AccountId: 011433970860
ContactId: fae0b32c-3845-45d7-b97f-dd8b9444cabd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1466280 ms
Total Talk Time (AGENT): 295083 ms
Total Talk Time (CUSTOMER): 725944 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/fae0b32c-3845-45d7-b97f-dd8b9444cabd_20250304T20:12_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, this is [PII] calling.
[AGENT][NEUTRAL] And how may I assist you today, Mr. [PII]?
[CUSTOMER][NEUTRAL] I, I wanna check on my, my claim. I, I called earlier and then, um, they're saying they need some paperwork. Well this paperwork's already been sent to you on there's a lady named [PII].
[CUSTOMER][NEGATIVE] It's been handling it and I've tried to call her no response but uh my wife has sent.
[CUSTOMER][NEUTRAL] This paperwork to y'all already.
[AGENT][NEUTRAL] OK, and let's see, she's the one in charge. OK. And may I have the a callback number just in case we get disconnected and the policy number, Mr. [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And the policy number is 02431002.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] For security, may I have your date of birth, mailing address and email address?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And it's, uh, [PII].
[AGENT][NEUTRAL] OK, the address seems to be a little bit different. Um, did you change the address?
[CUSTOMER][NEUTRAL] You got [PII]?
[CUSTOMER][NEUTRAL] Or is it [PII]?
[AGENT][NEUTRAL] No, we got it in [PII].
[AGENT][NEUTRAL] [PII]. Which one is the correct one?
[CUSTOMER][POSITIVE] Either one's good.
[AGENT][NEUTRAL] OK, OK, OK, I'm just making sure, all right, so let me see.
[CUSTOMER][NEUTRAL] The [PII]. I've been I remarried in a moved since, but my kids have my other place, so that's either one would be good.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] And you got [PII] is the other.
[AGENT][NEUTRAL] Yes, mhm, yes, that's what we have. OK. All right, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, let me check this last claim and see what's going on. Do you mind holding for me while I go over the last claim and see what they need? OK, thank you.
[CUSTOMER][NEUTRAL] That's fine, yeah.
[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] Thank you for holding, Mr. [PII]. OK, so it looks like um we have not received the pathology report and that's what we're, we're asking for.
[CUSTOMER][NEUTRAL] And that was from
[CUSTOMER][NEUTRAL] What do y'all have because my wife sent me copies of this stuff she sent y'all to.
[CUSTOMER][NEUTRAL] For this lady [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah, we have a lot of information, but none of them is the pathology report, um.
[CUSTOMER][NEUTRAL] Pathology report now y'all don't, I mean.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] And we, and she didn't even work there anymore and I, I left her a message today and I've been dealing with this for like two months, I mean.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, let me
[CUSTOMER][NEGATIVE] This is getting frustrating on my behalf.
[AGENT][NEUTRAL] Let me see if she's available one moment.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, let me send her a message one moment.
[AGENT][NEUTRAL] Let me see, bear with me one more minute. I'm just gonna try to get somebody in that department, OK?
[CUSTOMER][NEUTRAL] Yeah, because I mean this, this information has been sent to her. I don't understand the problem and the last we sent it was about a week and a half ago and she assured my wife that was all she needed.
[AGENT][NEUTRAL] Um, OK, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] offering.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII]. How are you? This is [PII].
[CUSTOMER][POSITIVE] Hey, I'm good how are you so?
[AGENT][NEUTRAL] I'm good, thank you. I have a member on the line that would like to speak to a representative. He keeps saying that [PII] is the one that processed this claim, but I don't know if we have a Lindsay. Yeah, I don't think we have a Lindsey in that department.
[CUSTOMER][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] We don't have a Lindsey.
[AGENT][NEUTRAL] Right, that's what I was thinking. I'm like, we don't have a Lindsay, um, it looks like it's the hay bar. I'm not sure if he's just confused, um, yeah, because I, I've been pulling all the claims and I'm like that's the shade, that's not [PII], that's yeah, but yeah, he.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Oh yeah, that's not anywhere close to [PII].
