AccountId: 011433970860
ContactId: dd6cb1b6-88e5-40b3-a94a-c84a39acae54
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1623579 ms
Total Talk Time (AGENT): 688067 ms
Total Talk Time (CUSTOMER): 491390 ms
Interruptions: 6
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/dd6cb1b6-88e5-40b3-a94a-c84a39acae54_20250123T17:54_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII], and I filed a couple of claims, um,
[CUSTOMER][NEGATIVE] On my insurance to my doctor and I'm not quite understanding. I've been getting notices in the mail and stuff like that. I'm not understanding what I need to do to take care of it.
[AGENT][NEUTRAL] OK, Ms. [PII], so you have some questions regarding claims that have been, you have filed with us for yourself, is that correct?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, ma'am, I can help you with that. And Miss [PII], what is a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And your policy number, please?
[CUSTOMER][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] OK, it's 02417404.
[AGENT][POSITIVE] OK, thank you. So give me a couple of moments to get all of your information pulled up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so Ms. [PII], any information that I do provide for you today will be a verification of benefits and not a guarantee of payment. I will have to verify several things with you first for security. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Oh, thank you. Well, you're about to have a birthday tomorrow, so happy early birthday.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm. And then your home mailing address, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one you gave me, so again, that is your best contact number. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you and lastly your email address please.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Now while a couple of additional things are um loading for me, Ms. [PII], have you ever set up your profile in our portal, our secured uh secured.
[CUSTOMER][NEGATIVE] I don't believe I have.
[AGENT][NEUTRAL] OK, so I'm also going to email you um a user guide and this the user guide will be for the online service center it will give you the information instructions on setting it up and also the different things that you can do within the portal because you can submit information to us for review through that portal.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] OK, great.
[AGENT][NEUTRAL] Alright, so give me
[AGENT][NEUTRAL] Just one moment.
[AGENT][NEUTRAL] And the email that you will receive from me, Ms. [PII] is going to come from [PII] team [PII].
[AGENT][NEUTRAL] And I did put APL online service center in the subject line for you so that that's easy to recognize.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, you're welcome. So I do see that we do have one claim on file for you uh let's see.
[AGENT][NEUTRAL] For a couple of different dates of service, [PII] and [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, let me see, let me open this.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so let me look at the remarks. OK, so the, the now remark currently is the same for each data service.
[AGENT][NEUTRAL] And it states in order to complete the processing of your claim, we need itemized statements of services provided listing the charges, diagnosis code or codes and procedure code or codes. This is something that you would contact the facility for.
[AGENT][NEUTRAL] Was this a hospital claim?
[CUSTOMER][NEGATIVE] No, it was just, um, I was just getting my yearly checkup and I didn't realize that the insurance wouldn't cover it.
[AGENT][NEUTRAL] OK, so you're, um, so yes ma'am, for us to complete the review of the claim fully we will have to receive that information and you would get that from the provider you can actually once you're set up in the online service center you will also have access to this explanation of benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But it will have that remark code on there so when you reach out to the providers for those two dates of service, you can just read them that.
[AGENT][NEUTRAL] For this type of policy, we always have to have the itemized statements.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That breaks out, you know, what they did along with the codes and the charges and your diagnosis of why they did all of these things.
[CUSTOMER][NEUTRAL] OK, um, I'm looking at it right now and let me see if I, let's see.
[CUSTOMER][NEUTRAL] So it it has the detailed account information.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And what happened? So I got a um shingle shot.
[AGENT][NEUTRAL] Right, but if you'll notice.
[CUSTOMER][NEGATIVE] And it gets priced right next to it.
[AGENT][NEUTRAL] So, on your policy, let me see if immun so these were, this was for a vaccination or immunization?
[CUSTOMER][NEUTRAL] Um, it was for the shingle shot immunization.
[CUSTOMER][NEUTRAL] Yeah, and, and, OK, and there's, uh, let's see, immunization administration and there's a number 90471 CPT.
[AGENT][NEUTRAL] Correct. That's a procedure code. So we need the a diagnosis code, but let me look, let me look at something on your policy, OK?
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] OK, so under this policy, immunizations are not a covered benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well,
[AGENT][NEUTRAL] Mhm. This is a hospital indemnity limited benefit plan. It's not a major medical.
[AGENT][NEUTRAL] Plan
[CUSTOMER][NEUTRAL] So probably a lot of this stuff isn't gonna get covered. How about blood work and stuff like that? Would that be covered?
