AccountId: 011433970860
ContactId: e2789421-d6ba-4e43-8302-55ed475b095e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1698579 ms
Total Talk Time (AGENT): 889899 ms
Total Talk Time (CUSTOMER): 502317 ms
Interruptions: 10
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/e2789421-d6ba-4e43-8302-55ed475b095e_20250117T15:08_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][POSITIVE] Hey, [PII], it's [PII]. How are you doing? Happy Friday.
[AGENT][POSITIVE] Yes, ma'am. Thank you, [PII]. How are you?
[CUSTOMER][POSITIVE] I'm doing good, thank you. Um, I have an insured that needs further assistance, if you don't mind.
[AGENT][NEUTRAL] Certainly.
[CUSTOMER][NEUTRAL] It's policy number 214.
[CUSTOMER][NEUTRAL] 763 9
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have [PII] on the line. There all of her information has been verified, and she is wanting to know, and I, I, I'll be honest with you, I am really struggling, [PII], because I don't know what these
[CUSTOMER][NEUTRAL] Abbreviations are 4.
[CUSTOMER][NEUTRAL] Um, anyway, she's wanting to know if she's maxed out all her benefits for both her and [PII]. Now I did tell her that the diagnostic testing.
[CUSTOMER][NEUTRAL] Has been maxed out for her.
[AGENT][NEUTRAL] And she's speaking of [PII], is that right?
[CUSTOMER][NEUTRAL] And in [PII], yeah, she wants to know each year but what is, I'm gonna ask you what is OASPT?
[CUSTOMER][NEUTRAL] Is that
[AGENT][NEUTRAL] Physical therapy.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Why didn't you say physical therapy. I'm sorry.
[AGENT][NEUTRAL] I don't know. The PO with the offices that the UT is urgent care, the ER is ER, but that PT is physical therapy.
[CUSTOMER][NEUTRAL] Well, see, that's what I thought, but she was asking about physical therapy for Colton and it looks like she
[CUSTOMER][NEUTRAL] I don't know. Can you help her?
[AGENT][NEUTRAL] I can try certainly because it looks like yeah we paid PT for her in both 23 and 24. I don't see any PT for Colton but.
[CUSTOMER][NEUTRAL] There's
[AGENT][POSITIVE] But sure I'll be happy to talk with her and try to help her figure out what she's needing.
[CUSTOMER][POSITIVE] I really do appreciate it, [PII]. Let me get her on the line. Hope you have a great 3 day weekend.
[AGENT][POSITIVE] Certainly. And that's her phone number that's listed. You too. I hope you have a great weekend as well. [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] [PII], yeah, you got it.
[AGENT][POSITIVE] Got it. OK, thank you, [PII].
[CUSTOMER][POSITIVE] Alright thank you one moment.
[CUSTOMER][POSITIVE] Miss [PII], thank you for your patience. I have [PII] on the line and she's going to assist you further with those benefits used. OK.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hi there Ms. [PII]. My name is [PII]. I'm in the claims department. So I understand you have some um questions about your benefit maximum for the calendar year. Is there a particular date of service you want me to look at or um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, I'm kind of just trying to see like what I have next time or what I haven't just to see if I was missing any appointments that I didn't put in.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I guess the 23 and 24 I see I really didn't do anything at 22, so those were easy to figure out.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, I don't need 22 because nothing was approved 22, so really just for 23 and 24 what was maxed out, what wasn't just see like what I was missing.
[AGENT][NEUTRAL] Sure, OK.
[CUSTOMER][NEUTRAL] For his appointments.
[CUSTOMER][NEUTRAL] She did already confirm
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] My son's therapy has not been paid out for some reason his kids getting denied, so I need to do his, but I didn't know as far as anything else.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Like imaging ER.
[AGENT][NEUTRAL] Sure, OK, so what I'm gonna do is kinda go over each benefit with you that was paid out. So in [PII] we'll go over your claims and then we'll go over [PII]'s after. Is that OK?
[CUSTOMER][POSITIVE] All the fun stuff.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yep.
[AGENT][NEUTRAL] OK, so your office visit, you're, yeah, you're fine. So your office visits for [PII], you're allowed to, I see that we paid to.
