They have a list of exceptions for claims to deny automatically
by John on Jan 3, 2025
2 out of 5 stars
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Per the rep I talked to, for dental insurance that I have, there's a list of like 200 claims that are automatically “downgraded” to be whatever Sun Life wants them to be. For example, my dentist did vertical bite wing X-rays and billed for that — Sunlife decided to only pay out for regular bite wing X-rays, and I was left with the remaining balance. This list is nowhere in my EoB and isn't on their site. My EoB says bite wing X-rays are covered twice a year during routine appointments. So they, the insurance company, will decide whether or not your dentist is allowed to bill for a certain procedure performed and then if the dentist doesn't agree, Sunlife will simply just say “we don't care” and pay for the procedure they think should've happened instead. It's essentially fraud, members aren't aware of this mystical list of exceptions and is never mentioned during open enrollment period. It exists so they can deny claims and take in more of your money while paying out less to the doctors.