This consumer guide is intended to educate you about the disability claims and appeals process as it relates to Sun Life. It includes a review of Sun Life’s claim procedures and complaints processes. We also report on relevant news, including public court decisions involving Sun Life disability claims. This guide is not endorsed or supported by Sun Life. You should not confuse it for any guide or publication Sun Life may produce about its short- or long-term disability plans.
Sun Life is one of Canada's big three life insurance companies. As you will learn, its claims and appeals processes are largely the same as any other life insurance companies in Canada. This guide will help you understand how Sun Life claims fit within the broader context of disability claims and appeals in Canada. Therefore, we will occasionally provide links for general articles on claims and appeals as they will apply equally to Sun Life.
Sun Life manages a variety of short- and long-term disability plans. It also acts as a third-party administrator for self-funded disability plans. This guide is not a substitute for the official Sun Life documents for your particular disability plan or insurance policy. You must read your own plan document or insurance policy to understand your rights and obligations.
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Sun Life, Sunlife, and Sun Life Financial are all shortened names for the Sun Life Assurance Company of Canada. Sun Life is one of the big three life insurance companies in Canada — the other two being Manulife Financial and Great West Life.
Sun Life sells and administers a range of insurance and financial products, including short- and long-term disability benefits plans. Sun Life sells individual and group disability insurance policies to consumers and employers. It also acts as a third-party administrator for disability plans set up and funded by large employers or non-profit groups.
If you need to file a short-term disability claim with Sun Life, it is important to get a copy of the specific benefits booklet that applies to you. There are no general rules for Sun Life short-term disability claims; the benefits and claims process can be unique based on your particular group insurance or income continuation plan.
When you are dealing with Sun Life for a short-term disability claim, it's important to know the role Sun Life is playing in the payment and administration of benefits.
There are two scenarios for how Sun Life will administer and pay short-term disability benefits. First, Sun Life can be the insurer, administrator and payor of benefits under a group insurance policy. Second, Sun Life can act only as the third-party administrator of benefits paid by your employer or association.
Whether Sun Life is acting as the insurer or as a third-party administrator will not change the claims process in most situations. Sun Life’s role as a third-party administrator does become relevant if you need to file a legal appeal or lawsuit for payment of benefits. If Sun Life is a third-party administrator, you would need to take legal action against the actual payer of benefits, which is usually your employer or association.
To learn more about short-term disability claims in general, check out our Ultimate Guide to Short-term Disability.
There are no general rules applicable to all Sun Life long-term disability claims.
If you need to file a long-term disability claim with Sun Life, the rules for eligibility, payment amounts, and claim procedures will be set out in the particular group policy or plan document that applies to you. These group policies and plan documents are unique, so the only way to know the rules for your situation is to get the document that applies to you.
Your benefits will be summarized in a document called the group benefits booklet or certificate of insurance. You can request a copy of this booklet or certificate from your employer, union or association. This booklet will include all the information relevant to your claim and you don’t need to get a copy of the original group insurance policy issued to your employer or association.
Sun Life also issues individual insurance policies, usually to self-employed professionals, executives or small-business owners. You would have to buy this type of policy from Sun Life, usually using an independent insurance broker. If you have an individual insurance policy from Sun Life, then the rules for your benefits would be found in the insurance policy and any amendments or riders attached to it.
Finally, there are situations where Sun Life will act as the third-party administrator of a disability plan set up and funded by a government, large employer or other association. We refer to these types of plans as non-profit disability plans. In these situations, Sun Life acts only as the administrator of the plan and exercise authority delegated to it by the organization that funds the plan. While there is no insurance policy per se, the rules for the benefits will be set out in a document called the “Plan Text” or something similar.
With non-profit disability plans you may have restricted rights on appeal. These plans may have strict procedures and deadlines that do not follow the rules applicable to regular long-term disability insurance policies. You may be unable to pursue your appeal using the lawsuit process and may be limited to using the grievance and arbitration process set out in a collective agreement.
Some examples of large group policies managed by Sun Life include:
To learn more about long-term disability claims in general, read our Ultimate Guide to Long-term Disability.