[CUSTOMER][NEUTRAL] Sorry for the strange request.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now your urgent care benefit, um, you're allowed to we paid 1.
[CUSTOMER][NEUTRAL] Monday
[AGENT][NEUTRAL] Um, that emergency room, you're allowed one we paid one and this is all for [PII] so.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now your uh diagnostic testing benefit, you're allowed one visit, we pay that one visit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then for your surgical benefit in the facility, you're allowed one we paid one.
[AGENT][NEUTRAL] And then your your physical therapy benefit you're allowed to visits we pay two visits and that's all for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] OK, and that was it.
[CUSTOMER][NEUTRAL] OK, did you want to do his for 23 or mine for 24 now?
[AGENT][NEUTRAL] Um, it's up to you if it's easier, we could do 23 for [PII] as well.
[CUSTOMER][NEUTRAL] It's whatever is easier on you.
[AGENT][NEUTRAL] OK, so we'll just do the 23, so [PII] had uh one visit.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] You're allowed the one. Now it looks like we also paid a hospital admission benefit.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] For [PII] as well as confinement.
[AGENT][NEUTRAL] And this is all [PII] still and then a surgical benefit as well.
[AGENT][NEUTRAL] So [PII] did not use any, um, neither one of his two office visits, neither one of the urgent care visits, and then there was no physical therapy paid for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so he's looking at 2 office so I can write that fast 2 urgent care.
[CUSTOMER][NEUTRAL] On to that does cover speech correct?
[AGENT][NEUTRAL] And then the
[AGENT][NEUTRAL] Um, I did have to pull your policy up. Let me pull that up real quick.
[AGENT][NEUTRAL] I believe it's combined.
[AGENT][NEUTRAL] So let me just double check that information.
[CUSTOMER][NEUTRAL] I think when I was reading it, it did say that.
[AGENT][NEUTRAL] OK, just bear with me while I pull up your policy.
[AGENT][NEUTRAL] And just to let you know as a verification of your coverage, not a guarantee a payment I have to read that to you when I'm quoting benefits just so you're aware.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm gonna pull it up too.
[AGENT][NEUTRAL] Um,
[AGENT][POSITIVE] Yeah, it is a combined benefit of physical, speech and occupational therapy. It's allowed 2 days per calendar year. Mhm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so we use the 2 office visits, the 2 and 2 speech needs to be done.
[AGENT][NEUTRAL] Right, like I said, he does have that benefit still available the office visits, uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Urgent care, we didn't pay any diagnostic testing or we didn't pay any PT as well and then uh like I said it looks like we just paid that ER visit.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] And then the hospital can come and surgical.
[CUSTOMER][NEUTRAL] And this is just for.
[CUSTOMER][NEUTRAL] Is this for all of my policies combined or is this just for like one of the policies like just accident or just hospital?
[AGENT][NEUTRAL] This is for the hospital indemnity.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so are you ready to go to [PII]?
[CUSTOMER][NEUTRAL] Yes, can you do?
[AGENT][NEUTRAL] Did you have any other questions about [PII]?
[CUSTOMER][NEUTRAL] No, but if it's not too much, can you do the accident insurance offer as well?
[AGENT][NEUTRAL] Certainly.
[CUSTOMER][NEUTRAL] Really, honestly, accidents probably just more gonna be for me when I had my accident last year.
[AGENT][POSITIVE] OK, yeah I'll be happy to look at that one too.
[CUSTOMER][NEUTRAL] OK, so I hang
[AGENT][NEUTRAL] OK, so for [PII] we'll go over yours, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You had 2 office visits.
[AGENT][NEUTRAL] You're allowed to?
[AGENT][NEUTRAL] You had the one visit?
[AGENT][NEUTRAL] You're allowed one. The urgent care, 2 visits you use 2.
[AGENT][NEUTRAL] You use both the PT benefits? You're allowed to?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The uh surgical benefit in the facility, you're allowed one. And then the diagnostic testing was also used. You're allowed that one.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK bye.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now for [PII].
[AGENT][NEUTRAL] For 2024 we pay that surgical facility benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, we paid an ER, uh, emergency room benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then we only paid 1 of the urgent care out of 2.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we didn't use any of the office visits, any of the physical therapy, um.
