AccountId: 011433970860
ContactId: e3167a93-6ac4-4021-ac82-5e85338348fc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 723669 ms
Total Talk Time (AGENT): 204655 ms
Total Talk Time (CUSTOMER): 213230 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/17/e3167a93-6ac4-4021-ac82-5e85338348fc_20250617T15:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, my name is [PII]. Um, I was seeing that my son [PII]'s, uh, claim was processed and it's still showing 0 $0. I don't understand.
[AGENT][NEUTRAL] OK, I can help you with that claim status, [PII]. Um, what's a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what's the policy number?
[CUSTOMER][NEUTRAL] 244-6222
[AGENT][NEUTRAL] Give me just a second to look that up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is his date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is the address that we have on file for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK thank you so much.
[AGENT][NEUTRAL] Alright, let me see here.
[AGENT][NEUTRAL] And it was for the most recent claim, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, it looks like this policy provides benefits due to a covered accident which is independent of disease, bodily infirmity, illness, infection, or any other abnormal physical conditions, and it shows that based on the information received, a covered accident did not occur, therefore, the benefits were not payable.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] But it was an accident. I don't I'm saying.
[AGENT][NEUTRAL] Let me look into your policy documents real quick.
[AGENT][NEUTRAL] Yeah let me see here.
[AGENT][NEUTRAL] OK, give me one moment let me see if I can get someone from claims um to go over this with you, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] with the care team. Um, I have a [PII]. I'm sorry, flabbergasted today, um, on the line in regards to her son's most recent claim for policy 244-6222.
[AGENT][NEUTRAL] Um, showing that it was, it was not a covered accident. I was wondering if you could go over with her why um it wasn't a covered accident. I'm not able to look into that.
[CUSTOMER][NEUTRAL] OK, what's the dependent's name?
[AGENT][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] And it's the claim ending in 1544.
[CUSTOMER][NEUTRAL] OK, let me take a look.
[CUSTOMER][NEUTRAL] Oh this claim was just processed today so let me see.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I mean, really, all I could do is read her the claim remarks and she just said it was an accident. She doesn't know how it's not covered.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right, it looks like based on the information that we have is not a result of a covered accident. So let me see what she sent. Let me see, she sent.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, cause the policy defines uh accident as uh.
[AGENT][NEUTRAL] Yeah, and I, I know we're not allowed to do research, but.
[CUSTOMER][NEGATIVE] Bodily injury.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, and all I, all I saw was X-ray and X-ray is covered, so I, I wouldn't know what to say either.
[CUSTOMER][NEUTRAL] So she's.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] So far, I'm just seeing it just in pain and
[CUSTOMER][NEUTRAL] Por thing has been going on. No trauma, no acute injury. Yeah, the information we have doesn't indicate, OK, yeah, I, yeah, it's, what we have here, there's no indication of any injury or trauma based off the information we have. The policy only covers due to bodily injury.
[CUSTOMER][NEGATIVE] So this wouldn't be a covered, covered, covered.
[AGENT][NEUTRAL] OK, do you want me to transfer her to you? I, I said that exact same thing.
[CUSTOMER][NEUTRAL] So yeah, it's exactly what it specified. Yes, it's exactly what's specified in that remark code. Yeah, cause only thing that we have.
[AGENT][NEUTRAL] Yeah, and I read that to her.
[CUSTOMER][NEUTRAL] Yeah, the only thing that we have is.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's the only thing that I would tell her that same information based on what we have, it doesn't indicate that it an injury occurred and read exactly what their remark code outlines.
[AGENT][NEUTRAL] Yeah, I, I did. OK.
[AGENT][NEUTRAL] But it doesn't look like there's an injury from it.
[CUSTOMER][NEUTRAL] No. Based on the information we have, it only lists that there was, that he was experiencing pain and there's no acute injury or trauma from what we have.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right, I will let her know. Thank you so much.
[CUSTOMER][POSITIVE] OK. Oh, you're welcome.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEUTRAL] OK, so I spoke with claims.
[AGENT][NEUTRAL] And they said that because based off of what was provided, it looks like he just came in um with some pain, but it didn't show that there was any sort of bodily injury or trauma that happened due to that pain.
[CUSTOMER][NEGATIVE] It was trauma. That's the reason why he had to have physical therapy. I don't even understand it. It was a sports injury. He fell from playing from playing football. I mean, he had all kinds, he had hip weakness and all that. I don't understand that.
[AGENT][NEUTRAL] Did it, did you send in that information that it was a sports related illness or a sports related injury?
[CUSTOMER][NEGATIVE] But, but the letter that came in that the doctor said that I had gave to all, to y'all say that it happens from playing basketball. It's a basketball injury, so I don't understand how it is.
[AGENT][NEUTRAL] Well, when I
[CUSTOMER][NEUTRAL] I mean, I have sent in a lot of information. I have sent that stuff from X-rays, physical therapy, everything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the doctor, I picked up a note from the orthopedic doctor stating there was a basketball injury. They had those words on the letter.
[AGENT][NEUTRAL] And that's what you sent in, uh.
[CUSTOMER][NEGATIVE] I just sent that in. And then the lady had told me she was gonna call the orthopedic doctor and she sent in, and she faxed something, so I don't understand.
[AGENT][NEUTRAL] Let me look here.
[CUSTOMER][NEUTRAL] I'm just about to talk to Mr. [PII] cause I don't understand what's going on.
[CUSTOMER][NEGATIVE] But this is ridiculous.
[CUSTOMER][POSITIVE] I've had claims for myself. I never have to go through this, and I do this one claim for my son, and it's just too much, so I'm just not gonna worry about it.
[AGENT][NEUTRAL] It looks like they diagnosed this as chronic knee pain, not, not from an injury. Um, and I don't see a fax from, um, you said that someone from the orthopedic faxed over something.
[CUSTOMER][NEUTRAL] Yeah, and then I sent in a letter. I picked up the letter from over to the doctor.
[AGENT][NEUTRAL] Um, I'm not seeing that.
[CUSTOMER][NEUTRAL] Well, do you see the letter that I sent in from the orthopedic doctor stating it was a basketball injury with the colds on there?
[AGENT][NEUTRAL] You look.
[AGENT][NEUTRAL] And it does say that in the doctor's notes that there was no acute injury or trauma, which is what's covered in this policy.
[AGENT][NEUTRAL] So it says it's been going on for at least 2 years, which would be chronic pain.
[AGENT][NEUTRAL] Um, not, not from the injury, it's from the chronic knee pain.
[AGENT][NEUTRAL] Is what I'm seeing.
[CUSTOMER][NEUTRAL] But the note, but the note from the orthopedic doctor has basketball injury.
[AGENT][NEUTRAL] Well, and like I said, I didn't see that. Um, I don't see that in here. Um.
[AGENT][NEUTRAL] So if they fax it to us, I would have them, uh.
[AGENT][NEGATIVE] Either send it to you or have them call us to get a correct fax number because I'm not seeing a fax number on here. I'm showing that this was a chronic.
[AGENT][NEGATIVE] Chronic um pain.
[AGENT][POSITIVE] With no trauma.
[CUSTOMER][NEUTRAL] All right then.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh well, thank you.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] No, that'll be all.
[AGENT][POSITIVE] Alright well thank you for calling APL and I hope you have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye.