ACCIDENT BENEFIT LAWYER HAMILTON

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What are Accident Benefits?

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.

What Accident Benefits Are Covered?

The Statutory Accident Benefit Schedule (SABS) currently covers these general benefit headings:

  • Income Replacement Benefits
  • Non-earner benefits
  • Caregiver benefit
  • Medical and rehabilitation benefits
  • Attendant Care Benefits
  • Lost educational expenses;
  • Visitor expenses;
  • Housekeeping and home maintenance;
  • Damage to clothing, glasses, hearing aids, etc;
  • Cost of examinations; and
  • Death and funeral expenses.

What are Income Replacement Benefits (IRB)?

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.

What is a Non-earner Benefit (NEB)?

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.

What is a Caregiver Benefit?

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.

For more information on non-earner benefits – click here.

What are Medical and Rehabilitation 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.

Attendant Care Benefits

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.

Other Benefits

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.

What are Death and Funeral Expenses?

These accident benefits 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.

What are Optional Benefits?

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:

  • Increase the amount of your income replacement benefits;
  • Allow non-catastrophically injured claimants to receive caregiver or housekeeping benefits;
  • Increase the amount of your medical, rehabilitation and attendant care benefits;
  • Increase the amount of your death and funeral benefits
  • Allow for a dependant care benefit
  • Allow for annual indexation of certain benefits

What are the three levels of accident benefits available?

Your entitlement to accident benefits depend on the severity of your injuries. There are three basic categories:

  • The Minor injury designation (MIG).
  • Catastrophic designation (CAT).
  • Non-Catastrophic Designation.

What is a Catastrophic (CAT) impairment?

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.

What is a Non-Catastrophic impairment?

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.

How do you apply for accident benefits?

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:

  • A package containing appropriate accident benefit application forms.
  • A written explanation of the benefits available to you.
  • Information on applying for benefits and, in particular, information relating to the election between income replacement, non-earner and caregiver benefits.

What if I am late applying for accident benefits?

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.

What is the initial application called?

The initial application for accident benefits is called an OCF-1.

Accident benefits are “Excess Insurance”.

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

  • Disability insurance plans;
  • Group benefits plans;
  • Employment Insurance (EI);
  • CPP Disability; and
  • ODSP.

Have you or a loved one been involved in a serious accident?

If you or your loved has been involved in a serious accident and has suffered life changing injuries – fill in a contact form or call us at 905-333-8888. We have been representing victims and their families who have suffered injuries in motorcycle accidents, car accidents, trucking accidents, pedestrian accidents and bicycle accidents since 2003. All our consultations are free and we never ask our clients for money upfront.

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Accident benefits are part of Ontario’s no fault insurance scheme.  If you have been hurt in an accident – whether it’s your fault or not, you may be entitled to receive accident benefits to assist with your recovery.  The amount of benefits you are entitled to will depend on the severity of your injuries that you have sustained in the accident.

An insurer is not required to pay an income replacement benefit, a non-earner benefit, benefits for lost education or visitors expenses in respect of a person who was the driver of an automobile at the time of the accident:

(i) if the driver knew or ought reasonably to have known that he or she was operating the automobile while it was not insured under a motor vehicle liability policy,

(ii) if the driver was driving the automobile without a valid driver’s licence,

(iii) if the driver is an excluded driver under the contract of automobile insurance, or

(iv) if the driver knew or ought reasonably to have known that he or she was operating the automobile without the owner’s consent.

In addition, if an occupant of an automobile at the time of the accident who knew or ought reasonably to have known that the driver was operating the automobile without the owner’s consent – that occupant may not be entitled to the coverage noted above.

In addition, if a person was engaged in an act for which the person is convicted of a criminal offence, or was an occupant of an automobile that was being used in connection with an act for which the person is convicted of a criminal offence – accident benefit coverage may not be available.

Unfortunately, you are only entitled to a maximum amount of $3,500 in medical and rehabilitation benefits – which can be increased to $65,000 if there is compelling evidence that a pre-existing medical condition will prevent you from achieving maximal recovery with access to only $3,500.  This is what you might have heard called the “MIG” or the Minor Injury Guideline. The next level of Medical and Rehabilitation benefits, for non-catastrophic injuries are combined with Attendant Care Benefits to a maximum financial limit of $65,000.00 for any one accident.

The $3,500 MIG limit does not apply to an insured person if his or her health practitioner determines and provides compelling evidence that the insured person has a pre-existing medical condition that was documented by a health practitioner before the accident and that will prevent the insured person from achieving maximal recovery from the minor injury if the insured person is subject to the $3,500 limit or is limited to the goods and services authorized under the Minor Injury Guideline.

Your insurance company shall pay medical benefits for all reasonable and necessary expenses incurred by or on behalf of the insured person as a result of the accident for expenses such as:

(a) medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services;

(b) chiropractic, psychological, occupational therapy and physiotherapy services;

(c) medication;

(d) prescription eyewear;

(e) dentures and other dental devices;

(f) hearing aids, wheelchairs or other mobility devices, prostheses, orthotics and other assistive devices;

(g) transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant; and

(h) other goods and services of a medical nature that the insurer agrees are essential for the treatment of the insured person.

You are not entitled to payment for goods or services that are experimental in nature, that exceed the maximum rate or amount of expenses established under the Guidelines or for transportation expenses other than “authorized” transportation expenses.

If you are hurt in an accident, you are entitle to reasonable and necessary expenses which you have incurred in undertaking activities and measures that are reasonable and necessary for the purpose of reducing or eliminating the effects of any disability resulting from the impairment or to facilitate your reintegration into your family, the rest of society and the labour market. In particular, you are entitled to such as:

(a) life skills training (b) family counselling (c) social rehabilitation counselling (d) financial counselling (e) employment counselling (f) vocational assessments (g) vocational or academic training (h) workplace modifications and workplace devices, including communications aids, to accommodate the needs of the insured person (i) home modifications and home devices, including communications aids, to accommodate the needs of the insured person, or the purchase of a new home if it is more reasonable to purchase a new home to accommodate the needs of the insured person than to renovate his or her existing home; and (j) vehicle modifications to accommodate the needs of the insured person, or the purchase of a new vehicle if it is more reasonable to purchase a new vehicle to accommodate the needs of the insured person than to modify an existing vehicle.

A Disability Certificate (OCF-3) is part of your application for accident benefits.  Your insurance company will provide you with an Application with Accident Benefits (which we can of course help you fill out).

You can also find a copy of the Disability Certificate on the FSCO website.  Your Disability Certificate is divided into 10 parts. Parts 1-4 are to be completed and signed by the claimant before giving the form to a health practitioner. The health practitioner then completes the rest and submits it to the insurance company.

Parts 5-10 are to be completed and signed by one of the following health practitioners:

  • Dentist
  • Chiropractor
  • Nurse Practitioner.
  • Occupational Therapist.
  • Speech Language Pathologist
  • Occupational Therapist
  • Physician
  • Psychologist

The list is broad, and the Disability Certificate will carry more weight if it is completed by a health practitioner:

  • Whose area of practice is related to the primary diagnosis.
  • Who treated the claimant prior to the accident.
  • Who is funded by OHIP.

Your family doctor is often a good choice.

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