[AGENT][NEUTRAL] And then of course we didn't use his uh diagnostic testing.
[CUSTOMER][NEUTRAL] Diagnostic and diagnostic was 2, yes, 2.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] There's the one, yeah, just one, but he didn't use his for 2024.
[CUSTOMER][NEUTRAL] Or one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I definitely missing stuff to submit for him.
[AGENT][NEUTRAL] And you know which tests are uh covered?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Are you aware of which tests are covered under the diagnostic testing?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Believe it was under.
[CUSTOMER][NEUTRAL] I think it was somewhere on this. I was looking at the.
[CUSTOMER][NEUTRAL] Whatever you call the form online.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] It's that the bone density screening, ultrasound, colonoscopy, all that stuff.
[AGENT][NEUTRAL] Yeah, for the diagnostic testing under the hospital and then it's uh it's limited to for the uh the major diagnostic testing is MR CAT scan, uh, thyroid uptake, CT or PET scan.
[AGENT][MIXED] And then under the advanced study files, which is a little lesser benefit but it does cover a few other tests that are listed here like art arteriogram, angiogram, uh, upper, uh, upper GI, lower GI sleep study.
[CUSTOMER][NEUTRAL] you can call for you.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Uh, nuclear stress test and then it.
[CUSTOMER][NEGATIVE] See, I did submit his sleep study and that was denied.
[AGENT][NEUTRAL] Um, I can take a look, I can take a look at that if you'd like.
[CUSTOMER][NEUTRAL] I have to go through
[CUSTOMER][NEUTRAL] I don't remember which one I have to have you open them all.
[CUSTOMER][NEUTRAL] To
[AGENT][NEUTRAL] And did you, would you know around what time he had the sleep study?
[CUSTOMER][NEUTRAL] I mean.
[CUSTOMER][NEUTRAL] Starting it would have been before [PII] because the original date was on [PII] and they moved it up.
[CUSTOMER][POSITIVE] You don't worry about it though. I can just reach a minute. I'll go work later for that.
[CUSTOMER][NEUTRAL] I got to look through enough stuff for me already.
[AGENT][NEUTRAL] Well, yeah, but we wanna make sure that we did process it correctly and then um.
[CUSTOMER][NEUTRAL] do
[AGENT][NEUTRAL] Also, if in case it was needing, it was needing something other information so we wanna check that.
[CUSTOMER][NEGATIVE] Well I know his therapies too were already denied too.
[CUSTOMER][NEUTRAL] Oh, was it?
[AGENT][NEUTRAL] I'm not sure that's what I'm saying we wanna check that to make sure if we were needing additional information so that we could get it processed so let me just look I think I have a couple options here where it might be so.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEGATIVE] Unfortunately I have to look them up claim by claim, so.
[CUSTOMER][NEUTRAL] I know that's what I felt bad doing. Let me see if I can pull up.
[CUSTOMER][NEUTRAL] Is in your chart to see if I can find out what. I just know originally was scheduled for [PII] and then we pushed it forward.
[CUSTOMER][NEUTRAL] Right before then.
[AGENT][NEUTRAL] So it would have been after the [PII] you said?
[CUSTOMER][NEUTRAL] It would have been before that.
[AGENT][NEUTRAL] Oh before that, OK.
[CUSTOMER][NEUTRAL] I might have submitted it late but like the actual service date.
[AGENT][NEUTRAL] Usually I try to look by the diagnosis code because sometimes that's helpful.
[AGENT][NEUTRAL] So let me just take a look.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm trying to pull up my chart now too to see if I can find it.
[AGENT][NEUTRAL] Yeah, um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I think I might have found it here.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] [PII] sleep lab Actioner out Baptist.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now probably what uh what I'm looking at is I don't see.
[AGENT][NEUTRAL] The procedure code.
[AGENT][NEUTRAL] So that could be why um do you know let's see.
[AGENT][NEUTRAL] Yeah, because then they scheduled speech therapy and that was on here on that same paper uh that was submitted.
[CUSTOMER][NEUTRAL] They have the note from like the procedure it says pediatrics PSG + 4 parameters.
[AGENT][NEUTRAL] Because this looks like it's just the like visit summary.
[AGENT][NEUTRAL] That I'm looking at.