[CUSTOMER][NEUTRAL] That's funny. What, what's the policy and claim?
[AGENT][NEUTRAL] It's 243-1002.
[CUSTOMER][NEUTRAL] So I guess before we get in transfer anything what what's going on like what's the question?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Yes. OK, so basically he's calling because he has called before and um he said he spoke to [PII], which I don't know who's [PII]. I'm probably thinking that it's whoever took the last call. Let me see who's that. um There was [PII]. There's no way that [PII] is [PII], there's.
[AGENT][NEUTRAL] That [PII] that [PII] probably [PII]. That's [PII], yeah, yeah, that's so.
[CUSTOMER][NEUTRAL] Yeah, I know, right?
[CUSTOMER][NEUTRAL] Maybe [PII] and he heard [PII], that's closer that I can see.
[CUSTOMER][NEUTRAL] Oh Lord.
[AGENT][NEUTRAL] Yes, OK. So, basically, um, he said that he sent the pathology report and then he was told that that's all they needed. And um so he thought that, um, or he thinks that we do have the pathology report, so why we ask him for the pathology report again? That's basically why he's calling.
[AGENT][NEUTRAL] Because I went ahead and, you know, pulled the last uh claim, um, and I told him that that's what we're needing. We need the pathology report to uh process the claim and we have not received any other documents after that. So he's just concerned because he thinks we do have the pathology report and we are still asking for the pathology report.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] And he thinks we have it.
[CUSTOMER][NEUTRAL] Oh man, OK, um.
[AGENT][NEUTRAL] So I don't know if you can go through the claim and see if you can find that pathology report because he keeps saying that it's it's there.
[CUSTOMER][NEUTRAL] I mean,
[CUSTOMER][NEUTRAL] In the most recent submission because it looks like, OK, because I was gonna say if this date is [PII] like we've only gotten the one set of documents so.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. We'll send the most recent submission online. Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, I think 16 pages. Let's see if we got it. Uh, [PII] is not one to overlook things like that, so I don't think she would ask for it if she felt like she had it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, that, that's, I know, that's why I'm like, I, I didn't even, I said no, we just need that and he's like, but somebody told me, [PII] told me that you have it. I'm like, OK, let me see what's going on.
[CUSTOMER][NEGATIVE] Right, like no.
[CUSTOMER][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] Renal cell carcinoma from [PII] was his diagnosis.
[CUSTOMER][NEUTRAL] OK, that could be different because yes he just submitted this information but I wonder if some of this [PII] stuff is.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] A path for this diagnosis date.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Let me, let me dig, let me dig, let's see.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let's see what those claims that we denied let's see.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 7008, critical illness, proof of loss.
[CUSTOMER][NEUTRAL] OK, that doesn't mean we don't have a path, so let's see.
[CUSTOMER][NEUTRAL] Oh man, all the time testing my knowledge. OK, surgical path, this says 722 of 24.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Negative for invasive carcinoma, so that wouldn't be covered anyways.
[CUSTOMER][NEUTRAL] Will you look at the most recent while I'm digging through this and see on his claim form what type of cancer I didn't write it down he's claiming so I can see if anything in these older ones is.
[CUSTOMER][NEUTRAL] The path
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, let me see. Oh, I pulled up where did it go?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Because it looks like he says June but this was not actually collected until July.
[CUSTOMER][POSITIVE] But he was positive for malignant neoplasm of sigmoid colon, which is why I'm trying to figure out because this is a path report for that.
[AGENT][NEUTRAL] Mm, yeah, and the, I do see a surgical pathology report, the first, um, and that 16 pages.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, but it says negative for malignancy.
[CUSTOMER][NEUTRAL] Well, they submitted billing too later on that has a positive diagnosis and down there at the bottom it says sigmoid colon cancer or something so.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Mm, OK, so.
