AccountId: 011433970860
ContactId: e477fc00-1474-4e12-bfb4-42736590698c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 681859 ms
Total Talk Time (AGENT): 159012 ms
Total Talk Time (CUSTOMER): 293731 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/e477fc00-1474-4e12-bfb4-42736590698c_20250611T13:45_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes ma'am, my name is [PII]. I'm calling regarding a recent claim that was filed.
[AGENT][NEUTRAL] OK. Is it for yourself or are you with the provider?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It is for myself.
[AGENT][NEUTRAL] Do you have your um policy number, Ms. [PII]?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Let me go ahead here.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Should it be on my dash yeah hold on let me get it for you right here.
[CUSTOMER][POSITIVE] Look, I should also have it here.
[CUSTOMER][NEUTRAL] Policy number is 02605156.
[AGENT][NEUTRAL] And what was your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And do you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, I'll give you my cell phone [PII].
[AGENT][POSITIVE] OK, thank you so much. And just need two more pieces of information, your address and your email address.
[CUSTOMER][NEUTRAL] Address is [PII] and email is [PII].
[AGENT][POSITIVE] OK, perfect. Thank you.
[AGENT][NEUTRAL] And was this a claim for yourself?
[CUSTOMER][NEUTRAL] Yes it was.
[CUSTOMER][NEUTRAL] So I originally submitted the documents for a claim, um.
[CUSTOMER][NEUTRAL] I work for um Doctor [PII]. He is a chiropractic physician.
[CUSTOMER][NEUTRAL] And um I ended up
[CUSTOMER][NEGATIVE] Actually hurting my arm. Um, the doctor here X-rayed it, diagnosed it as fractured. The elbow was fractured.
[CUSTOMER][NEUTRAL] We submitted the claims and were denied because they said the denial was that they do not consider a chiropractic physician, a physician that they're not treating within their scope, which we also submitted to our um
[CUSTOMER][NEUTRAL] I guess our
[CUSTOMER][NEUTRAL] The local salesman who sold us our policy, uh, the Louisiana statute of limitations through a chiropractic physician, what they can treat and within their scope, but due to, I guess, being located out of [PII], uh, nothing was ever done with that. Um, I went for a follow-up visit with my primary care physician who reviewed the X-rays that we provided for him on a disk. And um cause I was still having a lot of pain with it.
[CUSTOMER][NEUTRAL] I didn't know um if they needed to splint it or whatnot. Um, the doctor checked it out. I submitted also those claims with the diagnosis that state that it's fractured, um, and
[CUSTOMER][NEGATIVE] They did not they still will not pay out the fracture benefit. They paid $50 and I don't understand because in my packet the benefit plan states that all other fractures are, it's a $1,125 payout for a closed fracture, it's 50% of the fracture uh benefit.
[AGENT][NEUTRAL] Did you fill out the claim form that explained what kind of accident you had? It looks like that's what we most recently requested on [PII].
[AGENT][NEUTRAL] It's like yesterday.
[CUSTOMER][NEUTRAL] Um, what did you need for that?
[AGENT][NEUTRAL] And we need the accident claim form completed which explains how your accident occurred.
[CUSTOMER][NEUTRAL] OK, and where was that sent out to be completed?
[AGENT][NEUTRAL] Your home address?
[AGENT][NEUTRAL] It went out yesterday, should be receiving it in the next few days.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So with that information, what all do I need to do? Just explain because in the doctor's details, if you read the note, it states how the accident happened.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So did you upload these on our portal or were, were these faxed? I mean, I can pull it up.
[CUSTOMER][NEUTRAL] These were emailed to our yeah.
[CUSTOMER][NEUTRAL] And in the physician's notes it details how the accident happened that well um it was struck on the.
[CUSTOMER][NEUTRAL] On my car getting the.
[CUSTOMER][NEUTRAL] Some volleyball equipment out.
[AGENT][NEUTRAL] Was that with the original claim that was submitted in April?
[CUSTOMER][NEUTRAL] No, it was also in the notes from um.
