Understanding orthotics and orthopaedic shoes (Member)

Understanding orthotics and orthopaedic shoes
When what you don’t know can hurt you

If you have a prescription for custom-made orthotics or custom-made shoes, this guide should help walk you through your purchase. Asking questions and staying informed throughout the process will help ensure that your orthotics or shoes meet your needs. Your extended health care benefit helps cover:

  • Custom-made orthotics
  • Custom-made shoes
  • Modifications to footwear

Let’s take a closer look at each one…

About custom-made orthotics

An orthotic, a corrective device worn inside a shoe, can help the muscles, tendons and bones of your feet and lower legs function at their highest potential. Custom-made orthotics are manufactured from a 3-D image of your foot using raw materials. When appropriately prescribed to treat a medical condition and custom-made, orthotics can decrease pain, not only in your feet, but in other parts of the body, such as your knees, hips and lower back.

What to expect during your assessment
Once you have a prescription for custom-made orthotics, your next step is an appointment with a qualified foot care specialist. Your provider guides you through an extensive evaluation to ensure orthotics are the best option and that they’re properly designed for you.
During your initial assessment, your provider documents your medical history, symptoms and previous injuries, and takes into account your lifestyle and typical footwear.
During your examination, your provider observes:

  • Your overall posture
  • The structure, alignment, strength and range of motion of your legs and feet
  • Your presenting symptoms and condition
  • Your current footwear for fit, wear patterns and function.

During your gait analysis, your provider observes how you walk; identifying any existing accommodations or abnormalities.

Based on your assessment, your provider discusses your treatment options and explains how the treatment will help meet your specific needs.

In order to create true custom-made orthotics, your provider needs a 3-D cast that captures the exact contours of your feet in their ideal functional position. Approved casting techniques include foam box casting, plaster slipper casting, wax molding, contact digitizing and laser/optical scanning. Making a footprint on an ink pad, recording your shoe size or walking over a pressure plate doesn’t qualify, since none provide the information needed to create custom-made orthotics.

Manufacturing your orthotics will likely take a week (or longer), since authentic custom-made orthotics are created entirely using raw materials based on your 3-D cast.
When your orthotics are ready, your provider schedules a dispensing appointment. This is to ensure your orthotics fit you and your footwear.

Your provider will conduct another gait analysis while you’re wearing your new orthotics. Your provider should have the ability to modify your orthotics onsite, in order to ensure maximum comfort and function

Good patient education includes discussing how your orthotics should feel, how to break them in, when you should wear them, how to take care of them and your options if you’re not satisfied.

Your provider should conduct a follow-up call or appointment four to six weeks later to see how you’re doing.

What’s covered?
To be eligible for coverage under your plan your custom-made orthotics must be:

  • Custom-made using raw materials, created from a three-dimensional cast of your feet.
  • Prescribed by a specific health care professional – a doctor, chiropodist or podiatrist - as a medically-necessary treatment for a foot condition. Note: Some plans allow other health care practitioners to prescribe. Please refer to your employee booklet for details.

We also recommend that your orthotics are provided or dispensed by a foot care specialist – for example, a podiatrist, chiropodist, pedorthist or orthotist - specially-trained to assess, design, manufacture, and fit orthotics and footwear.

What’s not covered?
Some examples:

  • Orthotics or orthopaedic footwear purchased for convenience or general comfort only
  • Commercially-made products sold over-the-counter in pharmacies or other retail stores, such as cushioned heel cups or insoles
  • Orthotics for sports or recreational activities only
  • Discounted orthotics or orthopaedic shoes

What to watch for when buying orthotics
Avoid purchasing orthotics in the following scenarios:

  • Temporary situations like home or trade show exhibits, kiosks or health booths in malls or department stores
  • Online
  • As part of a group
    Some ‘dispensers’ hold mass screenings at work or home, offering orthotics to entire families or groups without properly evaluating each person.
  • For young children
    Orthotics for children under age five aren’t common, since many skeletal or soft tissue injuries that require treatment with custom-made orthotics don’t present in young children. Only medical doctors and pediatric specialists are able to prescribe this type of early treatment.
  • As part of a special deal or discount offers
    This is a sure sign something isn’t right. Providers who are eligible dispensers under your plan aren't allowed to offer deals under their code of ethics. Examples include offers of ‘free shoes with the purchase of orthotics’ or ‘two-for-
    the-price-of-one’ deals.

About custom-made shoes
Custom-made shoes are built ‘from the sole up’ using 100% raw materials to accommodate severe foot abnormalities. Although the reasons for needing custom-made shoes are diverse, there are three main categories based on medical necessity:

  • A congenital deformity is a structural deformity present at birth. For example, someone born with a deformed or missing limb.
  • A traumatic injury to one or both of your lower limbs, caused by a car accident, for example.
  • A disease process that affects one or both feet. For example, an amputation required due to diabetes or a significant bony deformity caused by arthritis or osteomyelitis.

What’s covered?
To be eligible for coverage under your plan your custom-made shoes must be:

  • Custom-made using raw materials, created from a custom-made ‘last’ of your foot. A last is an accurate three-dimensional model of an individual’s foot and ankle designed from a 3-D cast of the person’s foot. The shoe is built around this last from patterns reflecting its true individual design.
  • Prescribed by a specific health care professional – a doctor, chiropodist or podiatrist - as a medically-necessary treatment for a foot condition. Note: Some plans allow other health care practitioners to prescribe. Please refer to your employee booklet for details.

We also recommend that your custom-made shoes are provided or dispensed by a foot care specialist – for example, a podiatrist, chiropodist, pedorthist or orthotist.

About orthopaedic shoes
In many cases, foot conditions can be treated with off-the-shelf or stock footwear designed with specific features such as extra depth or extra wide widths for example. These shoes are mass produced, not custom-made.

What’s covered, what’s not
Although your plan doesn’t cover the cost of off-the-shelf orthopaedic shoes, it may help cover:

  • Custom-made orthotics placed within orthopaedic shoes
  • The cost of modifying off-the-shelf orthopaedic shoes, when medically-necessary and prescribed and modified by a qualified specialist. Examples include shoe lifts or extensions for someone with one shorter leg.
Examples of qualified specialists
Prescribers: Providers:
  • Physician
M.D.
  • Podiatrist
D.P.M.
  • Podiatrist
D.P.M.
  • Chiropodist
D.Ch. or D Pod M
  • Chiropodist
D.Ch. or D Pod M
  • Pedorthist
C.Ped. (C) or C Ped MC
   
  • Orthotist
C.O. (c) or CPO (c)
Did you know?
These health care professionals are licensed and governed under either provincial or national organizations. As such, they are subject to standards of practice and codes of ethics, which helps ensure both their accountability and your protection.

What to do when you have a claim

  • Complete a Sun Life Financial Extended Health Care claim form. You can get a claim form on our Plan Member Services website or through your benefits administrator.
  • Include a copy of your prescription, which should indicate the medical condition for which the orthotic, custom-made shoe or orthopaedic shoe is being prescribed.
  • Attach your original detailed receipt showing that the products have been paid in full and received.

Know your coverage
If you have access, visit our Plan Member Services website (sunlife/member.ca) or refer to your employee booklet to confirm your coverage details: from what’s covered, the percentage you’re covered for, and any limits that apply, such as a yearly maximum. You can also confirm if your plan accepts prescriptions from any other health care professionals. For example, some plans accept prescriptions from chiropractors, while others don’t.

Questions?
Talk to your benefits administrator or call our Group Benefits Customer Care Centre at
1-800-361-6212.