[CUSTOMER][NEUTRAL] So I need to get the the billing breakdown.
[AGENT][NEUTRAL] Yeah if you could obtain that that could be helpful like I said because I think what happened is it didn't have any codes on it. I'm not sure now um it probably should have been requested that um. 4533.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah they just put it as outpatient uh non covered outpatient but if you send that billing and so we have that actual code then we could review it for that type of benefit, um, but we do need that procedure.
[CUSTOMER][NEUTRAL] OK, and I'll do the same for his speech too.
[AGENT][NEUTRAL] Yeah, and like it does have his diagnosis code on here or the reason for the appointment, but it's just like I said, it's, it doesn't have any codes on it so it just says sleep disordered breathing was the following issue was addressed, but it doesn't have any codes on it. So if you wanna send that and would be happy to review it and you know there is no timely filing so you're OK with that.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, um,
[CUSTOMER][NEUTRAL] OK, so we're good for hospital because we to a hospital.
[CUSTOMER][NEUTRAL] Yeah, I missed a lot apparently.
[CUSTOMER][NEUTRAL] I ain't really slacking on the silent.
[AGENT][NEUTRAL] And then you want
[AGENT][NEUTRAL] You wanna look at the accident, is that where we're going next? OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Yeah, because I don't think I'm not gonna have anything on life and I shouldn't have anything on critical. I don't believe.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there any like everyday stuff that's covered under Critical?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And if you have the screening benefit it is.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, I think I do.
[AGENT][NEUTRAL] Do
[AGENT][NEUTRAL] Um, I can look at that one too for you, OK.
[AGENT][NEUTRAL] Now, um, under the accident, is that for both years as well?
[CUSTOMER][NEUTRAL] Um, yeah, you can, um.
[CUSTOMER][NEUTRAL] The surgery was.
[AGENT][NEUTRAL] And did, do you know if you had more than one accident?
[CUSTOMER][NEUTRAL] No, it should have just been one accident. Actually, mine started in 23.
[AGENT][NEUTRAL] It would have been one.
[AGENT][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Is when it started. I had the first surgery, 23, the second surgery 24, and then I don't know how that works if the accident carries over into 25 for the month of the third surgery in 25.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Usually there has to be uh unless there's a reason um.
[CUSTOMER][NEGATIVE] Money just took some major damage.
[AGENT][NEUTRAL] And have that
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so let's look at what you were paid for.
[AGENT][NEUTRAL] So under the accident policy for [PII].
[AGENT][NEUTRAL] We paid a screening benefit for you.
[AGENT][NEUTRAL] Um, we pay the X-ray benefit.
[AGENT][NEUTRAL] We paid a physician treatment benefit and those uh that was 3 benefits that were paid.
[CUSTOMER][NEUTRAL] And that's the total.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] The total of 3 for that one.
[AGENT][NEUTRAL] Yeah, it shows 3 and then let's see.
[AGENT][NEUTRAL] So it looks like um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] These are a little bit more uh.
[AGENT][NEUTRAL] OK, so we paid some therapy it looks like.
[AGENT][NEUTRAL] 1234.
[AGENT][NEUTRAL] 5.
[AGENT][NEUTRAL] That's all 2024.
[AGENT][NEUTRAL] We're supposed to be looking at 23.
[AGENT][NEUTRAL] And you said this was the same accident, is that right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then we paid the surgical repair.
[AGENT][NEUTRAL] Did you need me to break down the office visits that were paid?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, and then we pay the uh major diagnostic screening benefit looks like.
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] That's all 23 still correct?
[AGENT][NEUTRAL] That's for [PII], right?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so did we get everything? You have the screening, the X-ray, 3 physician treatments, the major diagnostic, the repair to the ligament, uh, and then the 10 visits for physical therapy.
[AGENT][NEUTRAL] That was for [PII] for you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now [PII] for Colton we pay the screening.
[AGENT][NEUTRAL] So the screening benefit was paid for.
[AGENT][NEUTRAL] Uh, Colton.
[CUSTOMER][NEGATIVE] OK, yeah, that should be right because he didn't have anything.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then for [PII] I show we paid uh the therapy.
[AGENT][NEUTRAL] For you.