[CUSTOMER][NEUTRAL] Thibodau Regional Health.
[CUSTOMER][NEUTRAL] Doctor [PII].
[AGENT][NEUTRAL] OK, I see that one. Let me see.
[AGENT][NEUTRAL] So the 522 offices that that was just a follow up to the initial accident correct that happened on [PII], is that right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I see your claim forms, I'm not sure why they're requesting.
[CUSTOMER][NEUTRAL] I'm not either.
[CUSTOMER][NEUTRAL] And then on my claim form it states you've reached the maximum whatever for this and they paid out $50.
[AGENT][NEUTRAL] OK, I'm just reading on here and seeing what these notes say.
[CUSTOMER][NEGATIVE] Yeah it's just kinda it just doesn't sit well with me, you know?
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] There's an injury
[CUSTOMER][NEUTRAL] You were seen by a physician. Oh no, we don't accept that physician. So another physician states the same thing. Oh, so, so maybe if you're saying that they're just waiting on something to finish processing this claim, but on my end it looks like it's saying for this claim you're receiving $50.
[CUSTOMER][NEUTRAL] They're not acknowledging the fracture and I have coverage for that.
[AGENT][NEUTRAL] Let me make sure we've got and the fracture notes were on the
[CUSTOMER][NEUTRAL] Oh OK
[AGENT][NEUTRAL] That was submitted in May.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, they're on the, there's a diagnosis code from.
[CUSTOMER][NEUTRAL] Um, homotibito spine and rehab and then they didn't accept that position, so then this same diagnosis codes were on the.
[CUSTOMER][NEUTRAL] A whole separate offices note so I don't understand.
[AGENT][NEUTRAL] OK, so we have, we, well, we do have a uh accident claim form, but this says, this is regarding the toe. You said you fractured your
[CUSTOMER][NEUTRAL] That was my daughter who plays volleyball who.
[CUSTOMER][NEUTRAL] Had to have her.
[CUSTOMER][NEUTRAL] Foot examined. She had a laceration. She had to get her toe X-rayed.
[AGENT][NEUTRAL] OK, I think that's.
[CUSTOMER][NEUTRAL] That was a separate incident, that's for [PII].
[AGENT][NEUTRAL] OK, let me
[AGENT][NEUTRAL] That was the claim form. I'm so sorry. That was the one I was looking at. I don't think we have.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I see it, fracturing your left elbow. OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I see that. OK.
[AGENT][NEUTRAL] OK, let me do this let me send this back through to our claims department for further review, um, because yeah, I do see the that you filled out the form.
[AGENT][NEUTRAL] Um, so we have that on file, um, and then I'm not sure why we're requesting it again because we have it, so.
[AGENT][NEUTRAL] And then I'll, I'll have them 512 date of service, um, for further consideration.
[CUSTOMER][NEUTRAL] Yes, and
[CUSTOMER][POSITIVE] OK, I appreciate it thank you very much.
[AGENT][NEUTRAL] Um, what is the best way to contact you back? Would you prefer to be called or would you prefer to be emailed?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You can, you can call me.
[CUSTOMER][NEUTRAL] And you can email me you could do both with whatevers.
[CUSTOMER][NEUTRAL] Either way.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'll get this sent back through um we'll get that reviewed and see if there's any further consideration for the claim because like I said, we do have the claim form so or the form filled out so I'm not sure why we're requesting it again so.
[CUSTOMER][NEUTRAL] Why they're not paying out the fracture benefit?
[AGENT][NEUTRAL] Well, I can't determine. I'm just, I can only just look at the information received. I'm not in the claims department, so unfortunately I can't determine looking deep into the policy.
[CUSTOMER][NEUTRAL] Does the claims department have a separate number?
[AGENT][NEUTRAL] Um, no, they don't, um, it's just we have our care team and then we have a process where we send requests through a, um, kind of like an email system, um, for them to review and then call back members so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right well uh thank you so much.
[AGENT][POSITIVE] OK, thank you for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.