AccountId: 011433970860
ContactId: dc663a68-caef-4a5c-a915-0a92d65e4b7c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 419049 ms
Total Talk Time (AGENT): 104274 ms
Total Talk Time (CUSTOMER): 138266 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/11/dc663a68-caef-4a5c-a915-0a92d65e4b7c_20250411T20:07_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi Ms [PII], this is [PII] in the care team. I have uh an insured on the phone and actually it's his wife that we're talking to and I did get consent to discuss his claim with her and they verified the policy or he verified the policy. The, the wife's name is [PII], it's [PII].
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, the policy number?
[CUSTOMER][NEUTRAL] Is 26.
[CUSTOMER][NEUTRAL] 05764
[CUSTOMER][NEUTRAL] And they are calling about claim number 3584364.
[CUSTOMER][NEUTRAL] I read the remarks and they have further questions about the claim and the denial on it.
[AGENT][NEUTRAL] OK, you can send them over.
[CUSTOMER][NEUTRAL] And I tried to get her to get, you know, let you guys call her back but she wanted to speak to somebody right now.
[AGENT][NEUTRAL] OK, that's fine.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Oh, are you
[CUSTOMER][NEUTRAL] Ms [PII], I haven't, I haven't released the call yet. Sorry, I didn't know you were ready. I'll release it now.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi Ms. [PII], uh, my name is [PII]. I am calling to get some clarification on a case or claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I see.
[CUSTOMER][NEUTRAL] I don't know if she transferred. Did she give you all of the information? OK.
[AGENT][NEUTRAL] Yeah, she gave me your policy number and the claim number that you're calling on uh and that claim was processed on today.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, and they're saying it's
[CUSTOMER][POSITIVE] Yes ma'am, and I understand his existing condition, he's never had anything wrong with his back ever.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] He's had his feet, he's had his knees.
[CUSTOMER][NEUTRAL] He's had his kidneys.
[CUSTOMER][NEUTRAL] And he's had uh infections, but never anything going on with his back.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me a second to see if I can pull up the information that uh they reviewed on this one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] He went to the emergency room because of an issue because he was, couldn't walk, and they took him into emergency back surgery. He's never had a problem with his back.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One second while I verify everything.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so it looks like uh they did uh they requested the medical records.
[AGENT][NEUTRAL] Um, and then review and it looks like he did when he went to the ER he went due to excruciating back pain.
[AGENT][NEUTRAL] And he was evaluated
[CUSTOMER][NEUTRAL] On what day?
[AGENT][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] Are you so 2 days before the surgery.
[AGENT][NEUTRAL] OK, yes ma'am, and that actually it was, it was prior to your policy's effective date which was [PII].
[CUSTOMER][NEGATIVE] Like you're fucking kidding me.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] And they don't make an exception for 2 days.
[AGENT][NEUTRAL] No, because the uh policy has a 12 month preexisting uh exclusion on it.
[CUSTOMER][NEGATIVE] That is so foul.
[AGENT][NEUTRAL] Yes, ma'am. So that's what looks like what the medical records are showing that he was treated in the ER for back pain prior to the policy being effective.
[CUSTOMER][NEGATIVE] Uh just because he had back pain.
[CUSTOMER][NEUTRAL] Then that excludes it, even if it had nothing to do if they were two different back pains.
[AGENT][NEUTRAL] Uh, I mean, what do you mean two different back pains?
[CUSTOMER][NEUTRAL] Two different, two different things because what he had surgery for was radiculopathy.
[CUSTOMER][NEUTRAL] Which was nerves in his legs.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They did the surgery on his through his back because that's where your nerves are.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] But it was for sciatica. I mean, I'm just, I think that that's so.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, but uh we did.
[CUSTOMER][NEUTRAL] And I'm not saying anything to you. I, I'm just.
[AGENT][NEUTRAL] Yes, ma'am. I do um, yeah, but that's the issue that he did receive treatment. He went to the ER.
[AGENT][NEUTRAL] Due to uh the back pain.
[AGENT][NEUTRAL] And so they considered that he went in seeking treatment for his back prior to the policy at the end.
[AGENT][POSITIVE] Uh, becoming effective.
[CUSTOMER][NEUTRAL] Oh, help me [PII]. OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll see if we can talk to his job, OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Alrighty, is there anything else that we can help you with on today?
[CUSTOMER][POSITIVE] OK, thank you.