[AGENT][NEUTRAL] 10 visits.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] And then a screening for [PII] for you.
[AGENT][NEUTRAL] And then the screening for Colton for [PII].
[CUSTOMER][NEUTRAL] No surgery for the [PII] for mine.
[AGENT][NEGATIVE] No, I do not, not for [PII]. If it was the same accident, it probably would be not payable.
[CUSTOMER][NEUTRAL] It was the first surgery they did in November. It was [PII], the second surgery because it developed so much scar tissue they did in [PII].
[AGENT][NEUTRAL] If it was
[AGENT][NEUTRAL] OK, let me look at that.
[CUSTOMER][NEGATIVE] I should have had doctor's treatments too and then the surgery for 24.
[AGENT][NEUTRAL] Yeah, I don't see any.
[CUSTOMER][NEUTRAL] Would that still be covered?
[CUSTOMER][NEUTRAL] Under that accident or no?
[CUSTOMER][NEUTRAL] It's just so
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Well, I think you're allowed, there's a certain number of visits you're allowed, but you do have to have that treatment in. So I see, let's see, let me see what this remark code. So claim, it looks like the second surgery was that uh the [PII]. Does that sound right?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][POSITIVE] Call me that thank you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] [PII] for the surgery, the second surgery?
[CUSTOMER][POSITIVE] Yeah, that sounds right.
[AGENT][NEUTRAL] Does that sound OK.
[AGENT][NEUTRAL] OK, so I see that we have a denial on that one. Let's take a look at it.
[CUSTOMER][NEUTRAL] Or was it because it was paid under hospital doesn't count as accident?
[AGENT][NEUTRAL] Well, they're two separate policies, so it wouldn't, yeah.
[CUSTOMER][NEUTRAL] So that.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] 2674.
[AGENT][NEUTRAL] OK, so yeah, that claim was denied as the uh benefit for this uh the surgical outpatient surgical benefit exhausted for this accident. So they pay the outpatient surgery benefit shown in the schedule for each day, um, but like I said, it is that one benefit, so therefore it was max, uh, the benefit maximum was met for that service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so probably everything from that accident has been maxed up at this point then.
[AGENT][NEUTRAL] It looks like it has, yeah.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] What happened, so if I'm still having surgery this year, it's still considered maxed out with this incident.
[AGENT][NEUTRAL] Right, because it does go by accident when the accident plan, so it doesn't really um.
[AGENT][NEUTRAL] Under it it doesn't.
[CUSTOMER][NEUTRAL] This one's not necessarily year by year but more like like what you did, OK.
[AGENT][NEUTRAL] Right. And then that, and of course, you can always submit for the hospital indemnity because you do have that benefit that's not tied to the accident. In other words, as long as it's an accident or uh a sickness diagnosis code, we don't look at that benefit being exhausted from the accident itself because that does start over per calendar year, just so you're aware of that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh the
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So you could still submit under the hospital indemnity, um, yeah.
[CUSTOMER][NEUTRAL] Dimity
[AGENT][NEUTRAL] And that's probably
[CUSTOMER][NEGATIVE] But now I know don't waste your time with the accident one.
[AGENT][NEUTRAL] Right, so now, um, and that's probably why when we looked under your hospital indemnity, we had the surgical benefit paid for 23 and then for 24 as well.
[CUSTOMER][NEUTRAL] And 24, right.
[AGENT][NEUTRAL] Yeah, mhm, so, yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, um, was there any other questions about the accident policy?
[CUSTOMER][NEUTRAL] Not about accidents.
[AGENT][NEUTRAL] And you wanted me to look at.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Which one would be.
[CUSTOMER][NEUTRAL] Like imaging, like X-rays and MRI's at the hospital, correct?
[AGENT][NEUTRAL] Right, but that, um, are you speaking of under which policy?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Under which plan?
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] Just like if I have an MRI I'm just trying to figure out like which one should I have been submitted to hospital.
[AGENT][NEUTRAL] Uh, hospital indemnity, if it's, um, not, of course, if it's an accident related, you would file it under your accident, um, but if it's just, uh, for, uh, like an illness or um, you know, like I said, it's an accident.
[CUSTOMER][NEUTRAL] Yeah, like I had a brain MRI to see what was going on with migraines, so that was unrelated to the accident that was under the hospital one.
