Waiting period
The waiting period is the length of time you must be continuously dependent before a claim is submitted*. It starts on the date you first require assistance for two or more activities of daily living or the date you first require continual supervision.
*The waiting period doesn't have to be met again when we receive proof you qualify for benefits within 180 days after we stopped paying benefits. The reason for the dependency doesn't have to be the same as for the previous claim.
Palliative care (end-of-life care)
Regardless of the waiting period in your contract, you can submit a claim 30 days after you:
- require substantial physical assistance for at least four activities of daily living.
- have been diagnosed with a terminal disease, or illness by a qualified physician or another healthcare professional acceptable to us; and
- are receiving palliative care that's supportive and provides comfort.
When to make a claim
The policy must be in effect on the date a claim is submitted. The insured person must be continuously dependent for longer than the waiting period, and the conditions described under the heading, how we determine dependency must be satisfied.
A claim may be submitted before the waiting period is satisfied if the insured person is receiving palliative care. This is described under the heading, Palliative care (end-of-life care).
We must receive the claim immediately following the end of the waiting period and no later than 120 days from that date. Any claim received after that time is late and we may decline it without assessing dependency.
We'll consider a late claim exception if:
- we receive the claim no later than one year from the date the insured person became dependent, and
- the claimant provides a written explanation describing why the claim is late and we agree the explanation is reasonable.
How to make a claim
Step 1: Notify us
To make a claim, contact the Individual Claims Services department. We will then send the appropriate claim form to be completed. You can call Individual Claims Services toll free at 1‑800‑800‑4SUN or e‑mail disable@sunlife.com.
The person making the claim must complete the form(s) and give us the information we need to assess the claim.
The insured person must be in Canada or the United States at the time a claim is made.
If they are not, they must return to be assessed by a physician licensed and practicing in Canada or the United States.
Before we approve the claim, the insured person's date of birth must be verified. If the date of birth given on the application is incorrect, we'll adjust the amount we pay to reflect the insured person’s correct age.
Policy premiums must continue to be paid until we notify the claimant that we've approved the claim.
The form(s) and information must be sent to:
Individual Claims Services Sun Life Assurance Company of Canada
227 King St S, PO Box 1601, Stn Waterloo
Waterloo ON
Canada
N2J 4C5
Physicians may charge a fee to complete certain forms. The person making the claim is responsible for any fees for this information.
Step 2: Collection of medical information
The claimant must give us the information we need to assess the claim. This includes our form which must be completed by a physician or another health care professional acceptable to us. The physician must describe the insured person's medical condition, limitations and functional abilities and provide objective medical information about their dependence.
We will tell you if we need any other information to assess the claim. This could include medical records, clinical tests, physiotherapy reports, psychological tests and any other objective medical information that supports the claim. Any fees charged by physicians to complete forms or provide information are the claimant's responsibility.
Physicians, specialists, or healthcare practitioners who provide information to us must be licensed and practicing in Canada or the United States. They may not be the policy owner, insured person, anyone entitled to make a claim under this policy, or any relative or business associate of these people.
We may require the insured person to be examined by any healthcare practitioners that we appoint. These may be licensed physicians, physiotherapists, occupational therapists, psychiatrists, psychologists, or others.
We pay for these examinations.;
We may also require the insured person to authorize us to gather and use information from other insurers or government agencies.
Step 3: Making the claims decision
Once we receive all information we require, we will assess the information and make a decision. We communicate this decision to the claimant and pay the benefit to the policy owner or the estate, if applicable. If we deny a claim, we send a letter explaining the decision to the owner. If the owner and the insured person are not the same person, we will send two decline letters:
- one letter to the insured person, fully explaining our decision, and
- a second letter to the owner, confirming our denial of the claim. No medical information is given to the owner for privacy reasons.
To contact the Individual Claims Services department, use: E‑mail: ltcclaims@sunlife.com
Telephone: 1-800-800-4SUN
Fax: 519-888-2164
Exclusions and limitations
The policy ends and benefits are not payable if the insured person's dependency started before the later of:
- the most recent date an application for this policy was signed,
- the policy date shown under the heading Policy summary, or
- the most recent date this policy was put back into effect if the policy has been reinstated.
We will not pay benefits if the insured person's dependency is directly or indirectly caused by or associated with the insured person operating a vehicle while their blood alcohol level is more than 80 milligrams of alcohol per 100 milliliters of blood. A vehicle includes any form of ground, air or marine transportation that can be put into motion by any means, including muscular power. We do not take into account whether or not the vehicle is in motion.
We will not pay benefits if the insured person's dependency is directly or indirectly caused by or associated with the insured person:
- committing or attempting to commit a criminal offence;
- attempting to take their own life, while sane or insane;
- causing themselves bodily injury, while sane or insane
- intentionally taking any drug other than as prescribed by a licensed medical practitioner and in accordance with the instructions given; and/or
- intentionally taking any intoxicant, narcotic or poisonous substance - this does not include smoking cigarettes, cigarillos, cigars, chewing tobacco or occasional use of alcohol.
We will not pay benefits if the insured person's dependency is directly or indirectly caused by or associated with civil disorder or war, whether declared or not.
We also will not pay benefits when the insured person is outside Canada or the United States for more than eight consecutive weeks. If we've paid beyond the eight consecutive week limitation, we have the right to deduct the overpayment from any future benefits.
Tips for an efficient claims process
- Make sure you understand the claim triggers and that the Client meets the definition of dependence as defined by the contract. This will help reduce ineligible claims, set better expectations for the insured person and reduce potential expenses.
- Verify the waiting period listed in the policy. After the waiting period has been met, complete and submit the claim form
- Make sure the form is complete, signed and dated before you submit it. .
You will need to include:
- the full address (including postal code) of all doctors the insured has consulted, and
- the phone number of all doctors the insured has consulted.
- Verify the insured's date of birth and check it against that listed in the policy.
- It is important that we obtain all medical reports from the physician to support the claim. If the reports are not sent to us, we cannot do a full evaluation and this will cause delays.
