Sun Life Financial review: Group insurance

I hope this letter finds you well. I am writing to express my dissatisfaction with the way my recent medication claim was processed under my insurance policy contract #160888. This letter serves as a formal complaint regarding the coordination of benefits and the payment discrepancy for my prescription medication, Diclofenac.

On September 11th, 2023, I submitted a claim dated September 7th 2023 claim #110923-BDu65-00 for the prescription medication Diclofenac, which cost $44.84. As per my policy with your company, I was expecting a reimbursement of $7.18, which represents the insured benefit plan's copayment coverage. However, I was reimbursed $0, which has happened previously and was brought to your attention. The explanation provided in the standard Explanation of Benefits (EOB) note S06 states:

"We have assessed your claim for the amount the other plan did not cover. However, we cannot pay this amount in full because your plan has a limit for these types of expenses. We were therefore able to cover the unpaid amount only up to that limit, and you are responsible for the remaining balance."

I must express my deep concern and dissatisfaction with this explanation. This situation has occurred more than once, and it is not acceptable. I find it unjust and unreasonable that the insurance company is not paying the full amount as per the insured benefit plan. The purpose of having insurance is to provide financial protection and assistance when medical expenses arise. The insurance policy is designed to coordinate benefits effectively and cover up to 100% of the costs, and not to exceed it, particularly for necessary medications.

I kindly request a thorough review of this situation and a prompt resolution. It is crucial that insurance companies uphold their commitments and fulfill their obligations to their policyholders. I expect a fair and accurate assessment of my claims, as outlined in my policy, without any arbitrary limitations or restrictions.

I would appreciate your immediate attention to this matter and a clear explanation of the reasons behind the discrepancies in my claim reimbursements. Please provide a detailed response outlining the steps that will be taken to rectify this issue and ensure that similar situations do not occur again in the future.

I expect to hear from your office within 10 business days of receiving this letter. If I do not receive a satisfactory response or if my concerns are not adequately addressed, I may have no choice but to escalate this matter to the appropriate regulatory authorities and seek legal counsel.

Thank you for your prompt attention to this matter. I look forward to a swift resolution and a continued positive relationship with your company.

Sincerely,

Selwyn Pais

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