If you have extended health benefits through work, there's a good chance your plan sets aside money for custom orthotics. Many people only learn how that coverage works after a claim comes back denied or short. Knowing how to get orthotics covered by insurance comes down to three things: what your plan pays for, whose prescription it accepts, and what paperwork it wants with the claim.
At Mount Joy Foot Clinic & Orthotic Centre in Markham, our chiropodists walk patients through this every fall, when many people realize their benefits reset in January. Below is what to check, in order, plus a timeline for using your orthotic benefit before year end.
Are Custom Orthotics Covered by Insurance in Ontario?
Often, yes, but not by OHIP. OHIP does not cover custom foot orthotics, so coverage in Ontario comes from extended health benefits: an employer group plan, a spouse's or parent's plan, a retiree plan, or an individual plan you've purchased.
Plans vary a lot. Some pay a fixed dollar amount per pair. Others pay a percentage up to a maximum. One plan might allow a pair every year while another allows one every two or three years, and some plans don't include orthotics at all.
Because of that, the only reliable answer is in your own plan booklet or your insurer's member portal. We can't tell you what a particular insurer will pay, but we can tell you exactly what to ask.
How to Get Orthotics Covered by Insurance: 5 Steps
1. Check Your Plan Before You Book
Log in to your insurer's app or call the member line and ask:
- Are custom foot orthotics covered, and what is the maximum?
- How often can I claim: every 12, 24, or 36 months?
- Does my plan year follow the calendar year, or does it reset on another date?
- Which practitioners can prescribe them: a chiropodist, a podiatrist, a physician?
- Do I need a referral from my family doctor?
- What documents need to go in with the claim?
- Do I need a pre-approval or estimate before the orthotics are ordered?
Write down the answers, the date, and the name of the person you spoke with.
2. Get a Chiropodist Prescription
Most plans want custom orthotics prescribed by a regulated health professional after an in-person assessment. In Ontario, chiropodists are regulated by the College of Chiropodists of Ontario, and our chiropodists both prescribe and dispense custom orthotics.
You don't need a doctor's referral to book with us. Some plans still require one before they'll pay, so if yours does, see your family doctor first and bring the referral to your appointment.
3. Have a Full Biomechanical Assessment
Insurers want proof the orthotics were medically needed and built from an accurate model of your foot. The assessment is that record.
At Mount Joy, the assessment covers your health history, a biomechanical exam, and a gait analysis. If orthotics are the right call, we cast your feet with a 3D laser scanner or plaster of Paris. You can see the full process on our custom orthotics page.
4. Submit Complete Paperwork
Missing documents are one of the most common reasons an orthotic claim gets delayed. Plans often ask for some combination of:
- The prescription
- A summary of the biomechanical assessment
- The casting method used
- A letter from the lab confirming the devices were custom made
- An itemized receipt
Our chiropodists provide the documents your insurer asks for, so check your plan's list and tell us at your visit.
5. Ask About Direct Billing and Second Plans
Some insurers allow direct billing for custom orthotics. Before we direct bill, we need an approved estimate from your insurer, which is another reason to call them early.
If you're covered by two plans, such as your own and a spouse's, you may be able to claim the remaining balance on the second plan. Ask both insurers how they coordinate benefits.
How to Use Your Orthotic Benefit Before Year End
Many group plans run on the calendar year. If yours does and you haven't claimed orthotics yet, that coverage usually won't carry over into the new plan year. Check your plan, since some reset on a different date or run on a rolling 12, 24, or 36 months.
At our clinic, custom orthotics are usually ready for fitting 10 to 14 business days after your assessment and casting. Some plans count the date the orthotics are dispensed rather than the date of your assessment, so ask your insurer which date they use.
If your plan resets on January 1, a realistic schedule looks like this:
- Early November: confirm your coverage and get a referral if your plan needs one.
- Mid-November: book your assessment and casting.
- Late November to early December: your fitting and dispensing appointment.
- December: submit your claim with all your documents.
December appointments fill quickly, and labs slow down over the holidays, so booking earlier gives you room for adjustments.
While you're checking, look at the rest of your foot care benefits too. Many plans list chiropody visits, compression stockings, and orthopedic footwear separately, and a health spending account may cover costs your plan doesn't.
What Custom Orthotics Cost Without Insurance
At Mount Joy Foot Clinic & Orthotic Centre, custom foot orthotics are $575 a pair. That includes the casting (3D laser scan or plaster of Paris), one pair of custom orthotics, and your dispensing appointment.
If you're paying some or all of it yourself, orthotics may count as an eligible medical expense on your tax return. Confirm with your accountant or the Canada Revenue Agency.
Do You Actually Need Custom Orthotics?
Unused benefits shouldn't be the only reason to get orthotics. They tend to help most with ongoing problems like plantar fasciitis and heel pain, flat feet, bunions, and foot changes from diabetes or arthritis.
A good assessment should give you an honest answer. Sometimes a footwear change or a stretching routine is the better first step, and our chiropodists will tell you if that's the case. When orthotics do make sense, we match the type to you: everyday orthotics, sports orthotics, soft accommodative orthotics for diabetes and arthritis, or children's orthotics for growing feet.
Frequently Asked Questions
Does OHIP Cover Custom Orthotics?
No. In Ontario, custom orthotics are covered through private extended health benefits, not OHIP.
Do I Need a Doctor's Referral for Custom Orthotics?
Not to book with our chiropodists, who can prescribe and dispense orthotics directly. Some insurance plans require a physician's referral before they'll pay, so check your plan first.
How Often Will Insurance Pay for New Orthotics?
It depends on your plan. Common limits are one pair every 12, 24, or 36 months. Your plan booklet or member portal will list your frequency limit.
Will My Insurance Cover the Full Cost?
That depends on your plan's maximum and whether it pays a percentage or a fixed amount. Ask your insurer for your exact orthotic maximum before your appointment.
Book Your Orthotic Assessment in Markham
If your benefits reset in January, now is a good time to book. Our team of registered chiropodists includes Suleman Bhatti, B.Sc, D.Ch, who has cared for patients in Markham since 2008 and graduated top of his chiropody class with the Board of Governors' Gold Medal, along with Tooba Shah, D.Ch, Vithusha Yogeswaran, D.Ch, and Felix Yong, Registered Chiropodist.
We're at Swan Lake Plaza, 5 Swan Lake Blvd, Unit 10, and see patients from Markham, Cornell, Unionville, and Stouffville. Book your custom orthotic assessment online or call us at 905-209-8000 and bring your plan details. We'll help you get your orthotics covered by insurance before your benefits reset.
