AccountId: 011433970860
ContactId: fe4c5144-7591-4496-962b-029e08cf0348
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 948280 ms
Total Talk Time (AGENT): 426641 ms
Total Talk Time (CUSTOMER): 453660 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/22/fe4c5144-7591-4496-962b-029e08cf0348_20250122T19:07_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. Um, I have a couple of questions about the gap insurance.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I think my company is um giving us the option to get the supplemental limited benefit group medical expense insurance.
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] What is your name?
[CUSTOMER][NEUTRAL] My name, my name is sorry.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I said my name is [PII].
[AGENT][NEUTRAL] OK, can you spell that for me?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] I'm not on your policy yet. I'm now like determining if I want to get on the policy, but I have some questions.
[AGENT][NEUTRAL] I know, but I needed your name so I know how to address you properly, [PII].
[CUSTOMER][NEUTRAL] OK, yeah, that's fine.
[AGENT][NEUTRAL] OK. Did they give you a brochure?
[CUSTOMER][NEUTRAL] Sorry, say that again.
[AGENT][NEUTRAL] You said that you're in the process of you you might enroll with one of our products. Did they get your employer give you an in a brochure of what's offered?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sorry, say that again.
[CUSTOMER][NEGATIVE] Your voice is a bit muffled.
[AGENT][NEUTRAL] OK, that's the first time I've heard that today, so you said that you're thinking about enrolling with our insurance. OK, so it's uh obviously it's open enrollment or you are a new employee. Did they give you a brochure, a piece of paper.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] A new employee.
[AGENT][NEUTRAL] That outlines the benefits.
[CUSTOMER][POSITIVE] Yes, that's what I'm looking at. Exactly, that's what I'm looking at.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so what's on that document?
[CUSTOMER][NEUTRAL] So I have the Medlink for supplemental Limited Benefit Group medical expense insurance.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] And so there should be an inpatient benefit and an outpatient benefit under that product.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Exactly, exactly. So it said benefits payable under this policy are limited to any out of pocket deductible amount incurred under your other medical plan and any out of pocket co-payment or co-insurance amount the covered person actually incurs under your other medical plan. So my question is,
[AGENT][NEUTRAL] Mhm. And so.
[CUSTOMER][NEUTRAL] Does that statement mean that the deductor it's this, um, kicks in after the deductible is met or before?
[AGENT][NEUTRAL] OK, so the meddling for policy is secondary to your major medical plan.
[CUSTOMER][NEUTRAL] So when is the secondary, my mhm.
[AGENT][NEUTRAL] And so what that
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] The Metlink policy is, is secondary. So your providers will submit the claim to your major medical carrier. Do you know who that is?
[CUSTOMER][NEUTRAL] Um, you mean 89. OK, so that, that would be 8 now.
[AGENT][NEUTRAL] Mhm, OK, so they'll submit the claim to Edna first.
[AGENT][NEUTRAL] And then they'll submit your claim to American Public Life to pay as a 2nd. That's when I say secondary, that's what I mean we pay 2.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so of covered charges, whatever amount Aetna applies towards your calendar year deductible.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Or they may say it's a co-insurance amount or it could be a copay amount, the Medlink policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] We'll reimburse that amount listed.
[AGENT][NEUTRAL] If it's a covered charge.
[AGENT][NEUTRAL] Under the APL meddling for policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it's like a, the meddling for it's like a supplement to your major medical coverage.
[CUSTOMER][NEUTRAL] OK, so my question is let's say I go with a deductible plan of uh.
[CUSTOMER][NEUTRAL] Um, let's say 3000 or something, right?
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] This policy cover any out of pocket costs prior to me reaching my deductible?
[AGENT][NEUTRAL] OK, so the $3000 figure is that the benefit under the Metlink for, or is that the deductible under?
[CUSTOMER][NEUTRAL] No, that's, that's a deductible. Let's say even a $5000 deductible. Will they cover my, um, let's say I go to the hospital, I still haven't met my deductible, but I have a what? $1000 bill. Will they cover that out of pocket?
[AGENT][NEUTRAL] OK, let me back up. The $3000 that you're referring to, is this that your major medical deductible, or are you saying that this is the deductible under the Meling for plan?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm saying let's see, let's say at 3000 was the deductible.
[AGENT][NEUTRAL] For your major medical deductible.
[CUSTOMER][NEUTRAL] My major medical deductible for it now in this instance.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] And so if you.
[CUSTOMER][NEUTRAL] And I haven't reached 3000.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so
[AGENT][NEUTRAL] Whatever amount is applied towards Aetnas.
[CUSTOMER][NEUTRAL] OK, let me ask the question again.
[CUSTOMER][NEUTRAL] So, it's February, let's say I, I enroll today, right? Policy kicks in in February. I go into the hospital in February. I definitely haven't met my deductible. I have an out of pocket cost of $1000. Will this pay for that $1000?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, if it's a covered item under the meddling for policy.
