Article 10: Additional Benefits (Medical Body Scan and Specialized Footwear) >>

10.2 Specialized Footwear Benefit

The Plan provides benefits for specialized footwear, sometimes known as “orthotics.” The annual benefit of $400 may be used to defray the costs of consulting with a certified orthotist or other provider certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics and the cost of fabricating and fitting the specialized footwear. Specialized footwear includes orthopedic shoes and custom-made, rigid plastic or polypropylene inserts for the shoe. This benefit is available to all eligible Participants and eligible dependents enrolled for medical benefits under the Plan. Participants enrolled in the Kaiser Permanente HMO Plan may utilize this benefit or they may choose to obtain orthotics through Kaiser Permanente.

“Eligible Expenses” subject to reimbursement shall include expenses for the professional services provided by an orthotist, prosthetist, pedorthist or other provider certified by the American Board for Certification in Orthotics, Prosthetics and Pedorthics when professional services are in connection with the treatment of foot disfigurement. For purposes of this benefit, foot disfigurement means foot disfigurement resulting from cerebral palsy, arthritis, polio, spina bifida, diabetes, accidental injury or abnormal condition.

A. Eligible Services

Eligible services for specialized footwear shall include the cost of fabricating custom-made rigid (plastic or polypropylene) foot orthotics (shoe inserts) and/or custom-made standard orthopedic shoes.

B. Maximum Annual Benefit

The maximum annual benefit payable per eligible Plan Participant and eligible dependents for eligible expenses incurred for the procurement of specialized footwear shall be $400.

C. Submission of Claims

Claims for eligible expense reimbursement under this provision shall be submitted to Coast Benefits Inc at:

Coast Benefits, Inc.
3444 Camino Del Rio North, Suite 101
San Diego, CA 92108

Claims must include the name and address of the provider, the date services are rendered, the diagnosis or condition being treated, and an itemized listing of services rendered. Reimbursement shall be made directly to the Participant or Member and not to the provider.

D. Exclusions

No benefits shall be provided under the terms of this provision for:

1. Dress shoes;
2. Casual shoes (e.g., tennis shoes or deck shoes);
3. Shoe inserts (except as provided above);
4. Foot pads;
5. Foot orthotics that are fabricated from soft plastic, cork or leather;
6. Socks or any supplies that are not custom-made or of which the equivalent can be purchased without prescription; or
7. Services provided to Participants that do not suffer from foot disfigurement as defined above under “Eligible Expenses”.