AccountId: 011433970860
ContactId: e2761ea8-f824-4a3f-8719-2af1ffdc90ca
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1266390 ms
Total Talk Time (AGENT): 812881 ms
Total Talk Time (CUSTOMER): 482030 ms
Interruptions: 14
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/e2761ea8-f824-4a3f-8719-2af1ffdc90ca_20250428T19:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII] over on the care team. How are you today?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][NEUTRAL] Doing all right thank you. I've got a member I'm gonna have to transfer to you um she's calling regarding a disability claim and she's uh I guess it was determined that she had a preexisting condition so it denied, um, and she is very confused as to why that was or doesn't believe it to be relevant to what she's going through currently, um, so I'm not quite sure what to do with it.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] It is 256-966-8.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, God, that is a lot of pieces of mail to look through.
[CUSTOMER][POSITIVE] I saw, I looked at all, I was like, oh my gosh.
[AGENT][NEUTRAL] Yeah, that's like 123456789, 1011, 12.
[AGENT][NEUTRAL] Let's see if there's like a medical director or something cause that's gonna be.
[AGENT][NEUTRAL] The quickest way medical record request, medical director review that's gonna be the quickest way to see what's going on.
[AGENT][NEUTRAL] Cause her diagnosis, it looks like per the.
[AGENT][NEUTRAL] Policy are part of the thing, uh, obstructive sleep apnea.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then.
[CUSTOMER][NEUTRAL] I think she said like narcolepsy or something like that. Yeah.
[AGENT][NEUTRAL] Uh, narcolepsy. Mhm.
[AGENT][NEUTRAL] So, the.
[AGENT][NEUTRAL] Question to the um.
[AGENT][NEUTRAL] To the medical director is, you know, obviously we're trying to determine if the insurer's disability is pre-existing, so they gave a timeline stating when she was treated.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And um for obstructive, let's say, insured was treated on [PII] and [PII] for obstructive sleep apnea and narcolepsy. Um, and then they put the definition of preexisting. In your medical opinion, do you agree that the disability is pre-existing based on the policy language, um, because she was claiming disability in January, so she was treated for this a year prior.
[AGENT][NEUTRAL] To her disability, it looks like. And the definition.
[CUSTOMER][NEUTRAL] Right, so according to her.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, according to her, and this is what I, I don't know that it's just that she doesn't understand, but I, I'm not gonna try to pretend that I understand. um, but she's saying that she's still being like undergoing diagnosis. And that's where I got confused because how are you, how are you gonna apply for this if you don't know what you have? I don't think it works that way. Um, so that's where she's not, yeah, I know, and that's why I was like, I'm, I'm just not going to touch this one.
[AGENT][NEUTRAL] Yeah, it doesn't.
[AGENT][NEUTRAL] Yeah, um, let's see.
[AGENT][NEUTRAL] OK, so no disability benefit will be payable if disability is caused by or resulting from a pre-existing condition and begins before you've been continuously covered under the policy for 12 months.
[AGENT][NEUTRAL] Um, so, basically, our definition is that a disease, injury, sickness, physical condition, or mental illness for which you have experienced any of the following treatment, incurred expenses, took medication, received care services, including diagnostic testing or related measures, or received a diagnosis or advice from a physician.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So,
[AGENT][NEGATIVE] And then it says during the 12 month period immediately before the effective date. Hey, give me just one second, my husband locked himself out of the house.
[AGENT][NEUTRAL] Yeah, so give me just a second.
[CUSTOMER][POSITIVE] OK. Good.
[AGENT][NEUTRAL] Just getting the front door was open. He got a self in, OK.
[CUSTOMER][POSITIVE] You're good.
[AGENT][NEUTRAL] OK, so the term preexisting condition will also include conditions which are related to such disease, injury, sickness, physical condition, or mental illness.
[AGENT][NEUTRAL] So the issue based off what I'm seeing is that what we've received, she is.
[AGENT][NEUTRAL] I'm just gonna review briefly.
[AGENT][NEUTRAL] Medical records from [PII] because that's the 12 months prior to her disability.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and based on the medical records, she's been receiving.
[AGENT][NEUTRAL] The the issue is that the preexisting definition includes advice from a physician, treatment, medication, diagnostic procedures. So she's already been in the process of receiving this information prior to ever claiming.
[CUSTOMER][NEUTRAL] Oh,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's interesting. OK.
[AGENT][NEUTRAL] Yeah, so I will, no, yeah, I will still talk to her about it, but just kind of like a heads up for you like I think it's because it does include them.
[CUSTOMER][NEUTRAL] Would you mind explaining that to her?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] I appreciate it.
[CUSTOMER][NEUTRAL] No, yeah, I didn't know about like even them just asking about it. That does make sense, but I don't know why I never thought about that.