Your process to apply for short- or long-term disability benefits will depend on your specific disability policy or plan. While the application forms are very similar from plan to plan, you must use the specific forms designated for your plan or policy. There are no “general application forms” you can find and use online.
You usually get the application forms from your employer or you can find them in the secure online portal for your specific group insurance plan.
Once you get the forms, the process to apply for disability benefits is very similar in all cases. You will need to submit three forms: a claim form that you fill out; a medical form your doctor fills out; and a form your employer fills out.
There is no one-size-fits-all process for appealing a disability claim denial from Sun Life. You must follow the appeal rules that apply to your specific disability plan. Start by getting a copy of the booklet that describes your specific disability benefits. You can get this from your employer, association, or insurance broker.
Generally, your short or long-term disability appeal will involve two or more opportunities to appeal to a Sun Life claim representative. These are called internal appeals. You will have a deadline for each round of appeal. These deadlines vary, but can be anywhere from 30 to 90 days.
You must notify Sun Life in writing about your intention to appeal before the end of the appeal deadline. Ideally, you should also get any new medical information to the claim representative before the deadline. However, if you are having delays in getting the information, they will usually extend the deadline as long as you notify them in advance.
If your attempts at an internal appeal through Sun Life get denied, your next step is to pursue a legal appeal. This means that you're taking your case before a judge who will make the final decision on whether your disability benefits get approved.
When you move to this external appeal, Sun Life will typically assign a new claims representative as well as a lawyer. In addition to the judge, this means you're getting a whole new set of fresh eyes on your claim. In many cases, just having this new team of people look at the evidence is enough to get your claim approved.
If not, the process for the legal appeal basically goes like this: You'll usually have to do an interview with Sun Life's lawyer and representative so they can get a better understanding of you and your situation. After that, you and your lawyer work together to get any new information or medical records, and each side presents their case to the judge for a final decision.
If you are appealing a long-term disability claim under a group insurance policy, we recommend you follow our 7 steps to appeal a long-term disability denial.
If you are appealing a long-term disability claim in a situation where Sun Life is acting as a third-party administrator, then you need to first determine if there are any unique appeal rules that will apply to you.
Sun Life has an internal complaints process. These are for complaints related to service you have received. The process is as follows:
You first raise your issue with your claims representative. If they do not resolve the issue, you ask them to escalate your concern to their supervisor or team leader. This will result in the team leader reviewing your complaint.
If the team leader or supervisor does not resolve your complaint, you can then contact the Sun Life Ombudsman Office.
Mailing address: Ombudsman’s Office, Sun Life Financial, 227 King Street St Waterloo, ON N2J 1R2
There are no general disability claim forms for Sun Life. While many of the forms are similar, each plan or policy has its own unique forms. It is important that you use the forms Sun Life has designated for your plan or policy rather than random Sun Life forms you may find online.
The best way to determine the status of your Sun Life disability claim is to contact the representative assigned to your case. If your claims representative will not respond to your inquiries, you can follow Sun Life’s complaint process. Try to work with the claims representative and use the complaint process as a last resort.
Most life insurance companies, including Sun Life, will agree to lump sum buyouts or settlements in certain situations. There is no provision under the policy or plan for such settlements, so both sides have to agree to them.
With some disability plans, buyouts can be prohibited unless the claim is in litigation. It is important to understand the difference between a buyout and a settlement.
Buyouts refer to a situation where an insurance company will make a one-time payout of an approved long-term disability claim. So, rather than continue to make monthly payments going forward, the insurance company will agree to give you a one-time payment that represents a portion of the future benefits payable under the policy.
Sun Life will sometimes agree to lump sum buyouts of approved long-term disability claims. In my experience, lump sum buyouts are best when they are initiated by Sun Life. This happens when Sun Life proactively identifies a group of individuals for whom they would consider buyouts, and then reaches out to those people.
People often ask me if they can initiate a buyout regarding their approved claim with Sun Life. In my experience, most people who want to initiate a buyout from Sun Life are not in the type of situation where Sun Life would agree to one. In my experience, Sun Life is not interested in buyouts of approved claims that are contested or contentious. Sun Life will only consider buyouts in stable situations where they believe it is a win-win for both you and them.
