Sun Life Financial Claim Denied (USA): How to Appeal a Group Benefits Denial

Sun Life Financial Claim Denied (USA): How to Appeal a Group Benefits Denial

Sun Life Financial is a major provider of group insurance benefits in the United States, primarily offering long-term disability (LTD), short-term disability (STD), group life insurance, dental and vision insurance, and supplemental health benefits through employers. Sun Life serves thousands of employers across the US, covering millions of employees.

If Sun Life has denied your group disability, life insurance, or other group benefit claim, your rights and appeal process are primarily governed by ERISA (the Employee Retirement Income Security Act) — a federal law that creates specific procedural rights and significant (but navigable) constraints on litigation. This guide explains the process.

About Sun Life Financial (US)

Sun Life Financial's US operations are headquartered in Wellesley Hills, Massachusetts. In the US market, Sun Life is best known for:

• Long-term disability (LTD) insurance (the most common claim type)
• Short-term disability (STD) insurance
• Group term life insurance (including accidental death and dismemberment, AD&D)
• Dental and vision insurance
• Absence management (FMLA/leave management services)

Most Sun Life group policies are ERISA plans — employer-sponsored benefit plans subject to the ERISA appeal process and ultimately to federal court jurisdiction.

Common Sun Life Denial Reasons

Long-term disability denials (most common):

• Own occupation vs. any occupation: Many LTD policies initially define disability as inability to perform your "own occupation." After 24 months, the definition typically shifts to inability to perform "any occupation." Sun Life frequently denies claims at the definition change point.
• Insufficient medical evidence: Sun Life argues that your medical records do not substantiate the severity of your condition or its functional limitations.
• Pre-existing condition exclusion: Sun Life denies coverage claiming your disability arose from a condition that existed before your coverage effective date (typically during a look-back period of 3–12 months).
• Mental/nervous condition limit: Most group LTD policies limit mental health and nervous condition disability benefits to 24 months. Sun Life may reclassify a physical disability as having a mental/nervous component to apply this limit.
• Failure to meet elimination period requirements: LTD policies typically have a waiting period (elimination period) of 90–180 days. Sun Life may dispute whether you were continuously disabled throughout this period.
• Surveillance and independent medical examination (IME): Sun Life conducts surveillance and may order IMEs. Adverse IME findings are commonly used to deny or terminate LTD benefits.

Short-term disability denials:

• Insufficient medical documentation during the disability period
• Dispute over whether the condition qualifies as a covered disability
• Pre-existing condition exclusion

Life insurance denials:

• Misrepresentation on the original application
• Policy exclusions (suicide clause, hazardous activity exclusion)
• Dispute about whether the death qualifies as accidental (for AD&D claims)
• Evidence of insurability (EOI) disputes

Dental claim denials:

• Treatment deemed not dentally necessary
• Coverage exclusions (cosmetic procedures, waiting periods)
• Frequency limitations

Your ERISA Appeal Rights

Because Sun Life group policies are ERISA plans, your rights and the appeal process are governed by federal ERISA regulations:

ERISA-Mandated Internal Appeal Process

Step 1: File an internal appeal within the deadline

• You have 180 days from Sun Life's denial to file your internal appeal
• This deadline is critically important — miss it and you may lose your right to sue in federal court
• Sun Life must provide a full appeal review, including consideration of all new evidence you submit

Step 2: Sun Life must respond within required timeframes

• LTD/disability appeals: 45 days (extendable by 45 more days for special circumstances)
• Life insurance appeals: 60 days (extendable by 60 more days)

Step 3: Exhaust administrative remedies before suing

• ERISA generally requires you to exhaust the internal appeal process before filing a lawsuit
• Failure to exhaust can result in dismissal of your lawsuit
• Exception: You may not need to exhaust if the plan's appeal process is inadequate or if Sun Life fails to follow ERISA's procedural requirements

ERISA Claim File Rights

Under ERISA regulations:

• You have the right to request your complete claim file from Sun Life at no cost
• The claim file should include all medical records, medical opinions, internal communications, surveillance records, and the criteria used to deny your claim
• Review this file carefully before preparing your appeal — it will reveal exactly what Sun Life relied on

The ERISA Constraint on Litigation (The "Arbitrary and Capricious" Standard)

This is a critical ERISA concept: if your Sun Life policy gives the plan administrator discretionary authority (which most ERISA plans do), a federal court reviewing Sun Life's decision will apply an "arbitrary and capricious" (or "abuse of discretion") standard — not a fresh review. This means the court will uphold Sun Life's decision unless it was unreasonable, even if the court might have decided differently.