[AGENT][NEUTRAL] Right. So, you know, when you are under the assumption that you've had that like, like if you receive a cancer diagnosis and you are being treated for cancer, um, we're going to do a pre-existing because did you have a mammogram, you know, two months ago and thought that you were gonna have, you know, they were suspicious of breast breast cancer and now you've got this policy and now you're getting treatment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So that's one of the, because if you were receiving any type of treatment, any diagnostic, anything, then that is going to.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Essentially follow up under preexisting so that I think it's the problem because she's been receiving even if she doesn't have a for sure mhm.
[CUSTOMER][POSITIVE] Right, yeah, that makes sense.
[CUSTOMER][NEGATIVE] Yeah and I think that's what she's not understanding yeah.
[AGENT][NEGATIVE] And it's unfortunate. I mean it sucks because it's like.
[AGENT][NEUTRAL] But now I, I think I might have this and it's like I'm aware, but.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] Yeah, so
[CUSTOMER][NEUTRAL] It does look suspicious on paper though, so I understand that.
[AGENT][NEUTRAL] It, it does because, you know, she's been treated since.
[AGENT][NEUTRAL] Um, [PII], February, March and June, but her effective date on her policy is November.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So that's the issue.
[AGENT][NEUTRAL] So
[CUSTOMER][POSITIVE] Well, I sure again, once again, I appreciate you breaking that down and helping me understand that because that's really good to know. All right, are you ready for Ms. [PII]?
[AGENT][POSITIVE] Of course. No problem, no problem.
[AGENT][NEUTRAL] Yes, I am.
[CUSTOMER][POSITIVE] Alright, alright, well thanks [PII]. I hope you have a great rest of your day.
[AGENT][POSITIVE] You're welcome. You too.
[CUSTOMER][NEUTRAL] OK, bye.
[AGENT][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Hey Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hey this is [PII] with the claims department. How are you?
[CUSTOMER][POSITIVE] I'm doing well.
[AGENT][NEUTRAL] Good, um, so [PII] was saying that you were a little confused on the most recent denial of your disability claim.
[CUSTOMER][NEUTRAL] Yes, yes. To my understanding, it was denied because it, it was based on me having uh a prior condition. I am aware of all of my prior conditions and my most recent most recent pull out of work, as in the reasoning behind testing is not related to my prior conditions. I do not have a diagnosis, hence the reason I'm, I'm still under the doctor's care to have more testing done. The first thing they did was blood work.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And they got 3 other things lined up as well, but it's uh pending as way as far as the hospital calling me back.
[CUSTOMER][NEGATIVE] Um, for me to be scheduled to come up there. So I don't even have a new diagnosis. My my past history, I'm already under a treatment plan for that. I take medication every day for those reasons. What is currently wrong with me has nothing to do with my prior condition.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] OK, so if you don't mind me asking just because I, there, there's a lot of mail associated with this particular, um, what is the reasoning for this?
[CUSTOMER][NEUTRAL] Oh yes, ma'am. I understand.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] This particular disability like what what is, do we have any type of information on what it may be related to?
[CUSTOMER][NEUTRAL] Um, no, the last last.
[AGENT][NEUTRAL] Cause I saw that you were.
[CUSTOMER][NEGATIVE] The last thing that was mentioned was the, the final testing that he said, well, not final, excuse me. When I was first removed from work, the first testing that he ordered was blood work. I'm supposed to go for 3 other series of testing behind that, but those 3 testings have nothing to do with my prior condition. He's doing all this to formulate a diagnosis as to what is wrong with me, and it's not based on prior history because
[AGENT][NEUTRAL] OK, so it's not in relation to your narcolepsy or anything.
[CUSTOMER][NEUTRAL] No, no. I've, I've, I am on medication, a very strong, how you say.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I want to call it a stimulant, I guess. So yeah, as far as that, that goes, I'm, I take medication daily. I haven't been on it for many, many years. It has nothing to do with whatever my prior condition is.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] Gotcha. OK.
[CUSTOMER][NEGATIVE] My most current, we don't even have an answer for, so I was confused. I was like, how can they deny me and the doctor hadn't even given me a diagnosis yet. He hadn't even finished run the testing to find out what's wrong with me.
[AGENT][NEUTRAL] Right. So, I guess.
[CUSTOMER][NEUTRAL] What, what in the world?
[AGENT][NEUTRAL] Yeah, that would, I mean, yeah, that would be confusing. Um, I'm wondering if there was some confusion.
[AGENT][NEUTRAL] On their part just to, you know, on why you were being pulled, I would have to go through and look at everything and see if they saw it somewhere and that's why they're making that, you know, that correlation.