[AGENT][NEUTRAL] Right, that would go under hospital indemnity because you do have that one benefit for diagnostic testing and that MRI would qualify. And whether, and it doesn't have to be a sickness, or I'm sorry, it doesn't have to, right, it doesn't have to be an accident under the hospital indemnity. It can be an accident or a sickness diagnosis.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, never mind, I see that was paid on [PII].
[CUSTOMER][NEUTRAL] OK, so with, so like.
[CUSTOMER][NEUTRAL] In 2 weeks next weekend I have an MRI for my knee due to the accident. Can that still be filed under hospital or no, because it was related to that accident?
[AGENT][NEUTRAL] You can still file it under the hospital indemnity. Like I said, it doesn't matter which diagnosis under the hospital indemnity. Under the accident, it does have to be related to an accident and if that benefit's been exhausted for that accident, then, you know, like with that second surgery you had, it would just, you know, you would get a, a denial it letting you know that the benefit maximum was met.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] But yeah, under that hospital indemnity it doesn't matter if it's 2025 and you haven't used that benefit you can go ahead and submit a claim for that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think that's it because I don't have anything under cancer other than the cancer screenings, but I know those have been paid.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Critical illness, I don't think.
[AGENT][NEUTRAL] Looks like
[AGENT][NEUTRAL] Let me take a look at that real quick.
[AGENT][NEUTRAL] Because usually what happens when you submit those wellness claims we will review them under each of your eligible policies. So in other words, if you send in a cancer screening under your accident or uh you know that accident screening or you send it in under um cancer or vice versa, critical illness, we would look at it for each policy that might be eligible. And like I'm looking at, for instance, under the critical, let me see, under your.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This one's under cancer, so under the cancer policy we paid both the 23 and 24 screenings for you.
[AGENT][NEUTRAL] You know that preventative, uh huh and then let me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Are you able to see [PII]'s too?
[AGENT][NEUTRAL] Um, yes.
[AGENT][NEUTRAL] Now I show, let's see.
[AGENT][NEUTRAL] Now the um cancer policy looks to be it's individual.
[AGENT][NEUTRAL] So you've got an individual policy for your cancer policy and an individual for the uh for obviously for your disability policy. So um the, the critical illness is uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so yeah, never mind, I see he's not on that cancer.
[CUSTOMER][NEUTRAL] For both.
[AGENT][NEUTRAL] That's the single parent policy, so both of you on that one. Let me take a look at that real quick. So again, under the critical illness we paid both your screening for 23 and 24.
[CUSTOMER][NEUTRAL] Sorry, I should have looked at that first.
[AGENT][NEUTRAL] And then for.
[AGENT][NEUTRAL] [PII] under the critical illness we paid both the screening for [PII] and then for [PII] as well.
[CUSTOMER][NEUTRAL] OK, and then.
[CUSTOMER][NEUTRAL] The list of the covered conditions, that's the only ones that are covered, correct?
[AGENT][NEUTRAL] Yes, under the um cancer or under the uh excuse me, critical illness, yeah, let me just take a look real quick. I can take a peek at it and let you know which qualify.
[CUSTOMER][NEUTRAL] For critical.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] He was just diagnosed with ADHD and autism. I just didn't know if those qualify for anything on there or not, but I didn't see either of those.
[AGENT][NEUTRAL] Right, I don't think that's listed in the.
[CUSTOMER][NEUTRAL] No, I don't see that.
[AGENT][NEGATIVE] Unfortunately it's not.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK, well I have a couple of things to go soon and to catch back on [PII] because I didn't do anything for that.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] Thank you so much for your help.
[AGENT][NEUTRAL] Did you, you're welcome, um, and did you have any other questions, Ms. [PII]?
[CUSTOMER][NEUTRAL] Nope, I think I asked you enough this morning.
[AGENT][NEUTRAL] OK
[AGENT][POSITIVE] Well thank you for calling the APL. I hope you have a great rest of your day and a great weekend.
[CUSTOMER][POSITIVE] Thank you so much you too.
[AGENT][POSITIVE] Alright thanks bye bye take care.
[CUSTOMER][NEUTRAL] Bye bye.