A Claims System Built to Last

In today’s environment, what challenges do employees and employers face with administering benefits?

Employers want benefits to be easier. Tasks like managing disability and absence require constant monitoring of extensive data. Often with one health event, there is a host of paid benefits that a member is entitled to receive, such as disability and hospital indemnity or paid family and medical leave, as well as unpaid benefits like federal or state and local leave programs. For the employee, who may be filing a claim for the first time, it can be daunting. I remember when I had a baby—and I work in this industry—feeling unsure and wondering, “OK, what do I do? How am I going to get paid?” Employees and employers will have questions throughout the process.

How does Sun Life use technology to address these challenges?

Our claims capabilities are built to last. We have a modern, single-source claims system that enables consistent communication with members and integrates claims data so that members automatically receive additional benefits they may be eligible for, without having to file separate claims.

We build APIs that automate the transfer of employee data between Sun Life and our clients’ HR platforms, such as Workday. Managing this data is typically a manual task for HR that can take significant time, but real-time APIs facilitate the dataflow quickly and seamlessly.

What challenges do employers and members face in accessing healthcare for diseases such as cancer or even mental health issues?

People have a difficult time navigating the healthcare system. Even after diagnosis, people might want a second opinion or need help finding medical specialists. Provider shortages and costs have also created an access bottleneck—for mental health as well as physical health.

When you think about someone with a cancer diagnosis, put yourself in their shoes. They are thinking: “What’s going to happen? What do I do next?” In addition to trying to manage their treatment, they are likely experiencing anxiety, stress, and depression. They may be too overwhelmed or not have time to schedule a therapist visit. Mental health issues also still carry stigma, especially in the workplace, making it harder for people to seek care or even recognize when they need help.

How does today’s employee benefits environment compare to the recent past?

There are newer benefits like state-mandated or optional paid leave, more conditions covered by supplemental health plans, newer technologies, and more health services embedded in core benefits.

We’re utilizing AI—not to make claims decisions, but to drive efficiencies that give our analysts space to make their claims decisions and support members.

We offer virtual behavioral health therapy, at no additional cost, to members receiving disability or critical illness benefits for cancer. We also offer virtual health programs for those on disability with musculoskeletal conditions or long COVID.

To improve access to care, we provide healthcare navigation services that help people find the right providers for their specific needs. This model is designed to help improve health outcomes and drive down the cost of care. As we look to make benefits easier, we look to make health easier, too.

What barriers do employee benefits brokers face in helping address these challenges?

Brokers need to be savvy and understand how technology solutions drive the benefits experience. They must keep up with the evolving paid leave landscape and the ongoing challenges with healthcare access. It’s also important to communicate value as part of the cost discussion and to keep up with the benefit trends that will help their clients recruit and retain talent.

What is Sun Life doing to help overcome those barriers?

We are a strong partner to brokers in helping them stay informed and we keep up with the topics that are top of mind for our broker community. We educate on connectivity and newer API functionality, as well as compliance topics to help reduce employers’ risk. We regularly host webinars to communicate best practices and potential changes in claim and utilization patterns. We also distribute research, white papers, and other materials to help our brokers stay ahead of the curve.

Why is the job of claims examiner still important in the changing benefits landscape?

I started in this industry as a claims examiner, so I have experienced the rapid pace of change. Especially in the areas of absence, disability, and health, claims examiners, nurses, and vocational rehabilitation consultants are continuously upskilling. Yet they still maintain compassion. I call it “bringing it back to basics.” When someone has filed a claim, they are going through something big, whether they just had a baby or are experiencing a traumatic health event. I am always touched by the empathy I hear in claims conversations. These wonderful professionals truly embrace that human element that goes hand-in-hand with taking care of people.