[CUSTOMER][NEUTRAL] It was like certain, certain parts that they resected weren't positive, I guess, but
[CUSTOMER][NEUTRAL] I'm not sure um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I get OK so on this one.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because it looks like we've paid.
[CUSTOMER][NEUTRAL] 4.
[CUSTOMER][NEGATIVE] That cancer already.
[CUSTOMER][NEUTRAL] And that was a [PII] diagnosis.
[CUSTOMER][NEUTRAL] So maybe he had several surgeries. I'm not sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, so I'm trying to figure out on this one like what is he trying to claim because if we've already paid it we're not going to pay anything else.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And he all the only other policy he has is accident, critical illness, renal cell carcinoma is what he's trying to claim.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Now.
[CUSTOMER][NEUTRAL] OK, that is different.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh is this one?
[CUSTOMER][NEUTRAL] OK, we already paid that. OK, so we have a path for his previous colon cancer.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But we don't have renal cell carcinoma which looks like it's C19.7, nope.
[CUSTOMER][NEGATIVE] I don't know what that number is supposed to be.
[CUSTOMER][NEUTRAL] It see something but date of diagnosis [PII].
[CUSTOMER][NEUTRAL] It's like just the form and what was filled out by the physicians it looks like.
[CUSTOMER][NEUTRAL] I'm just trying to search through this before you send them over so I know that I've looked through and I can say OK this is what I know we have I've looked through all your documents.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We don't have anything for this diagnosis, but we do have something for this one,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Patients a [PII] male who presents for a follow up for renal mass, renal cell carcinoma.
[CUSTOMER][NEUTRAL] That's the one.
[CUSTOMER][NEUTRAL] 362 4.
[CUSTOMER][NEUTRAL] What's that 27.
[CUSTOMER][POSITIVE] Maximum payable for this condition.
[CUSTOMER][NEUTRAL] C 18.9 malignant neoplasm of colon.
[CUSTOMER][NEUTRAL] And see 64.1.
[CUSTOMER][NEUTRAL] OK, so I think the reason why.
[CUSTOMER][NEUTRAL] Because I do show records here where we are showing renal cell carcinoma for the claim that we actually.
[CUSTOMER][NEGATIVE] Denied before this one as needing.
[CUSTOMER][NEUTRAL] Are the maximum payable for this condition has been exhausted?
[CUSTOMER][NEUTRAL] Um, and they included both colon cancer and
[CUSTOMER][NEUTRAL] Renal in the, in the diagnosis code it's the 3624.
[CUSTOMER][NEUTRAL] Um, renal cell carcinoma.
[CUSTOMER][NEUTRAL] And I'm trying to see because under his policy.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Trying to see where it's at.
[CUSTOMER][NEGATIVE] Uh, benign brain tumor, that's not a good coma.
[CUSTOMER][NEUTRAL] I think invasive cancer, so we only pay invasive cancer once.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Now I'm wondering why we're asking for a path report if we only pay for cancer once.
[AGENT][NEUTRAL] Oh boy.
[CUSTOMER][NEGATIVE] It's just all over the place confusing me.
[AGENT][POSITIVE] Really yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Imagine me that I have no idea, none of what you're saying. I have no idea. I'm like, OK, I'm just looking at the paperwork. I'm like, oh, OK.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] No doubt, no doubt.
[CUSTOMER][POSITIVE] Yeah, right, like I'll take your word for it.
[AGENT][NEUTRAL] Yeah. Basically, OK, yeah, I, I see that too, but I, I don't know what it means and what it is.
[CUSTOMER][NEUTRAL] That's hilarious. OK, so in the policy, um, pay applicable critical illness as shown in the schedule for the first time a covered person is diagnosed with any one of the illnesses that are listed.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Um, must not have been previously paid, must also not be excluded. If after the first one is paid, they're diagnosed with a different one.
[CUSTOMER][NEUTRAL] Then we'll pay that one.
[CUSTOMER][NEUTRAL] Um, if it's not excluded.