[AGENT][NEUTRAL] So if it's an outpatient surgery on that schedule that you have, it should list that there is an outpatient facility benefit.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] Yeah, so I see urgent care facility, hospital emergency room.
[CUSTOMER][NEUTRAL] And so it started at hospital emergency room, urgent care facility, outpatient surgery, diagnostic testing.
[CUSTOMER][NEUTRAL] Um, OK, so it doesn't do like a normal outpatient services.
[AGENT][NEUTRAL] When you say normal, what do you mean?
[AGENT][NEUTRAL] In a hospital?
[CUSTOMER][NEUTRAL] So let's say I in a hospital.
[AGENT][NEUTRAL] OK, I think I heard you say outpatient.
[AGENT][NEUTRAL] You gave me ER, you said urgent care and then you said out diagnostic, and then you said outpatient.
[AGENT][NEUTRAL] Did you say outpatient hospital?
[CUSTOMER][NEUTRAL] Yes, and then I
[CUSTOMER][NEUTRAL] It's a house outpatient surgery, so that means it doesn't cover outpatient hospital.
[AGENT][NEUTRAL] What, what's the benefit on this, the brochure that you have for outpatient surgery?
[CUSTOMER][NEUTRAL] OK, so and I covered outpatient services it says hospital emergency room, urgent care facility, outpatient surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, diagnostic testing, outpatient treatment for a mental or emotional disorder in a hospital outpatient facility.
[AGENT][NEUTRAL] Mhm. And so you said that you would have, what's hypothetically having a surgery in outpatient surgery in February?
[CUSTOMER][NEUTRAL] No, no, hypothetically, having like a normal outpatient visit, which wasn't preventative.
[AGENT][NEUTRAL] Yeah, preventive is not covered under the policy.
[CUSTOMER][NEUTRAL] No, I know it's all covered under your policy. I'm saying, let's say preventative would be covered under my primary, right? So anything that's not preventative, I would come, I would have to pay out of pocket.
[AGENT][NEUTRAL] Correct, because it's not covered under the meddling for.
[CUSTOMER][NEUTRAL] Would your policy
[CUSTOMER][NEUTRAL] Exactly. Wait.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, it's not covered under the meddling for. Yeah, so I'm saying that um the meddling for, first off, my first question is, if I haven't reached my deductible and I have out of pocket costs, would the meddling for um kick in?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It will if it's covered under the Metlink policy. So, I mean, it's, you know, we're talking hypothetically, but the service has to be covered under the Metlink policy.
[CUSTOMER][NEUTRAL] That's my first question.
[CUSTOMER][NEUTRAL] OK, so if you, you go to an urgent care facility, it's covered, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Emergency room.
[CUSTOMER][NEUTRAL] If you do outpatient surgery is covered. If you go to the emergency room, it's covered. If you do diagnostic testing.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And I don't know if it, uh, some of the metling policies will say that it covers certain diagnostic tests. I don't know if that one does.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, this is what it says, diagnostic testing in a hospital outpatient facility or MRI facility. We go up to the maximum outpatient benefit.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Subject to the outpatient benefit deductible.
[CUSTOMER][NEUTRAL] Independent labs such as quest and labco are not covered.
[CUSTOMER][NEUTRAL] So what does that mean?
[AGENT][NEUTRAL] Are not covered lab inquest lab charges from Quest is not covered, right so.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's what they say.
[AGENT][NEUTRAL] So sometimes when you have a lab they'll send it out to an independent or lab drawn they'll send it to an independent.
[AGENT][NEUTRAL] Um, laboratory such as Quest or LabCorp of America.
[AGENT][NEUTRAL] Um, and it's saying that if we receive a bill, if APL receives a bill from Quest Diagnostic or Labor, and if you do not have the lab writer, then it would not be covered.
[CUSTOMER][NEUTRAL] OK, that's fair. So what I want to know is if it's a normal outpatient visit?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Will it be covered?
[AGENT][NEUTRAL] When you say the normal outpatient visit, is this, uh, like in a doctor's office or a specialist office?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK, so if it doesn't notate it there, um, and that's that brochure that you have that it, it wouldn't be covered.
[AGENT][NEUTRAL] Do you see an outpatient treatment writer on that brochure?
[CUSTOMER][NEUTRAL] OK, so what it has here is outpatient.
[CUSTOMER][NEUTRAL] OK, let me see what I have. So I have outpatient benefit rider, and it says maximum outpatient benefit $250 per covered person per car runs for outpatient services. 500 the the option two is $500 per covered person per or car runs for covered outpatient services.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that means this is any normal outpatient service, right?
[AGENT][NEUTRAL] I can't guarantee it because it depends on what's on your schedule. I think there is an outline of what's covered like you were saying urgent care emergency room.
[CUSTOMER][NEUTRAL] So that's what I'm reading to you. So, um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, if you have surgery in a hospital, that would be covered.
