FAQs about Claims

In order to make the medical and dental claims process less mysterious, we've provided answers to some basic questions about claims*. If you have other questions or need more information about medical and dental claims, send us an e-mail.

*Answers may vary according to your plan.

Am I covered for...?
Have I got enough out-of-country coverage?
How do I submit a claim?
Where do I send out-of-country claims?
What is the turnaround time for processing claims?
How are out-of-country claims processed?
How do you calculate refunds?

Am I covered for...?

Look in your Employee Benefits Booklet to check what items you are covered for. It tells you all about the benefits available through your employer's group benefits plan with us. If you're still not sure about an item, ask your plan administrator.

Have I got enough out-of-country coverage?

Your employer's plan may include an out-of-country benefit, but does it give you adequate coverage? Check for several things, including:

Does the plan cover emergency travel assistance services, such as a 24-hour hotline and emergency medical evacuation?
Are your spouse and children covered too?
Is there a time limit? For example, some plans cover you for 60 days.
Are there any other limitations, e.g. a dollar maximum or pre-existing conditions?

If in doubt, check with your plan administrator. Depending on your needs, you may need to buy additional travel insurance.

How do I submit a claim?

Obtain a claim form from your plan administrator or download a personalized copy from Plan Member Services at www.sunlife.ca/member. Complete the form, sign it and remember to enclose the original receipts. Keep a copy of your claim form and receipts. Submit claim forms by mail or online if it is a dental claim. Your dentist may also submit dental claims on your behalf.

Check the deadlines in your plan for submitting health and dental claims. For most plans, we must receive your health and dental claims by 90 days after the end of your benefit year or 90 days after your coverage ends, whichever is earlier.

Where do I send out-of-country claims?

If you have an out-of-country claim for a doctor's bill, should you send the claim to your provincial health plan first, or to us? Answer: send your claim to us. Our travel assistance providers will coordinate your claim with your provincial plan, any other carriers, and us.

What is the turnaround time for processing claims?

The answer depends on the type of claim and how it is submitted:

Drug purchases made using Pay-Direct drugs and dental claims submitted electronically via EDI (electronic data interface) are processed on the spot. You do not incur out-of-pocket expenses for the portion of the cost covered by your employer's plan.
Routine medical and dental claims sent on claim forms usually take three to five working days from the day we receive them. More complex claims usually take longer.
For most out-of-country claims, you should receive a cheque within four weeks of mailing the claim.

How are out-of-country claims processed?

If you have out-of-country coverage and send us a claim upon returning home, this is what happens:

We courier out-of-country claims to our provider, Europ Assistance, in Washington, DC.
Europ Assistance confirms coverage, and if appropriate, contacts the medical provider to obtain a discount.
If the expense is partly covered by a provincial health plan, Europ Assistance sends an authorization form to you for your signature, to authorize direct reimbursement from the province.
Europ Assistance submits a claim to the provincial health plan on your behalf.
If you have additional coverage, Europ Assistance coordinates the claim with the other carrier.
Europ Assistance adjudicates the claim and mails a cheque to you.

Note: The above does not apply to claims received from federal government employees covered under the Public Service Health Care Plan, whose out-of-country claims are handled by World Access of Canada.

How do I calculate refunds?

If you submitted a claim, but the cheque you received from us was less than what you calculated, the Claim Statement (Explanation of Benefits) sent with the cheque shows how the refund was calculated. The reasons for the refund being less than your claim could include:

Your plan may have a deductible. This is the amount of eligible expenses you must pay before your plan begins paying benefits for the year.
Your coverage may include "co-insurance." This means your plan covers a percentage of an eligible claim after deductibles, and you are responsible for the balance. For example, some plans pay 70 per cent of eligible expenses and employees pay the remaining 30 per cent themselves.
Payment for some expenses may be limited in the contract to a specified amount.
Dental costs are paid according to the Dental Association fee guide specified in your plan. When dentists charge more for a procedure than the amount in the fee guide, the difference is not covered.