If your long-term disability (LTD) claim has been denied by Sun Life, one of the most critical parts of the appeals process may involve an “independent” physician review. While this may sound like an objective second opinion, the process is often anything but neutral. In reality, these reviews can be a significant hurdle in securing your benefits—especially if you don’t know how to respond effectively.
This article breaks down how Sun Life uses independent physician reviews during appeals, the questions these physicians are asked to answer, and what claimants can do to challenge unfair or inaccurate conclusions.
Why Sun Life Uses Independent Physician Reviews
When you appeal a denied claim, Sun Life typically brings in an outside physician to review your medical file. These reviewers are hired by Sun Life—not your doctor, and not an impartial third party. Their job is to evaluate whether your documented symptoms and medical records support functional limitations that would prevent you from working.
These doctors never meet with you in person. They rely solely on your medical records, internal claim notes, and any statements from your treating providers. Their report can have a major impact on whether your claim is approved or denied.
What Is Sun Life’s Doctor Looking For?
When Sun Life sends a claim for an independent medical review, the referral forms include specific questions to guide the physician’s review. These typically include:
- Can the claimant return to full-time work? The reviewer is asked to consider all of the claimant’s conditions—individually and in combination—and determine whether they preclude full-time work under the physical demands of the claimant’s job.
- What specific activities, if any, is the claimant unable to perform? This includes walking, standing, concentrating, lifting, or other essential functions associated with the claimant’s occupation.
- What is the prognosis for improvement and return to full-time work activities? The examiner is asked to evaluate the likelihood that the claimant’s condition will improve to the point where the claimant can return to full-time work.
- Has there been a significant change in the claimant’s condition? The reviewer must evaluate whether there’s clinical evidence of a functional decline compared to previous periods when the claimant was still working (even with accommodations).
- Are the reported symptoms and limitations consistent with the objective medical evidence? For example, if a claimant reports disabling fatigue or cognitive dysfunction, but their examinations consistently show them alert and oriented with no abnormal neurological findings, the reviewer may conclude that there’s a “disconnect.”
- Do you agree with the treating provider’s restrictions? Examiners are expected to analyze whether the treating physician’s restrictions are too lenient or too restrictive based on the complete medical record.
If the reviewing physician disagrees with the treating provider, Sun Life asks that the reviewers attempt to contact the treating provider to discuss the differing opinions. This is called peer-to-peer communication.
The Peer-to-Peer Communication Process
This “peer-to-peer” process is intended to resolve disagreements, but in reality it’s often ineffective. Providers may be too busy to take the call, or office staff may redirect the reviewer to fax over questions instead. If the treating physician doesn’t respond—or doesn’t respond with enough detail—Sun Life may rely entirely on the examiner’s opinion.
Are These Reviewers Truly Independent?
Although Sun Life calls these reviews “independent,” the reality is more complicated. The doctors are selected and paid by Sun Life. While their reports include disclaimers claiming impartiality, their financial relationship with the insurance company raises concerns about neutrality.
In practice, some independent reviewers tend to favor conclusions that minimize functional impairment, especially when objective findings are lacking. These conclusions often rest on the absence of specific diagnostic tests rather than a holistic view of how symptoms affect real-world function.
How to Respond to a Sun Life Review
If you receive a copy of the independent physician review during your appeal, take it seriously. These reviews often serve as the backbone of the insurance company’s denial decision, so how you respond can make or break your claim.
Here’s what we recommend:
- Share the report with your treating physicians. Ask them to prepare a detailed letter or statement responding to each issue raised in the review. It’s important that they address any disagreements with the reviewer’s interpretation of your medical records or restrictions.
- Provide additional medical evidence. If the examiner claims there is no objective support for your symptoms, consider providing functional capacity evaluations (FCEs), neuropsychological testing, or updated imaging and lab work to support your limitations.
- Explain how your condition affects your daily life. This is especially important for conditions with fluctuating symptoms, such as long COVID or post-viral fatigue syndrome. A personal statement or even a log of symptom patterns can help demonstrate the real-world impact of your condition.
- Address “normal” findings directly. Many reviewers claim there’s no impairment because exams show the claimant to be “alert and oriented” or in “no acute distress.” These observations often miss the bigger picture, such as the fact that fatigue or dizziness can flare up unpredictably or after only brief activity.
Example: Challenging an Unfavorable Review
One of our clients—a software engineer in his early 40s—applied for LTD benefits from Sun Life after developing disabling symptoms following a COVID infection, including postural tachycardia, dizziness, fatigue, and cognitive dysfunction. Despite detailed records from several specialists, Sun Life’s reviewing physician concluded that he could return to full-time light-duty work.
The review emphasized that his physical examinations were “normal,” that he had not undergone cognitive testing, and that there were no abnormal objective findings to support impairment. The reviewer dismissed his treating provider’s restrictions as overly conservative and unsupported.
With our help, the client gathered additional documentation from his specialists and obtained updated statements that directly refuted the reviewer’s conclusions. His treating provider emphasized that the physical exams were not designed to measure the functional limitations associated with autonomic dysfunction and cognitive fatigue. We also provided evidence of medication side effects, the impact of activity on symptoms, and a symptom diary that tracked his attempts to resume daily tasks.
By presenting a cohesive and medically supported rebuttal, we were able to demonstrate that the reviewer’s opinion did not accurately reflect the reality of our client’s limitations. Our appeal was ultimately successful.
RELATED POST: Responding to Peer Review Reports In Long-Term Disability Appeals
How the Ortiz Law Firm Can Help
At the Ortiz Law Firm, we have helped clients across the United States successfully appeal long-term disability denials from Sun Life and other major insurers. We understand how these independent medical reviews work, and we know how to fight back when an examiner minimizes or dismisses your symptoms.
Our team works directly with your treating providers to gather strong rebuttal evidence and build a compelling appeal package. We understand the medical and legal nuances that make or break LTD appeals, and we’re here to help you get the benefits you deserve.
If your long-term disability claim has been denied by Sun Life, don’t face the appeals process alone. Call the Ortiz Law Firm at (888) 321-8131 for a free case evaluation and let us help you recover the benefits you deserve.