[CUSTOMER][NEUTRAL] Well, I think, here's where the, here's where the, here's where the confusion came in. He did put something about sleepiness or something, so I guess in their minds, sleepiness as far as the prior condition, how that would tie into that, but it's that it, the, what I had going on at that time has nothing to do with the prior condition because I take medication to prevent that from happening. That's how we know it's something more severe. I don't know if it's
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I, I don't want to speak of negative things, but as far as like needing CAT scans to see if there's a tumor present or what other extensive stuff it could be, but it's not the prior condition because he would have been able to look at me and be like, oh, OK, well, it's your narcolepsy or it's your whatever.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][NEGATIVE] Gotcha.
[AGENT][NEGATIVE] Right, like maybe we need to do a med change because this one's not working anymore or something.
[CUSTOMER][NEUTRAL] I mean, he's the neurologist, so he would be.
[CUSTOMER][NEUTRAL] Right. He would be able to look at me and be like, OK, this is related to your, whatever I've already been diagnosed with. No, it's not that. We got something more extreme going on. I take a medication for that past condition, so there's no reason for me to have any type of weird stuff like that going on.
[AGENT][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] Gotcha. OK.
[CUSTOMER][NEGATIVE] So we're looking for the underlying, which is why he sent me for the blood work and we're pending the hospital to give us a call back for the next testing procedures or whatever has to happen next because they're trying to find the problem. They don't even have a diagnosis as to what it is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so blood work right now has been run um.
[AGENT][NEUTRAL] Right now, no official diagnosis. Just know that it's not related, OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so this is what I'm gonna have to do. I don't I I can't give you a time frame just because I don't really know, um, I'm going to look through this. I'm going to send to the examiner and the supervisor of this product, um, an email and just kind of be like, OK, I've spoken to the insured this is, you know, what's going on, um.
[AGENT][NEUTRAL] You know per her statement with me on the phone, this is not related, this is something completely unrelated she's still undergoing diagnostic testing because she was pulled out of work due, due to this issue that she does not yet have a diagnosis for and then see kind of where we can go from there and give you a call back and let you know kind of.
[CUSTOMER][NEGATIVE] Yes, and let them know that it's not related and I take a medication and have been on the medication for 7 whole years for the other problem. They made him whenever he put what sleepiness or whatever, whatever, it's not tied to the original problem that I had before. Not all the what I say the preexisting condition has nothing to do with what's happening right now. I take a very powerful medication to keep me awake, so there's no reason for
[AGENT][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] That to be even being considered and furthermore, he don't even have a new diagnosis because he hadn't even finished testing me.
[AGENT][NEUTRAL] Got you, OK.
[CUSTOMER][NEUTRAL] I could understand if they had a diagnosis that says, OK, yes, it's sleep apnea or yes, it's narcolepsy or whatever, then we'll be like, OK, we're back to the drawing board, but no, they, there's, it's impossible for them to have that because he's still sending me for testing.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Got you. OK, yes, so let me, let me send them something, um, let me shoot them an email and kind of let them know what's going on um we'll have to I'm gonna go ahead and look through everything that was submitted for this particular, um, disability claim as well just so I can be like, you know, I can see where you drew this conclusion however in speaking with the insured this is what the insured is stating.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And then kind of see what the next steps would be from there and then it'll probably be me that calls you back but um I'm not 100% it it could be it could be one of them that contact you so just know someone will be in contact. I can't give you a time frame. I wanna say give us you know a day or two at least, um, but I don't, I don I don't know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So just be patient I promise somebody will be in contact with you before the end of the week for sure um I'm hoping maybe 24 48 hours, but it could be longer it depends on how long it takes them to kind of figure this out and then what next steps need to be taken.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Well, considering there was already the the final decision as far as the rejection or whatever, as far as them being an actual appeal in the computer, would I physically have to get somebody to type something up and send it to you or what our phone conversation, uh, how do you say?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Would it be like sufficient? Yeah, um, it wouldn't hurt if you can have someone draw something up for you, it would not hurt to send that in and with a physical statement that says this is not related.
[CUSTOMER][NEUTRAL] Be the same as basically.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] So if your doctor or his medical, you know, assistant or whoever can draw something up for you, even if it's the nurse or whatever, you know, someone that is assisting your physician in your treatment and your diagnosis, you know, trying to obtain that, it's not going to hurt at all to have that on file. That way, not only do we have
[CUSTOMER][NEUTRAL] Yeah, and we try to talk to the doctor to see what they can get, but after you talk to the people, basically let them know, say, look, the crazy old lady said if you can't produce a paper that says that I do have a diagnosis that the doctor don't even have, she wants to see proof of that.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I want to see proof of that.
[AGENT][POSITIVE] Yeah, OK, I got you. So I will, right, right.
[CUSTOMER][NEGATIVE] Cause there's no way you got it and I don't got it. If the doctor don't got it, you guys can't have it.