[CUSTOMER][NEGATIVE] I didn't realize that insurance would not cover this stuff.
[AGENT][NEUTRAL] No, ma'am. This policy that you have provides benefits if you're admitted as an inpatient into the hospital.
[AGENT][NEUTRAL] Or would I have to have, you know, anesthesia it does have an anesthesia benefit. You have a hospital admission benefit, a confinement benefit, an intensive care benefit, and a general anesthesia benefit.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And once you set up.
[CUSTOMER][NEUTRAL] I wish they would have told me that from the.
[AGENT][POSITIVE] Oh, I'm so sorry. I did not mean to overspeak you. I'm so sorry.
[CUSTOMER][NEUTRAL] No, no, no, go ahead. Go ahead.
[AGENT][NEUTRAL] No, but this, that's, that's what the benefits on this particular plan that you have covers.
[CUSTOMER][NEUTRAL] Wow, OK, so it looks like they're not gonna cover any of my.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Just the, the.
[CUSTOMER][NEUTRAL] Procedures that I had, had done as far as the physical goes. So preventative maintenance is not covered.
[AGENT][NEUTRAL] Uh, I do not see any.
[AGENT][NEUTRAL] Give, give me just a second to look at a couple of other things.
[AGENT][NEUTRAL] OK. Now, you do have
[AGENT][NEUTRAL] Mm, let's see.
[AGENT][POSITIVE] Thank you for your patience and while I'm looking at.
[CUSTOMER][POSITIVE] No, that's fine. I appreciate your time.
[AGENT][POSITIVE] Yes ma'am, you're very welcome.
[AGENT][POSITIVE] It's just taking some time. I'm just having to look through several things again, I do appreciate your patience, Ms. [PII].
[CUSTOMER][POSITIVE] OK, thank you though. I appreciate your time.
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] OK, so do you mind letting me place you on a brief hold please while I try to look at some additional information?
[CUSTOMER][POSITIVE] No, I'm fine. Thank you.
[AGENT][POSITIVE] OK, great. Thank you. Yes, ma'am.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] God dang it, this is such trash.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], it's [PII]. How are you?
[CUSTOMER][POSITIVE] I'm good. How are you, [PII]?
[AGENT][NEUTRAL] I'm all right. Could you please look at a policy? I wanna make sure I'm not overlooking something because what I see on PIBFT does not reflect what this policy certificate is showing me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, what's the policy?
[AGENT][NEUTRAL] I don't think. It is 241-7404 for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me get all this pulled up.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] I don't wanna transfer her but I don't wanna give her any incorrect information.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] You know, it looks like according to her policy.
[AGENT][NEUTRAL] That it's just like for confinement according to how I'm interpreting it. However, there's all of these other benefits on PIBST, but I don't see these amounts.
[AGENT][NEUTRAL] Broken out into her.
[CUSTOMER][NEUTRAL] Yeah, I see what you're saying, um.
[AGENT][NEUTRAL] And so I don't, you know, she's, she called about a claim status which we've handled that. But then she was like, you know, then she had some additional questions and I was telling her that, you know, immunizations aren't covered and so she was wanting to know about like lab work. Well, I don't think lab work is covered. But um
[AGENT][NEUTRAL] I was looking at the policy er and then I was looking at PIBF too and I'm like, well, what I, I don't know.
[CUSTOMER][NEUTRAL] Yeah, because even when you go to her policy that was uploaded in [PII], it doesn't have all of these surgery benefits listed either.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Oh Jesus, this group is.
[CUSTOMER][NEUTRAL] OK hang on let me.
[AGENT][NEGATIVE] This group is a not this BWA association, it's, it's every call is a problem every every call.
[CUSTOMER][NEGATIVE] Oh no.
[CUSTOMER][NEGATIVE] That sucks.
[AGENT][NEUTRAL] Eco and so I don't.
[CUSTOMER][NEUTRAL] Let's see they have.
[CUSTOMER][NEUTRAL] I was trying to see if like there was any amendments or riders that would be the reason for all the extra benefits. OK, so I do see a general anesthesia benefit.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But again, no real surgery is listed.
[AGENT][NEUTRAL] Hey
[AGENT][NEUTRAL] What about office visits?
[CUSTOMER][NEGATIVE] That's on the [PII] but it's not.
[AGENT][NEUTRAL] See, I'm looking, whichever.