[CUSTOMER][NEUTRAL] There's no limit on how many additional basically we'll pay any of them you're diagnosed with for the first time.
[CUSTOMER][NEUTRAL] Um, the critical illness amount paid for an initial.
[CUSTOMER][NEGATIVE] is subsequently diagnosed with the same critical illness.
[CUSTOMER][NEUTRAL] Then
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] We will pay the critical illness benefit previously paid multiplied by the recurrence amount so that's gonna be a percentage.
[CUSTOMER][NEUTRAL] As long as it's 6 months after the day of the initial critical illness and it's not excluded. I wonder if that's why she's asking.
[CUSTOMER][NEUTRAL] That makes more sense now.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Because we paid for his original it said May.
[CUSTOMER][NEUTRAL] Of [PII].
[CUSTOMER][NEUTRAL] I believe
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, should I put him in because it's been a while.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, go ahead.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you for holding, Mr. [PII]. I've got Miss [PII] on the line. Uh, she's been checking on that for you and she's gonna give you some information, OK?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hey Mr. [PII] how are you? Fine, how are you doing? I'm doing well um OK so I'm trying to look through everything and just kind of determine what might be going on here because I did see that we had records that indicated both colon cancer and renal on a claim that we previously paid um are denied it it may have been a denial as the max had already been met.
[CUSTOMER][NEUTRAL] So then I was trying to determine OK what are we looking at so do you have?
[CUSTOMER][NEUTRAL] Let me ask you something here now. Sure, the colon cancer was a separate issue. That was last year. Y'all pay on that. I've been diagnosed since then with kidney cancer, the renal, whatever you call it, separate cancer.
[CUSTOMER][NEUTRAL] When, when were you diagnosed with that? Do you know? First of this year, uh, first part of this year?
[CUSTOMER][NEUTRAL] It, it's in those not my wife sent them to my phone. I'm driving right now. She'd have to be the one that's [PII], but uh.
[CUSTOMER][NEUTRAL] When they first diagnosed it, the way they do this long story short, they don't even do a biopsy no more. I turned that information over to [PII] that.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Handle all this is the company I work for she's no longer here. Got you. But I had scheduled a freezing thing.
[CUSTOMER][NEUTRAL] At the doctor's office called me the week of.
[CUSTOMER][NEUTRAL] Saying no we get they are wanting a biopsy now. So first biopsy was a failed attempt. They went into my that gum liver and we're talking about my right kidney had liver sample tissues and there had to do a second biopsy.
[CUSTOMER][NEUTRAL] And now we're wanting to do the freezing, which is the [PII] of this month on my right kidney. So first biopsy was a failed attempt. My wife sent that. The second biopsy, I think, was the [PII]. The lady in questioned me about this information earlier when I called. OK. Sent that and and sent it to my phone.
[CUSTOMER][NEUTRAL] Both come from the pathology, uh, department.
[CUSTOMER][NEUTRAL] Which is a it's a separate cancer it's not.
[CUSTOMER][NEUTRAL] Linked to the colon cancer, the colon cancer was isolated. It had had not protruded through my colon. They removed a section of my colon last July, so this is a separate claim.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] That being said, do y'all pay on a separate claim?
[CUSTOMER][NEUTRAL] So I actually looked at that in your policy and as long as a 2.
[CUSTOMER][NEUTRAL] Condition like or the same condition, so invasive cancer as long as it is 6 months after the first diagnosis, then it's like a percentage like a recurrence percentage um let me see what that is in your policy, um, let's see, it's 100%, so yeah, yours would be a 100% benefit it looks like for recurrence, um, or for 6 months.
[CUSTOMER][NEUTRAL] Yeah, I think the, the data service I saw on the last one was like [PII]. Does that sound right? Yeah, yeah, it's been nearly a year. Yeah, it's getting real close and then this I do show that there's a.
[CUSTOMER][NEUTRAL] Uh, it looks like it's a surgical path.