[AGENT][POSITIVE] Yeah, no, I that makes sense that makes perfect sense, um, yeah, I'll send them something and if you can get them to send us something please do because like I said not only would we have this conversation.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But we would have that statement from their office saying this is not related we're still trying to kind of figure out what's going on with her um and this is when she initially sought treatment for this issue that would definitely help out in this situation because as it stands they're looking at what they've reviewed.
[AGENT][NEUTRAL] And based off what they're seeing it appears to be related and they I guess they don't have anything that makes them feel otherwise so having that statement is going to help further the conclusion that oh OK well this is not related she's not being treated for this it's actually something completely different so yeah I would.
[CUSTOMER][NEGATIVE] Right. Well, if they don't have an actual, if they didn't formulate their decision based on the actual diagnosis, then that sounds like a whole another legal matter because I'm going to pursue it to the fullest and if you can't tell me, if you got a diagnosis that my doctor don't even have, please show me in black and white, please. I need that.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Absolutely no I I understand that and I don't truthfully, I mean, you know, we're not in the market to dip our insured we're, we're here to try and and help you and provide payments for you guys when when you need it, you know, so I feel like there has to be something that they received that would give them that assumption. um, I don't know what that is because I didn't process it, but that is why I'm gonna send them a message, yeah.
[CUSTOMER][NEUTRAL] I get it. I get it, but the, but the um the, the medical records is nothing but sleepiness. I could see how they would determine that, OK, maybe that's what's wrong with it. But I'm telling you, I'm on a high-powered narcotic that keeps me awake, so no, it's not related to that whatsoever. My neurologist would have said that when I walked in the office, he would have been as simple as saying, OK, have you not been taking your narcolepsy medicine or what's going on? Do we need to up your dosage or whatever. No, it's not that. It's really not that. It's something more severe.
[AGENT][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Got you.
[AGENT][NEGATIVE] Right, he would be like, oh, this ain't working, girl. Right.
[AGENT][NEUTRAL] Right
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I got you. OK, let me send this to them, um, and we'll, we'll, you know, go back through what we do have and then, um, I will, I will tell you the physician's statement, what he did fill out for this claim, not for the previous one, he did put your diagnosis as your sleep apnea, your um your narcolepsy he put, they put that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] When they filled it out, they put those diagnosis on as far as like what you're being treated for.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. All right. I will backtrack with them and see.
[AGENT][NEUTRAL] So, I don't, yeah, cause I don't, I mean, it says pending sleep something for sleep apnea and narcolepsy.
[AGENT][NEUTRAL] They
[CUSTOMER][NEUTRAL] That's testing, that's testing for. They're testing for everything.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, but because you.
[CUSTOMER][NEUTRAL] That's not saying that I have it.
[AGENT][NEUTRAL] Because you have been treated for it. I don't know if they were making it, like if they were putting it um as like your history and that what you're being treated for is not related, you know what I'm saying? Like maybe they were confused on filling it out. I don't know, but I do, I just letting you know that is the information they provided to us is that the diagnosis is the, the narcolepsy and the sleep apnea. So, um, and I think that's why.
[CUSTOMER][POSITIVE] Got you, got you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The preexisting thing came about because the physician on their form that they sent to us, they did put that that's what the treatment was for. So if that's not what was going on and they were just kind of noting your history, um then that statement's definitely gonna come in handy because if that's not what they're treating you for and they've already been treating I mean you know you're, you're medicated.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And that's not what the issue is and we, we are going to need something else because they have filled this out with and, and led us to the assumption that this is treat further treatment for that condition, you see what I'm saying?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Got you. Yes, I understand completely.
[AGENT][NEGATIVE] Yeah, so, yeah, so I'll still send them something um but I would definitely reach out to them and be like hey this is what they're yeah they're denying this for this but I'm not, you know that you're not treating me for this and then have them send over something, a statement on a letterhead or something that says we are not treating her currently for this there is a new issue that we are trying to resolve and determine what that may be, yeah.
[CUSTOMER][NEUTRAL] Oh are you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. All righty then.
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Alright, is there a way you can send me an email so when I do get that from them I can attach it to that and send it straight to you?
[AGENT][NEUTRAL] Um, yes, I should be able to send you something. Um, it's actually going to come from our care team email address, um, that's just what we use for any correspondence, but I will send you something, um, from that email that way whenever you get something you can kind of respond and be like hey this is from my physician or you know from their office or whatever can you please have this reviewed or you know whatever.
[AGENT][NEUTRAL] And then we'll move forward with that review as well.
[CUSTOMER][NEUTRAL] Gotcha. OK. Thank you. Mhm.
[AGENT][POSITIVE] OK. You're very welcome. All right.
[CUSTOMER][NEUTRAL] Mhm bye.
[AGENT][NEUTRAL] Bye bye.