PROSTHETIC APPLIANCE BENEFIT

Who Is Eligible

All covered members and their eligible dependents (family coverage) are entitled to this benefit.

What Is The Benefit

The Fund will provide coverage for prosthetic appliances when such appliances are covered by the City health insurance you have selected. You should be aware, however, that the prosthetic appliances covered by the various health plans are not identical, and that the Fund’s payment is coordinated with your particular plan.

For those appliances covered by your City health plan, reimbursement by the Fund is coordinated with the rules and regulations of that plan. Under coordinated reimbursement, the Fund covers your health plan’s initial annual deductible, and 20% of the customary and usual costs for the covered prosthetic appliance. Reimbursement under all City health plans usually covers 80% of your cost after the annual deductible has been met.

Generally included for coverage, when prescribed by your physician, are the purchase, rental and repair of hospital beds, wheelchairs, trusses, artificial eyes and limbs, orthopedic appliances, diathermy equipment, orthopedic shoes, etc. Prosthetic shoes, when qualified for payment, are limited to two pairs per calendar year. If you have any questions as to whether a prosthetic appliance is covered, please contact the Fund Office.

Also covered under the Prosthetic Appliance Benefit are physician-prescribed hair prostheses (wigs) for any member or eligible dependent who suffers hair loss as a result of chemotherapy or radiation treatments. The Fund will pay up to $75 in out of pocket expense every two calendar years toward the costs for such wigs.

The Fund’s maximum payment is $2,500 for each covered member and for each eligible dependent during the calendar year. However, if both spouses/domestic partners are covered members, the Fund’s maximum payment is $5,000 for each covered member and each eligible dependent during the calendar year.

Covered members who have only basic coverage under certain City health plans are not eligible for reimbursement from their medical carrier; however, when prescribed by a physician, they will be provided with the use of crutches, wheelchairs, walkers and attachments, chair commodes and canes. For those covered members, and for covered members who are not covered by an insurance plan, the Fund will cover 20% of customary and usual costs for the prosthetic appliance, and the member will be responsible for the balance.

Where physician-prescribed orthopedic shoes are not covered by member’s health insurance carrier, the Fund will provide coverage to the member only if it is determined that the shoes or insert or mold for which reimbursement is claimed qualifies as a prosthetic appliance. The Fund may require the services of an orthopedic specialist to determine whether the item qualifies for reimbursement.

 Exclusions And Limitations

The Fund will not pay claims for prosthetic appliances if they have not been prescribed by a physician.

How To Obtain The Benefit

The Welfare Fund’s Multi Benefit Claim Form is used for the Prosthetic Appliance Benefit. This form is available at the Welfare Fund Office and for your convenience claim forms are often available through the Union delegate at your work location or at the Union’s website at www.mightyunion.org.

To apply for the benefit, have the physician complete the appropriate portion of the claim form (or you may attach the physician’s prescription to the claim form). In addition, you must attach the original copy of the bill for the prosthetic appliance to the claim form.