[CUSTOMER][NEUTRAL] Oh, OK. I think I get what you're, it's saying. So the outpatient benefit rider and then they have covered outpatient services. So the $250 for a covered person for accounts for covered outpatient service and so the list of covered outpatient services well I we just went through.
[AGENT][NEUTRAL] Outpatient surgery?
[AGENT][POSITIVE] Yes. Correct.
[CUSTOMER][NEUTRAL] OK, got you, OK, that makes sense.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm, OK.
[AGENT][NEUTRAL] Any other questions?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I think that will be it. I think the main thing I wanted to confirm was that um it would kick in prior to even if I haven't met my deductible.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's what I wanted to be. I know.
[AGENT][NEUTRAL] Yes, so the Metlink policy assists with um.
[AGENT][NEUTRAL] The uh amount that major medical applies towards your deductible, your co-insurance, or co-pay amount, but it has to be a covered item under the Metlink policy.
[AGENT][NEUTRAL] So if, if you let's, yeah, so yeah, it has to be a covered item.
[CUSTOMER][NEUTRAL] OK, got you.
[AGENT][NEUTRAL] And so if you've not met your 2025% deductible, of course, more than likely if you had an outpatient surgery or any service, um, it's going to apply towards your deductible, right?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And so then when APL receives that claim, um, it should also have a copy of your of Edna's explanation of benefits attached to it, and that EOB or explanation of benefits will tell us how much Edna applied towards your deductible or your co-insurance or co-pay amount and that's what we go by to determine what we pay.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What's what's in those three columns?
[CUSTOMER][NEUTRAL] Wait, so let's say.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If they've um they've applied, um, say $1000 to my deductible and I mean and I still have $1000 out of pocket because I'm more interested in the out of pocket, would that out of pocket be covered by um APL?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, so if they apply $1000 towards your deductible, that would be an out of pocket expense for you, but we'll pick that up if it's covered by your policy, but I think I understood you to say one of the schedules or the brochures you you have it's 250, you said 250 per occurrence.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, for clearance, yes.
[AGENT][NEUTRAL] And so of that 1000 that they may apply towards your deductible, we would only pay 250 of that if that's the benefit that you select.
[CUSTOMER][NEUTRAL] OK, got you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, because this is, um, in lieu of an HSA plan, right, I need to determine, do I put money in an HSA or do this instead.
[CUSTOMER][NEUTRAL] Because I'm not allowed to do both, so I'm trying to see what makes sense, because if it will cover the things that I'll use the money in the HSA to power, then it makes sense to do this because even if I had out of pocket costs, which I have used the HSA to cover, this would cover it.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Oh, I get it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] At least to uh the maximum coverage, yes.
[AGENT][NEUTRAL] Covered charges, yes.
[AGENT][NEUTRAL] Mhm. Mhm.
[CUSTOMER][POSITIVE] OK, so this is, this was amazing. Thank you very much I I appreciate it.
[AGENT][NEUTRAL] OK. Are we all clear?
[CUSTOMER][NEUTRAL] I think I am. I, I just, you know, right now when you're enrolling, it's pretty easy to get like people to answer questions, but the way you have a claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I know. I know it. I know it. I know. Do you have a certain time? When is the cut-off period for you to enroll?
[CUSTOMER][NEUTRAL] Um, I have 30 days, but I would like to get it done today if possible, so I wanted to get as much information as I could.
[AGENT][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] So that brochure that you have in your hand seems pretty outlined as to what is covered under whichever one you choose.
[CUSTOMER][POSITIVE] OK. Thank you.
[CUSTOMER][NEUTRAL] OK, so I have to like go through everything and make sure I'm making the best um.
[AGENT][POSITIVE] Totally understand.
[CUSTOMER][POSITIVE] Yeah, that's the best option.
[CUSTOMER][POSITIVE] Awesome thank you so much I appreciate it.
[AGENT][NEUTRAL] I do understand that?
[AGENT][POSITIVE] All right. Thank you for call.
[CUSTOMER][NEUTRAL] And when you say in network benefits, sorry, hold on, what is your in network benefits because in my in in network might be different from your in network, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, and so.
[AGENT][NEUTRAL] Our policies, there's no in or out of network because we are a secondary payer we pay second and so we're gonna basically follow Aetna's, however Aetna processes the claim, we're gonna follow Aetna's um.
[CUSTOMER][NEUTRAL] OK, got you.
[AGENT][NEUTRAL] I don't wanna say guidelines, but whatever amount they apply of covered charges to either your deductible, co-insurance, or co-pay will reimburse those amounts if it's covered up to the policy benefit maximum.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK makes sense.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Makes sense thank you I appreciate it.
[AGENT][NEUTRAL] Oh, you're welcome. [PII]. Anything else?
[CUSTOMER][NEUTRAL] I think this will be it, but I will reach out if I have any additional questions. Thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, call us back if you have further questions.
[CUSTOMER][POSITIVE] Awesome thank you bye.
[AGENT][POSITIVE] You're welcome thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye-bye.