GROUP INSURANCE
Claim adjudication
guidelines for the extended
healthcare benefit
INTRODUCTION
Claim form
This document outlines the claim guidelines to be followed
under your policy. It also specifies the documents that must be
submitted for healthcare claims for the following products
or services:
When submitting claims for these types of services, use the
Claim for Healthcare Benefits form – the same form used for
drugs, or other health claims. This form is available on our
website at desjardinslifeinsurance.com and on our plan
members’ secure website.
A. Orthotics and orthopaedic shoes
B. Compression stockings
A. Orthotics (podiatric ortheses)
and orthopaedic shoes
C. Orthopaedic braces
D. Health professionals
E. Vision
Useful definitions
“Orthopaedic shoes” refers to custom-made shoes.
“Off-the-shelf shoes” refers to prefabricated shoes.
“Footwear modification” refers to permanent modifications
made to shoes, for example:
• scaphoid support
• arch support
Under your insurance contract:
To be eligible, all expenses must have been incurred as a result
of illness, pregnancy or an accident, and cover care that:
• is medically necessary1 to treat the insured person,
• metatarsal insole
• is generally provided for an illness or injury of similar type or
seriousness, and
• plantar arch support
• unless otherwise indicated, was on the prior
recommendation of the attending physician.
The following documents are required when submitting a claim
for podiatric ortheses or orthopaedic shoes:
Reasonable and customary fees
From your physician/practitioner:
Reasonable and customary fees are the expenses that are
normally charged in the area where the treatments and
services are rendered. These fees are based on suggested retail
prices and revised annually.
1. Original recommendation/referral from the prescribing
physician, podiatrist, or chiropodist2, including the diagnosis
that necessitated the podiatric orthesis or orthopaedic shoes.
Reasonable and customary limits are always applied when a
claim is abnormally high compared to other claims for the
same service in the same area.
NOTE: Podiatric ortheses and orthopaedic shoes must
be prescribed prior to the date of purchase, and the
recommendation must be recent.
Chiropodist recommendations are only accepted outside Quebec, where
the profession is regulated.
2
Predetermination of benefits
From the supplier:
When the total cost of any medical equipment or proposed
treatment (medical or dental) is expected to exceed $500,
we recommend that you submit a detailed treatment plan
before purchasing the equipment or beginning the treatment.
2. Original receipt with provider’s name and address, date the
provider received the podiatric orthesis or the orthopaedic
shoes, patient’s name, and breakdown of the cost of
the podiatric orthesis or orthopaedic shoes.
Simply fill out section A of the claim form, sign it and attach
the treatment plan, which must include a description of the
equipment to be purchased or the treatments to be provided,
the expected treatment dates, the cost of the treatments or
equipment and the name and qualifications of the healthcare
provider or supplier. Any other relevant information (such as
medical recommendation and diagnosis) should also be
submitted with the treatment plan.
3. The date you picked up your orthotics or orthopaedic shoes.
Mail the treatment plan and the form to the address that
appears on the form.
Requests are usually processed within five working days.
We then advise the member in writing of his or her eligibility
for reimbursement.
4. Confirmation that the podiatric orthesis or orthopaedic shoes
have been paid for in full.
5. Copies of the biomechanical examination and gait analysis
reports, both dated and signed by the health professional.
NOTE: The examination must be performed by a health
professional who is a member in good standing of a
provincial or Canadian professional association recognized
by Desjardins Insurance. The examination must be within
the scope of the professional’s abilities and recognized field,
and it must have been performed by the specialist identified
on the receipt.
6. Complete description of the process used to create the
podiatric orthesis or orthopaedic shoes, including the casting
technique and the raw material used.
1
“Care that is medically necessary” refers to a service or item that is recognized
by the Canadian medical profession and considered to be effective, appropriate
and necessary by their form, intensity, duration and frequency for the diagnosis
or treatment of a disease or injury.
NOTE: Only techniques using a three-dimensional (3-D)
image or unique 3-D cast impression of the feet using a raw
material are eligible.
7. Copy of manufacturing lab invoice with:
• patient’s name
• qualifications/credentials, including name, address and
telephone number of the laboratory
• date provider placed order and date of delivery
to provider
• type of orthotic
For claims for footwear modifications, a receipt detailing
the cost of the modification(s) is required as well as the
documents previously listed.
NOTE TO PLAN MEMBERS IN QUEBEC: Under Quebec
legislation, plan members in that province are not required to
submit the documents in points 5, 6 and 7, but they may be
required to do so after submitting a claim for foot orthotics
or orthopedic shoes.
Reasonable and customary fees may apply.
The brace must be constructed of rigid material, such
as metal or plastic. Elastic supports are not eligible.
A brace or orthosis exclusively used in the practice
of a sport is not eligible.
Purchase vs. rental: if you decide to rent an apparatus or device,
an estimate and the duration of the rental will be required. The
maximum amount payable will be limited to the purchase price.
