, I don't think that away. We can get what is it I need? You need a copy of, of what medications they prescribed me.
[AGENT][NEUTRAL] So if you're wanting to file a claim for prescriptions, they ask for a copy of the prescription when filing a claim for medication.
[CUSTOMER][NEUTRAL] We can do that. We can get the paperwork. Can you get that? The doctor can give it to you or the pharmacy should probably get you a list of, OK, because I see those little papers. I, OK, write that down so we are you I got drugs, so we do chemo radiation drug. I'm just gonna send you everything.
[CUSTOMER][NEUTRAL] Probably, but do you have, do you, I can't find on here where it says what it pays for anything like on chemo, does it pay a, a flat rate when I get chemo or?
[AGENT][NEUTRAL] Let me get back to your policy here.
[CUSTOMER][NEUTRAL] I wish we could see that shows there's something on online here. Well, I'm, see, I'm looking here and it's saying payments and claims and everything, but I'm not seeing anything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That tells what pack on the place.
[CUSTOMER][NEGATIVE] All it tells is what it takes for lump sum and I, and I can't get that.
[CUSTOMER][NEUTRAL] Why can't you get the it's the one time, oh.
[CUSTOMER][NEUTRAL] So you got that last. Yeah.
[CUSTOMER][NEGATIVE] Well they don't want you because again they want to have it again. Well that's what you're, I'm, I'm lucky now get it again it again.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, I found the radiation chemotherapy benefit on page 15.
[AGENT][NEUTRAL] Um, it says we will pay the actual charges not to exceed 5000 per 12 month period.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] For them combined or each?
[AGENT][NEUTRAL] It's like
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Here it is. I got it. Oh, you found it?
[CUSTOMER][NEUTRAL] Yeah, 5000 for 12 month period.
[CUSTOMER][NEUTRAL] Yeah, for what? chemo and radiation, radiation and chemotherapy.
[AGENT][NEUTRAL] Yeah, it's a combined, combined benefit, so it would be for both. And then if you look down, you should see drugs administered, there's anesthesia, surgical, blood, all those down there.
[CUSTOMER][NEUTRAL] So I just want to
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I see them.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] That doesn't pay for biopsy, doesn't pay for biopsy.
[AGENT][NEUTRAL] Do you guys have the cancer claim form?
[CUSTOMER][NEUTRAL] Like the we're online we're doing it online. I'm just looking at her policy online. Where would that be? Is that something her doctor would give her?
[AGENT][NEUTRAL] No, so the claim form is located on our home site under claims and forms.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] And page one is nothing but instructions and it breaks it down for you. It's super helpful. It'll tell you like if you're filing a claim for like chemo, radiation, immunotherapy, it tells you exactly what you need to submit with it. Same for transportation, same for prescriptions, um, all of that.
[CUSTOMER][NEUTRAL] That's what we did before.
[CUSTOMER][NEUTRAL] Oh, OK. Oh, OK.
[CUSTOMER][POSITIVE] Well, thank you. All right. Well.
[AGENT][NEUTRAL] And then yeah and then on there is also the fax number and the mailing address you guys can of course upload claims through that portal but if for some reason you wanted to fax it or mail it all that information's on that sheet too, so you'll need to um so that's just a helpful reference point if you ever forget what you may need.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] OK, this right here.
[CUSTOMER][POSITIVE] Oh yeah, OK, I got it.
[CUSTOMER][NEGATIVE] OK, I just was the, the first one that came through, everything was denied and I'm like maybe we're not doing something right.
[AGENT][POSITIVE] Yeah, so I apologize.
[CUSTOMER][NEUTRAL] But apparently we did that was someone in the class.
[AGENT][NEUTRAL] Yeah, I apologize for the confusion. It can be a lot and these can be a lot of paperwork too, so I, I get it.
[CUSTOMER][NEUTRAL] Yeah, well, we, we did this through, we got a copy of everything that we could up to [PII], so probably.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Probably we'll add some more.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Probably wait a month and go and get another.
[CUSTOMER][NEUTRAL] Um, thing from the, from car tie.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And send everything that's done for that month.
[AGENT][NEUTRAL] OK. Yeah.
[CUSTOMER][NEUTRAL] And we just continue doing that until I'm done?
[AGENT][POSITIVE] Yeah, absolutely. If that's how you prefer to do it and that works best for you, absolutely.
[CUSTOMER][POSITIVE] All right. Well, thank you so much. You, it was a lot of help.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] My pleasure, and if you have any other concerns or questions, please feel free to call.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh bye bye.