A Summary of Accident Benefits for Ontario Accident Vicitms.
Your insurance policy provides you with accident benefits – statutory accident benefits – (otherwise known as SABS – i.e. medical, rehabilitation and attendant care, caregiver, non-earner and income replacement benefits) which are available to a claimant injured in a motor vehicle accident – no matter who is at fault.
The SABS currently covers these general benefit headings:
Income replacement benefits (IRBs) compensate accident victims for their loss of income from employment or self-employment, so long as the applicant meets the necessary requirements. The SABS puts tight limits on the amount of income that can be recovered under the SABS, and many applicants will find that the income replacement benefits they receive do not adequately compensate them. Many will have to look to the tort claim to recover additional pecuniary damages.
Starting one week after the accident, IRBs compensate an insured person for 70% of gross income up to a weekly maximum of $400. The maximum amount can be higher if the claimant had purchased optional benefits prior to the accident. IRBs were not affected by the June 1, 2016 SABS changes.
For more information on income replacement benefits – click here.
The non-earner benefit is unique among the benefits available under the SABS. Unlike the other benefits, which aim to compensate claimants for specific financial losses or expenses, the non-earner benefit compensates for daily loss of life functions. It is similar in nature to non-pecuniary damages and general damages in the tort claim. Given its strict requirements, it is one of the toughest accident benefits to qualify for under the SABS. In particular, it is difficult to qualify for applicants with soft-tissue injuries or psychological impairment.
Claimants must suffer from a complete inability to perform their daily activities in order to qualify.
Non-earner benefits pay a base rate of $185 per week for the qualifying period. Prior to June 1, 2016, some claimants, such as students, could potentially qualify for higher amounts. These higher amounts are not available for accidents after June 1, 2016.
For accidents prior to June 1, 2016, non-earner benefits can potentially last the claimant’s entire life. For accidents after June 1, 2016 these benefits have been severely curtailed, being terminated two years after the date of the accident.
It is important to understand that you cannot receive a non-earner benefits if you’ve elected to receive income replacement or caregiver benefits. You cannot receive both.
For more information on non-earner benefits – click here.
Caregiver benefits are only available to catastrophically impaired claimants who were also the primary caregiver of one or more dependants at the time of the accident. Non-catastrophically injured claimants who purchased optional benefits may also qualify.
Caregiver benefits pay eligible claimants $250 for the first person in need of care per week, and $50 per week for each additional person in need of care. They last up to 104 weeks after the accident unless claimants can show that they suffer from a complete inability to carry on a normal life.
Claimants cannot receive caregiver benefits if they elected to receive income replacement or non-earner benefits.
Medical and rehabilitation benefits are the most common of all the benefits available to motor vehicle accident victims under Ontario’s no-fault accident benefits regime. Medical and rehabilitation benefits provide you with the modalities needed to help restore your health and return to work and society.
Claimants are entitled to “reasonable and necessary” medical and rehabilitation treatment, and all modalities must be submitted to the insurer in advance by way of a treatment plan.
The amounts available for medical and rehabilitation benefits change significantly depending on whether the accident took place on or after June 1, 2016. As of June 1, 2016, the amounts available for medical and rehabilitation benefits merge with attendant care benefits.
For more information on medical and rehabilitation benefits – click here.
Attendant care benefits allow you to be reimbursed for expenses related to hiring an aide or attendant to help you you’re your day-to-day functions. These functions include help with dressing and personal grooming, bathing, cooking and feeding, and getting around. Attendant care also includes paying for a stay in a long-term health facility or home, if not covered by the Ontario Health Insurance Plan (OHIP).
Attendant care benefits pay up to $3,000 per month ($6,000 if catastrophic) for incurred expenses of professional attendants. Non-professional attendants can only be compensated for the amount of income they have given up in order to care for the claimant, if any.
The total amounts available for attendant care vary depending on if the accident is on or after June 1, 2016. On June 1, 2016 the total amounts available for caregiver benefits were merged with medical and rehabilitation benefits.
For more information on Attendant Care Benefits – click here.
Other benefits include:
Lost educational expenses – can compensate you for expenses lost due to not completing a course in elementary, secondary, post-secondary or continuing education up to $15,000.
Visitor expenses – Can covers travel expenses for certain close relatives to visit you.
Housekeeping and home maintenance benefits – These pay for hiring someone to clean and otherwise maintain the home and are only available to catastrophically injured claimants (section 23, SABS). Non-catastrophically injured claimants may be eligible if they have purchased optional benefits (see Optional Benefits). The maximum amount payable under this benefit is $100 per week.
Miscellaneous expenses – such as damage to clothing, glasses, hearing aids, and other similar expenses. These pay for the small items that may have been damaged in the accident and that are not otherwise covered by a property damage claim.
These expenses provide death and funeral benefits to eligible beneficiaries. Death benefits provide $25,000 paid to a spouse and $10,000 to each qualifying dependant. Funeral benefits pay up to $6,000 for funeral expenses.
Most people do not know – but as an insured person, you are allowed to purchase optional benefits that provide “additional amounts” to your basic benefits covered in the SABS.
Optional benefits are available to:
Note, optional benefits do not apply to all claimants. Optional benefits only apply to:
Your entitlement to accident benefits depend on the severity of your injuries. There are three basic categories:
The MIG covers the least serious injuries. Section 3(1) of the SABS defines a minor injury as one or more of a:
Applicants who fall under the MIG are limited to $3,500 in medical and rehabilitation benefits. Attendant Care benefits are not available.
These are the most seriously injured claimants, such as brain injured or paralyzed accident victims with spinal cord injuries. These claimants have access to the widest array of benefits.
They are the only ones, absent optional benefits, to be entitled to caregiver and housekeeping and home maintenance benefits, and they have much higher amounts for medical, rehabilitation and attendant care benefits available to them. They also have access to case manager services to help direct their treatment.
For more information on catastrophic click here.
While there is no official name for this designation, anyone who is not designated as catastrophic or MIG defaults to a designation of non-catastrophic impairment. The maximum combined attendance care, medical and rehabilitation benefit available to you is $65,000.00 unless optional benefits are purchased.
Firstly, you should notify your insurance company within seven days or “as soon as practicable after that day” upon getting into an accident. This does not have to be done in writing.
Your insurance company will then send you:
Late applications are still permitted if the claimant has a reasonable explanation for the delay. The insurer must respond promptly. If the claimant has no reasonable explanation, the insurer must still respond but has 45 days from the time they receive the completed and signed application.
The initial application for accident benefits is called an OCF-1.
Many accident victims will be covered under other benefits plans that provide similar benefits to the SABS, such as group benefits plans. The SABS are excess insurance, as per section 268(6) of the Insurance Act. This means that claimants who have other benefits plans must first apply to other providers, such as
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