What this means for your appeal:

• The internal appeal record is crucial — federal courts generally cannot consider evidence that was not in the administrative record
• Your appeal must be thorough and include all supporting evidence, because you may be limited to that evidence in court
• Getting an attorney experienced in ERISA disability law to assist with your appeal (not just litigation) is valuable

Step-by-Step: Appealing a Sun Life Denial

Step 1: Obtain Your Complete Claim File

Immediately request your complete claim file from Sun Life. Review it carefully:

• What medical evidence did Sun Life rely on?
• Were there peer review or IME reports? What do they say?
• What clinical standards did Sun Life apply?
• Is there surveillance footage or other non-medical evidence?

Step 2: Gather Comprehensive Medical Documentation

A successful Sun Life appeal typically requires:

• Updated and detailed physician letters explaining your diagnosis, functional limitations, and why you cannot perform work duties
• Functional capacity evaluation (FCE): A formal assessment of your physical or cognitive capabilities, conducted by a licensed therapist
• Neuropsychological testing: For cognitive or mental health conditions
• Specialist consultations: Opinions from specialists relevant to your condition
• Vocational expert report: An expert opinion on whether you can perform your occupation (for own occupation denials) or any occupation
• Medical records covering the entire disability period

Step 3: Address Sun Life's Specific Denial Grounds

Your appeal letter must directly address every reason Sun Life gave for the denial:

• If Sun Life claims insufficient medical evidence, provide detailed, objective medical documentation
• If Sun Life ordered an adverse IME, obtain a rebuttal opinion from your treating specialist
• If Sun Life applied a pre-existing condition exclusion, document your medical history to challenge the exclusion's application
• If Sun Life claims mental/nervous limitation, obtain physician documentation establishing a purely physical basis for your disability

Step 4: Submit a Comprehensive Appeal Letter

Submit a formal appeal letter through Sun Life's appeals process. Include all supporting documentation. Send by certified mail and keep copies of everything.

Sun Life Appeals:

• Contact information is on your denial letter
• Sun Life Financial US: One Sun Life Executive Park, Wellesley Hills, MA 02481

Step 5: Consider ERISA Litigation

If Sun Life upholds the denial after internal appeal, consult an ERISA disability insurance attorney. Many ERISA attorneys work on a contingency basis for disability cases. The statute of limitations for ERISA lawsuits is typically specified in your policy (often 1–3 years after the final denial).

Sun Life-Specific Tips

Don't wait for the deadline: Request your claim file and gather medical evidence immediately after receiving the denial. The 180-day internal appeal deadline is firm.

Obtain independent physician opinions: Sun Life's own medical reviewers have financial incentives to uphold denials. Counter adverse opinions with detailed rebuttal letters from your treating physicians and independent specialists.

Document functional limitations in detail: Sun Life often disputes functional limitations (what you can and cannot do) rather than the diagnosis itself. Objective evidence — FCE reports, documented clinical findings, activity restrictions on medical records — is more persuasive than general statements about your condition.

ERISA attorneys: The ERISA claims process is complex. Many disability claimants benefit from ERISA attorney assistance at the appeal stage, before litigation becomes necessary.

Conclusion

Sun Life Financial's disability and group benefits denials can be devastating — particularly for people who have paid premiums for years and are now unable to work. The ERISA appeal process gives you the right to a full internal review, your complete claim file, and ultimately federal court review of Sun Life's decision. Make your appeal thorough — the record you build now is the record a judge will review if you end up in federal court. Use ClaimBack at claimback.app to generate a professional appeal letter for your Sun Life group benefits denial.

---

Related Reading:

• Cigna Claim Denied: Your Appeal Rights
• Aetna Claim Denied: How to Appeal
• How to Write an Insurance Demand Letter
• Can You Sue Your Insurance Company?