[CUSTOMER][NEUTRAL] It's not on the [PII].
[AGENT][NEUTRAL] Right, it says that all that's been removed. What I'm looking at on the [PII] 1 that was uploaded.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It has all this stuff in there about this section being removed.
[CUSTOMER][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] The like
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Like number 6.
[AGENT][NEUTRAL] Under group hustle indemnity amendment writer.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I see, I see.
[AGENT][NEUTRAL] Number 6 says that section 5 of both policy and certificate is removed in its entirety.
[AGENT][NEUTRAL] We will pay the outpatient uh per day when treatment due to an injury or covered sickness is so, is that not saying that it was removed? I mean, it says it's removed in its entirety.
[CUSTOMER][NEUTRAL] OK, so let's start up at the top on that. So under number one it says the following benefits are added to the schedule. That's where her surgery is at. So accident and sickness surgery, there's the inpatient, there's the outpatient, and what we pay, whatever, and then the general anesthesia and the ICU and then text is added 3 section 5 benefits is removed and replaced with following with the following so that's text.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Number 5 definitions basically being redone. OK, the following text in the outpatient accident and sickness treatment benefit.
[CUSTOMER][NEUTRAL] Oh, it's just text so where it says we will pay the applicable outpatient accident and sickness treatment per day when treatment due to an injury or covered sickness is received by cover person in a physician's office and then right up under the next one it says and replaced with the following we will pay.
[CUSTOMER][NEUTRAL] And basically they just reworded it so it's not the offices have been removed they just change they changed the language is what it is.
[AGENT][NEUTRAL] So I need
[AGENT][NEGATIVE] So I don't even need to that policy is not even the full, I mean, I need to look at.
[AGENT][NEUTRAL] To see a breakdown of like how much.
[AGENT][NEUTRAL] An office visit is and how I really need to look at the first one that was issued for her, is that correct?
[CUSTOMER][NEUTRAL] Um, let me look and see if it matches what we do have in PIPFT.
[AGENT][NEUTRAL] Yeah, cause it's
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] HVB.
[CUSTOMER][NEUTRAL] Because it looks like they just changed language it doesn't look like they changed actual benefits they just updated the language based on that amendment. So in the previous one.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK. So she does have a physician's office, but lab work isn't covered. I mean, that's not something that's covered anyway. OK, well, I'll just.
[CUSTOMER][NEUTRAL] No, yeah, so the physicians is 50 and if you look at the outpatient and sickness and PIBFT it's 50 as well, so it does line up they just updated the language in [PII] policy.
[AGENT][NEUTRAL] Max and 3, that's.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Well, it would have been nice to update the [PII] policy to include all of the benefit information.
[CUSTOMER][NEUTRAL] I know I don't know why they didn't go ahead and put all of that up there, but I guess it's because they have that amendment writer but yeah all those benefits that you see are at at the end, basically they're not on the schedule.
[AGENT][NEUTRAL] Because
[AGENT][NEGATIVE] Jeez.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So she has emergency room, urgent care, physician's office, speech, physical, or occupational therapy. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And in addition to the other stuff, the confinement admission and intensive care.
[CUSTOMER][NEUTRAL] Yes, mhm, and the inpatient outpatient surgery.
[AGENT][NEUTRAL] And that's it.
[AGENT][NEUTRAL] Yeah, see, so they added that because
[CUSTOMER][NEUTRAL] Because yeah, when you look under that uh huh, they added that that's under number one of that, um, amendment so they added that so the ICU, which I think was on the schedule actually um was it.
[AGENT][POSITIVE] Wow.
[AGENT][NEUTRAL] Mm mm. Well, not on the first one.
[CUSTOMER][NEUTRAL] Yeah, it's on the 2nd 1, but it says, so the ICU that's confinement, but they added an ICU admission benefit.
[AGENT][NEUTRAL] Yeah, it is.
[AGENT][NEUTRAL] It's on the
[AGENT][NEUTRAL] It doesn't happen.
[AGENT][NEUTRAL] Jesus, OK.
[CUSTOMER][NEUTRAL] And then um and then the surgery of course there's inpatient and then there's outpatient in a.
[CUSTOMER][NEUTRAL] Facility and then there's outpatient in a physician's office and then there's the general anesthesia.
[CUSTOMER][POSITIVE] Yeah, so these are additional benefits.
[CUSTOMER][NEUTRAL] That were added to the other stuff.
