AccountId: 011433970860
ContactId: f4fe681d-fbe6-4f0c-9d2b-0323f5917f8c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 766059 ms
Total Talk Time (AGENT): 207849 ms
Total Talk Time (CUSTOMER): 243985 ms
Interruptions: 6
Overall Sentiment: AGENT=1.1, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/f4fe681d-fbe6-4f0c-9d2b-0323f5917f8c_20250324T16:31_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], uh, I'm not sure how I got you, but I have an insured on the line. He's calling in regards to I was trying to call the HIQ.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] That's what I was trying to do, but it came to you, um, so I'm not sure if you'll be able to assist the young man, but, um, he has some questions in regards to benefits for HI-17 policy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] HI [PII]. OK, and what's his name and policy number?
[CUSTOMER][NEUTRAL] OK. Um, yeah.
[CUSTOMER][NEUTRAL] The policy number is 2 I'm sorry, the name is [PII].
[CUSTOMER][NEUTRAL] And the policy number is 2600713.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I have verified the information and his callback number is when you're ready for that.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] I'm ready.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, you can go ahead and put him through and I'll, I'll do my best to answer his benefit questions.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and also the claim number is 357-73777, which is the only one that was processed. OK, alright, um again I was trying to call the HIQ, yeah, I'm sorry, I'm so sorry.
[AGENT][NEUTRAL] 353.
[AGENT][NEUTRAL] Uh huh, yeah, so all the, no it's OK all the calls roll over to us now, um.
[AGENT][POSITIVE] Unless it's like something special so we get almost everything at and they're gonna open a new queue every month to come to us rather than the queue that it's in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yes, so there's some changes. That's why you got it. That's OK. It's OK.
[CUSTOMER][POSITIVE] Oh Jesus. OK. I'm sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'm sorry [PII]. OK, so here it comes, um, again this is, um, he's trying to realize why we didn't pay, why wasn't he, he's on the impression there is no limitation on this, um, this policy. He's with BWA, OK, again this HR plan. Alright, OK, [PII], alright honey, one moment.
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and you want to know why his claim, parts of his claim was denied, is that?
[CUSTOMER][NEUTRAL] Yes, yes, he said on he was on the impression that it would pay for everything, of course.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Oh, wow. OK.
[CUSTOMER][NEUTRAL] But there's limitations, yeah, OK, OK, [PII], I'm sorry, honey, right honey, right, one moment.
[AGENT][POSITIVE] That's all right. Go ahead.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hello, [PII]. This is [PII] in the care team. How can I help you today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I was just going over the I guess the claim benefits form that I received uh I received a check for some claims that I filed.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, there's, uh, I, I guess there's very limited payment on the vision therapy that I've been going in for, and I called and purchased this policy specifically because this, uh, care provider was in network and I was told to purchased a policy that there would be 100% coverage on the the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The center and I don't, I don't see that here and I was wondering if this, if you have all the correct information and why that's the case.
[AGENT][NEUTRAL] OK, [PII], um, what is your claim number?
[CUSTOMER][NEUTRAL] Um, let's see here.
[CUSTOMER][NEUTRAL] Claim numbers, let's see, I only have a list of the claims on here. Let's see check date, check number, policy number.
[CUSTOMER][NEUTRAL] Uh, claim number oh there it is 357 7.
[CUSTOMER][NEUTRAL] 377.
[AGENT][NEUTRAL] Thank you, sir. Let me pull up that claim, um, and so you were just under the understanding that it should have paid more than what it did, is that correct?
[CUSTOMER][NEUTRAL] Yeah, I, I asked them when I purchased the policy what type of coverage there was on the vision therapy specifically because I had a diagnosis from the doctor and they informed me that it would all be paid and there was no max on this and so that's why I'm confused.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so the policy, um,
[AGENT][NEUTRAL] According to what I'm looking at here on your claim.
[AGENT][NEUTRAL] The claim was paid and after the claim was paid, the maximum benefit payable for that date of service was met, so it's $50.
[AGENT][NEUTRAL] And this is just to verify your benefits. It's not a guarantee of payment. It was $50 that was paid, um.
[AGENT][NEUTRAL] For your data service of [PII] [PII].
[AGENT][NEUTRAL] And [PII], so after that $50 was paid for that day, then it maxed out the benefit.
[CUSTOMER][NEUTRAL] OK and you said after it was paid, you mean that there was additional payment sent to.
[CUSTOMER][NEUTRAL] The the clinic or you're just saying this payment, the $50 is that what you're referring to?
[AGENT][NEUTRAL] Yes, this payment, the $50 is all that the policy pays.
[AGENT][NEUTRAL] It's an indemnity plan. So indemnity means a set amount for a covered procedure and your set amount is $50.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, um, how come when I asked that question when I opened the policy, it wasn't answered because, you know, now I'm, I'm having a completely different, you know, this, this, uh, you know, I can't afford this therapy and I specifically ask these questions, get them diagnostic codes, and they tell me they'd be 100% coverage on the MT. So you know it's this ain't my problem at this point and this is, you know, this is, this is a huge problem because uh I had to.
[AGENT][NEUTRAL] Mhm. Yeah.
[CUSTOMER][NEUTRAL] Purchase this policy during open enrollment to get coverage for my pre-existing.
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] So you know why, why, why different than when I purchased the policy.
[AGENT][NEUTRAL] OK, so what I can do is um.
[AGENT][NEUTRAL] Have somebody from the claims department call you back.
[AGENT][NEUTRAL] And answer those questions for you because I can only answer how the claim was processed and the claim was paid and that's all I can see but we can get you some further help and have somebody from the claim department call you back and answer those further questions that you have.
[AGENT][NEUTRAL] And if you don't mind, yes sir, and if you don't mind holding for just a moment, I'm gonna send in a request to have somebody call you so I'm gonna put you on a quick hold.
[CUSTOMER][POSITIVE] Yeah, that'd be great. I'd appreciate that.
[AGENT][NEUTRAL] Why I do that and I'll be right back with you, sir.
[CUSTOMER][POSITIVE] Alright thank you.
[AGENT][POSITIVE] You're very welcome, Mr. [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 33
[CUSTOMER][NEUTRAL] Please listen carefully at the man skin.
[AGENT][POSITIVE] [PII], thank you so much for waiting for me, sir. So, I've got that requested to have somebody from the claims department and examiner call you back and they should be calling you back within 24 hours.
[AGENT][NEUTRAL] To give you some answers, OK?
[CUSTOMER][NEUTRAL] OK, I
[CUSTOMER][NEUTRAL] Yeah I appreciate that um and and the person who's gonna call me back is the, would you say the claims adjuster?
[AGENT][NEUTRAL] It'll be a claims somebody in the claims department, and examiner from the claims department will return the call.
[CUSTOMER][POSITIVE] OK, I appreciate that thank you.
[AGENT][POSITIVE] You're very welcome, sir. Is there anything else that I can help you with before we go?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] All right. Well, you have a wonderful day, sir, and thank you for calling APL.
[CUSTOMER][POSITIVE] All right thank you bye.
[AGENT][POSITIVE] Bye bye, [PII]. You're welcome.