The rental cost can never exceed the amount you would have
paid had you purchased the apparatus or device.
D. Health professionals
The following documents are required when submitting a claim
for a health professional’s services:
1. Original receipt with:
• Patient’s name, date of treatment, amount
per treatment.
B. Compression stockings
• Professional’s name, qualifications, address, professional
association and registration number.
The following documents are required when submitting a claim
for compression stockings, also known as support stockings:
1. Original recommendation/referral from the prescribing
physician, including the compression strength and the
diagnosis that necessitated the compression stockings.
NOTE: For the purchase to be considered legitimate,
the recommendation must be recent.
2. The original receipt.
3. The compression strength.
4. Confirmation that the compression stockings have been
paid for in full.
NOTE: The professional must be a member in good
standing of a provincial or Canadian professional
association recognized by Desjardins Insurance.
2. Physician’s referral including the diagnosis, when required.
3. Confirmation that the treatments have been paid for in full.
The treatment must be within the scope of the professional’s
abilities and recognized field, and it must be provided by
the specialist identified on the receipt.
Reasonable and customary fees may apply.
Reasonable and customary fees may apply.
E. Vision
C. Orthopaedic braces
The following documents are required when submitting a claim
for orthopaedic braces:
1. Original recommendation/referral from the prescribing
physician, including the diagnosis that necessitated
the orthopaedic brace.
NOTE: For the purchase to be considered legitimate,
the recommendation must be recent.
2. The original receipt.
3. Confirmation that the supplies have been paid for in full.
Reasonable and customary fees may apply.
NOTE: For the purchase to be considered legitimate,
the recommendation must be recent.
The following documents are required when submitting a claim
for vision care:
1. Original receipt.
2. The date you picked up your glasses or contact lenses.
3. Confirmation that the services have been paid for in full.
4. Copy of the prescription may be required (if purchased on
the Internet a copy of the prescription is required).
NOTE: For the purchase to be considered legitimate,
the recommendation must be recent.
Reasonable and customary fees may apply.
General guidelines
Please note the following practices in the processing of
all claims:
For your protection, be vigilant and apply
the following precautions:
• Check all receipts and insurance statements for accuracy.
• Please refer to your booklet to determine the eligible fees
and the specifics of your insurance.
• Do not accumulate your claims until they add up to a
significant amount. Submit your expenses as they are incurred.
• Always attach your original receipts and all of the other
required documents to your claim form and keep copies
for your files. The original copies will not be returned.
• Never sign a blank form—a service provider could use it to
charge for services you didn’t receive.
• In accordance with the rules and regulations of the
majority of health professional associations, services
provided by a family member are not eligible for an
insurance claim (dentists’ services are an exception).
• In certain cases, proof of payment may be required,
such as:
–– debit card receipt or statement (bank statement)
–– credit card receipt or statement
–– copy of a cashed cheque (front and back)
NOTE: Receipts stamped “Paid” by the provider, generic
off-the-shelf receipts and handwritten receipts are not
acceptable as proof of payment.
• Your health professional’s medical reports, clinical charts or
documented explanations may be required to assess the
medical necessity of the expenses.
• Beware of providers who encourage you to purchase supplies
for your entire family (orthopaedic shoes, orthotics, stockings,
dental services) BEFORE they have assessed each family
member’s medical needs. Proof of medical diagnoses for each
member of your family is required before any item can be
approved for purchase.
• Prescribers and providers must be licensed in their province of
residence and registered with their professional association.
Look for proper designations in their titles:
–– physician – MD
–– podiatrist – D.P.M.
–– chiropodist – D.Ch. or D.Pod.M.
• Never submit claims before receiving and paying for the care.
Under your contract, you must pay for the services before
submitting a claim.
• A symptom is not acceptable as a diagnosis. For example:
–– “pain over heel area” is a symptom and cannot be
accepted as a diagnosis
–– “plantar fasciitis” is a diagnosis
Receipts with modifications or added information
will be declined.
If any information is missing, you or the supplier will be asked
to provide it before the claim can be processed.
Please note, any cost for obtaining this information will be
the responsibility of the patient.
Upon receipt of this information, we will review and process the
claim accordingly.
Desjardins Insurance has been offering a wide range of life
and health insurance and retirement savings products to
individuals, groups and businesses for more than a century.
As one of Canada’s five largest life insurers, it oversees
the financial security of over five million Canadians from
offices across the country. Desjardins Insurance is part
of Desjardins Group, the country’s leading cooperative
financial group.
Questions
Feel free to get in touch with our Customer Contact Centre if you’d like
more information about the documents required by Desjardins Insurance or
to confirm whether a healthcare professional, specialized medical centre or
medical device is eligible. Our representatives can also help you figure out
how much you can expect your benefit payment to be and help you with
any other questions you may have.
Visit our website:
desjardinslifeinsurance.com
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Financial Security Life Assurance Company.
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