[AGENT][NEGATIVE] Jeez.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] The hospital in
[AGENT][NEUTRAL] Hm, hold on.
[AGENT][NEGATIVE] I'm so confused because I like it has $2000 for the intensive care. I don't see that anywhere.
[CUSTOMER][NEUTRAL] That's, that's for the admission that's that number one under the amendment. So it's it's just like hospital like hospital admission. So if they're admitted to ICU they would get that, but they only, it's not payable on the same day as like hospital admission or any confinement. It's going to be.
[AGENT][NEUTRAL] But it's
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] I see, I see that, um.
[CUSTOMER][NEUTRAL] They're admitted and confined.
[CUSTOMER][NEUTRAL] And it's only payable once per period of confinement when they're in the ICU but it's not gonna be payable in addition to.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] I mean, I, I'm, I'm trying to follow what you're saying, [PII], honestly, but this is so confusing.
[AGENT][NEGATIVE] Uh, to me, it is so confusing because I'm.
[AGENT][NEUTRAL] When she looks at her policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] To see what her, uh, I don't know, let's just say.
[AGENT][NEUTRAL] Her ICU benefit is and PIPFT I see 2000.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's for the admission.
[AGENT][NEUTRAL] But I don't
[AGENT][NEUTRAL] But I don't see that in her policy certificate that she would be looking at.
[CUSTOMER][NEUTRAL] So if, if she's looking at the [PII] she's gonna have to look at that amendment it's, it's under the amendment, so on page, what is it?
[AGENT][NEUTRAL] 8 or 1.
[CUSTOMER][NEUTRAL] Hang on, let me get to it so I'm on the [PII] and the amendment is on page.
[CUSTOMER][NEUTRAL] It's listed as page one, but it's going to say group hospital indemnity amendment so you know it's 28 of 30 it's 28 if we're looking at all pages combined.
[AGENT][NEUTRAL] What's
[AGENT][NEUTRAL] The total page number.
[AGENT][NEUTRAL] OK, yeah, that's fine. I've got it. I got it. OK, so let me just try, like, yeah, and I don't know what she can and can't see out in the port. This is that, see that's really confusing for an insured. It's confusing for me.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I mean,
[AGENT][NEUTRAL] OK, alright, let me see if I can help her again.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] But I appreciate you so much in, in looking at that. OK. Talk to you later.
[CUSTOMER][POSITIVE] No problem. No problem. OK.
[AGENT][POSITIVE] OK, [PII], thanks.
[CUSTOMER][NEUTRAL] Uh, uh-huh.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][POSITIVE] Miss [PII], I have not forgotten about you and I appreciate you so much in holding for me.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so on this policy, you, OK, so lab work is not covered.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Um, again, this policy helps you if you are admitted to the hospital.
[AGENT][NEUTRAL] If you were to be in intensive care, you do have benefits. If you had to go to the emergency room or an urgent care facility, a doctor.
[AGENT][NEUTRAL] Or if you had to have, you know, speech, physical or occupational therapy.
[AGENT][NEUTRAL] But, but again, it's a limited benefit. So, for example, a physician's office for outpatient accident and sickness treatment for going to the doctor.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Your benefit on this policy is $50 per day.
[AGENT][NEUTRAL] And a maximum of 3 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So it's a ter terrible coverage.
[AGENT][NEUTRAL] It's, it's just, you know, it's not a major medical plan. This is a just a it's a limited benefit plan.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I didn't realize that when I signed up for it.
[AGENT][NEUTRAL] Now,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If you um you know if you have any questions regarding your enrollment excuse me, or changing anything the member services is the company that you would speak to about that and I would be happy to give you their phone number if you don't already have it.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, I'm good. I signed up with another insurance policy. I just took this insurance until my Medicare kicked in.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Oh, OK. OK, sure.
[CUSTOMER][NEGATIVE] And my Medicarek, so I no longer need this insurance, but in the meantime, I was trying to do preventative maintenance and uh I did not realize that it wasn't covered.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] OK. Well, thank you for your time.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Well, you are certainly very welcome. And again, thank you so much for your patience and while I was looking through all of your policy information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK. Well, if that's all I can help you with at the moment, Ms. [PII], it was my pleasure in speaking with you today and thank you again for calling APL.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][POSITIVE] OK. Thank you very much for your help.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Absolutely. Yes, ma'am. You're welcome.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] A bus.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] Trash trash trash. It was a terrible, terrible insurance policy.