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ORTHOTIC
INSURANCE POLICY AND PROCEDURES
Dear
Patient:
One
way to ensure that your orthotics keep doing the job is to
be certain that if they are outgrown, lost, stolen or in
need of repair, you are not
without them for very long. The Performance Plus Orthotic
Insurance Plan
covers you for a full two years at a cost of $45.00. The
plan is especially
useful for children with growing feet or if Spot decides
to chew up one of
your orthotics! To apply, fill out the application
form that is attached to
the instruction guide that came with your orthotics or print
this document and enclose a check or
money order. (Note: This coverage is only
applicable for four weeks after the orthotics
manufacturing date. Please refer to your original
instruction guide.) There are some cases where
coverage may be denied. See "Cases
Where Coverage May Be Declined" to learn more.
The
Following items are needed when filing a claim:
1.
Your positive casts
2.
Performance Laboratories return address postage paid label
3.
Yellow invoice as proof of insurance
4.
Claim Form
To
request return address labels or claim forms click
here. Request items
that
are needed in the "Additional Comments for the
lab" section.
Outgrowth
Protection: One
prescription change (outgrowth) from a new casting is
available free of charge during your two-year policy.
This does not cover your doctors casting fee and
visit. When
visiting the doctor for a new casting for outgrowth bring
your yellow invoice and have the Doctor write your invoice
# or work order # in the Special
Instructions section on the front of the prescription
form and indicate that this is an outgrowth insurance
policy case.
Required
Adjustments:
Orthotic Adjustments ordered by your doctor are
made without cost to you.
When visiting the doctor for an adjustment bring
your yellow invoice and have the Doctor write your invoice
# or work order # in the Special
Instructions section on the front of a prescription
form and enclose the prescription with the rework ticket
so there will be no charges applied to his account.
This policy does not cover any fees for an office
visit that may be necessary to reevaluate your condition.
All adjustments must be made through your Doctor.
Any adjustments sent directly to the laboratory
will be returned unadjusted to you via UPS COD to cover
mailing costs.
Breakage
and Damage Guarantee:
During normal wear, if your orthotic breaks or sustains damage, we will
make one replacement from your original casts at no charge
providing the orthotics and all broken pieces are returned
to the laboratory with your positive casts.
Include $10 for postage.
See Instructions for Filing a Claim. Does not include deliberately
damaged or broken devices.
All returned devices and pieces will be inspected
for abuse.
Loss
Replacement: If
your orthotics are lost or stolen, we will make
replacements from your original casts at a cost of $30 per
orthotic, or $60 per pair. Plus $10 Postage. A maximum of
three replacement pairs per coverage period is permitted. See Instructions
for filling a claim.
Expiration
of Policy:
You must purchase your policy no later than two
weeks after receiving your orthotics.
If you mail in your application after the two-week
grace period we reserve the right to refuse coverage and
return your payment.
Outgrowth:
After a claim has been made for outgrowth
your coverage expires.
To continue coverage you can purchase a new
policy on the replacement pair no later than two weeks
after receiving them, which will then cover you for a
period of two years from the date the replacement pair was
fabricated. Loss
Replacement: After
a claim has been made for loss replacement your coverage
does not expire.
However, there is a limit to three loss replacement
pairs per policy.
Instructions
for filing a claim: You must mail your cast(s), a completed claim form, and a
copy of the yellow invoice to the laboratory with
the postage paid labels provided via the US Post Office or
a UPS Out Post. The special UPS label can be given
directly to a UPS driver en route. Include your check or
money order for the appropriate amount made payable to PERFORMANCE LABS INC. Use
bubble pack and pack them thoroughly in a corrugated
container. If
your casts are fractured or broken include ALL
pieces and pack the pieces in a plastic bag. (The
Lab can usually repair most fractures if all the pieces
are returned).
Seal and affix the appropriate label.
Allow two to three weeks for delivery.
Return shipping is via UPS.
Do not use a PO Box as your address on your claim
form. Expect
delivery from 9am
- 5pm / Mon - Fri.
Cases
Where Coverage May Be Declined:
-
You
applied for the insurance plan after the four week grace
period which
starts
from the date your orthotics were manufactured. The date
of
manufacture
is located on the instruction guide that came with your
orthotics.
Your $45.00 Insurance premium will be returned in full.
-
Your
positive casts are destroyed during the initial
fabrication process.
The
positive casts are designed to undergo the pressure of
forming orthotics
one
time. A small percentage of casts break due to this
extreme pressure.
Since
the positive cast must accompany all future claims ,
coverage may be
denied
if they sustain damage. Your $45.00 insurance premium will
be
returned
in full.
-
If you
received coverage and you do not have the positive casts
that the
lab
returned to you, your claim may be denied. Since the
positive casts
must
accompany all claims, coverage may be denied if you cannot
locate them.
Be
sure to store them in a safe place for future use.
CLAIM FORM
PHOTOCOPY PERMITTED
Date__________
Patient Name______________________________
Age______
Weight_______
Sex_______
Height___’___”
Mailing
Address (Do Not Use
PO Box)
Name_________________________________(
) Check
If Same As Above
Address_______________________________
City________________________ State__________ Zip______________
Phone
(_____)-_______-___________
Yellow
Invoice Date ______/______/______
Yellow
Invoice Work Order # (upper right) _________________
Yellow
Invoice # (upper
right)_______________
Check
One
_____
Breakage and Damage Guarantee Include$10 Postage.
Include Orthotic
And
All Pieces.
(See Breakage and Damage Guarantee)
_____
Loss
Replacement $30 Per
Orthotic / $60 Per Pair / Add
$10
Postage (See Loss Replacement)
Make
Check Payable To: PERFORMANCE LABS INC.
IMPORTANT:
Thoroughly Read Policy Instructions And Procedures So Your
Claim
Will Not Be Delayed.
For Further Information go to
performlab.com
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