Like most life insurance companies, Sun Life will consider lump sum settlements for denied disability claims that are in litigation. This is done on a case-by-case basis and there is no right for any person to get a settlement.
These settlements are related to denied disability claims, as opposed to approved disability claims. These settlements are negotiated by your lawyer and result in one-time settlements of all claims you have against Sun Life. The settlements usually include clauses for confidentiality so people can’t speak about them.
Sun Life has been involved in several notable court cases involving long-term disability benefits. Here is a partial list of some of the important cases:
Fidler v. Sun Life Assurance Company of Canada
This is a decision of the Supreme Court of Canada. It is the leading case on when courts can order an insurance company to pay mental distress damages after wrongfully denied a person's long-term disability benefits.
Clarke v. Sun Life Assurance Company of Canada
This is a recent case about the deadline to file legal appeals in Ontario. It gives guidance on when the limitation clock starts to run.
Stene v. Sun Life Assurance Company of Canada
The court ruled that Sun Life's group disability policy, issued to Telus in British Columbia, was under the exclusive jurisdiction of the Labour Relations Act. In other words, the disability claimant was barred from suing Sun Life in the courts and had to resolve all disputes via the union grievance process.
Lipovetsky v. Sun Life Assurance Company of Canada
In this case, the claimant refused to attend an Independent Medical Examination unless she was allowed to bring a friend with her and could record the examination. Sun Life objected to both requests. The judge allowed her to bring a friend, but rejected the request to record the examination.
Following are answers to some frequently asked questions we receive about Sun Life.
We get this question all the time. When your claim gets denied it can feel like you are dealing with the worst insurance company in the world. In reality, it is hard to objectively say that one insurance company is better or worse than another. Often a bad experience can be an isolated event because of the claim representative you are dealing with. Sometimes there are legitimate grounds for Sun Life to dispute your claim, even though it doesn't feel that way to you. What may seem like malice can often better explained by a breakdown in systems or an overwhelmed employee. We have spoken with many people who are satisfied or happy with their interactions with Sun Life.
While we don't have access to Sun Life's claim statistics, we can assure you that Sun Life approves plenty of long-term disability claims. However, there are certain long-term disability claims that are not black and white — meaning that there can be reasonable disagreement on whether the claim should be approved or denied. If your long-term disability claim was denied, it is likely that you fit into this group of claims. It can be frustrating when you know for a fact that you are disabled, but your claim gets denied because there is insufficient evidence to prove what you know to be true. If Sun Life believes there are reasonable grounds to deny your claim, then they will do so. Often presenting your case in the right way will lead to Sun Life approving your claim. This means you need to present evidence that will be convincing to Sun Life.
The short answer is no, Sun Life's internal appeal process is not a waste of time. Generally, we encourage everyone to engage the internal appeal process before suing Sun Life for denial of long-term disability benefits. We have had good success in helping people get Sun Life claims approved during the internal appeal process. In or experience, Sun Life takes the internal appeal process seriously and does not "force" people to sue them to win payment of benefits.
There are always exceptions and there are situations where it will not be possible to win approval during internal appeals and a lawsuit will be necessary.
"Spy" is a harsh word — but yes, all insurance companies are allowed to do surveillance or monitoring of disability claimants. When doing so, they are not allowed to violate your privacy rights. Any surveillance or monitoring must be done in the public domain. This means they may only monitor you in public spaces or use information that is publicly available online.
Sun Life disability benefits can be either taxable or non-taxable depending on the specific disability plan. The tax status of long-term disability benefits depends on the percentage of the premium paid by you and the percentage paid by your employer. The only way to know if your disability benefits are taxable is to ask your employer or your Sun Life claim representative.
Still feeling unsure about your Sun Life disability claim or appeal? Sometimes a quick call with us can help you move forward with confidence. Call us at 1-888-732-0472 or click on "Free Consultation" at the top of your page to start a conversation with our support team.