In addition to your right to seek compensatory damages through a tort action via the aforementioned third-party liability system, I will first proceed with an accident benefits claim against your own automobile insurance company via the first-party no-fault auto insurance plan, where I’ll claim selected accident benefits on your behalf. Unlike the third-party liability system, where your claim for compensatory damages can potentially be significantly reduced or eliminated depending on the degree to which you were at-fault in the motor vehicle accident, in the no-fault auto insurance system, I can still claim accident benefits on your behalf even if you were 100% at-fault.
Application for Accident Benefits Package
After you report your involvement in a motor vehicle accident, your claims adjuster will send you via regular mail, an Application for Accident Benefits Package, which will provide you with information in regards to benefits that you may receive under the Ontario Regulation 34/10: Statutory Accident Benefits Schedule (“SABS 34/10”), under Ontario’s Insurance Act, R.S.O. 1990, c. I.8, as a result of injuries you sustained in your motor vehicle accident.
If you want to know more about what to do immediately after you’re involved in a motor vehicle accident, just before you kickstart the Accident Benefits Application process, then click this “link” to read my blog entitled “What To Do After a Car Accident in Ontario?”
Medical and Rehabilitation Benefits
I’ll pursue medical and rehabilitation benefits on your behalf, in order that you get the medication and rehabilitation treatment you need to facilitate your rehabilitation and reintegration back into the labour market and your activities of daily living.
Concerning your medical and rehabilitation benefits, it’s important to understand that there are 3 different injury classifications, tiers or levels that will determine the applicable benefits that are available to you, which are as follows:
- The Minor Injury Guidelines classification, which have policy limits of $3,500;
- The Non-Minor Injury or Non-Catastrophic Injury classification, which have policy limits of $65,000 (if optional increased benefits weren’t purchased), in combination with attendant care benefits; and
- The Catastrophic Injury/Impairment classification, which has policy limits of $1 million (if optional increased benefits weren’t purchased), in combination with attendant care benefits.
Medical and rehabilitation benefits are available to you for reasonable and necessary expenses that have been incurred. This is a fact specific inquiry.
Medical benefits are integrated with rehabilitation benefits for the purposes of the SABS 34/10. The SABS 34/10 outlines what constitutes medical and rehabilitation benefits. Medical benefits include, but are not limited to, the following:
- Non-OHIP insured medical services, medication and prescription eyewear.
Rehabilitation benefits focus, again, on reintegrating you to the labour market and your activities of daily living, such as, but not limited to, the following:
- Life skills and family or employment counselling, vocational or academic training and workplace or modifications.
Attendant Care Benefits
I may claim attendant care benefits on your behalf in your accident benefits claim.
Attendant care benefits pay for reasonable and necessary expenses for your self-care. Such benefits are available if you are substantially unable to engage in self-care tasks, such as, but not limited to, the following:
- Hygiene; or
- You require supervisor care.
Quantum of Attendant Care
And after June 1, 2016, attendant care benefits are now combined up to a maximum of $65,000 with medical and rehabilitation benefits, if you are in the non-minor or non-catastrophic injury classification, and up to $1 million combined with medical and rehabilitation benefits, if you are in the catastrophic injury/impairment classification.
The Three Weekly Disability Benefits
I’ll also claim one of the three weekly disability benefits in your accident benefits claim.
If you sustained injuries as a direct result of your motor vehicle accident, then you may be eligible to receive one of the following three weekly disability benefits, as follows:
- Income replacement benefits;
- Non-earner benefits; or
- Caregiver benefits.
Once your insurer receives your Application for Accident Benefits (OCF-1) form, they will make a preliminary determination about whether any of these weekly disability benefits apply to you, but they don’t have the last word on it, as you can appeal their decision to the Licence Appeal Tribunal if you disagree.
Income Replacement Benefits
Income replacement benefits (“IRBs”) are payable if you were at least 16 years of age or more and employed or self-employed on the date of the motor vehicle accident, or worked at least 26 of the 52 weeks before the accident (or was receiving employment insurance at the time of the accident).
The disability test to be met is a substantial inability to perform the essential tasks of employment within 104 weeks of the accident. After 104 weeks, the test changes to a complete inability to engage in any employment for which you are reasonably suited by reason of education, training or experience.
After September 1, 2010, the calculation changed to 70 percent of your gross income after a one-week waiting period. After 104 weeks, the amount payable is the greater of your weekly income benefit or $185 per week. Unless optional increased benefits were purchased, the maximum payable to you is $400 per week. The SABS 34/10 provides a ramp down calculation after age 65.
The SABS 34/10 sets out the requirements for entitlement to non-earner benefits (“NEBs”), as follows:
- You must suffer an impairment as a result of an accident; and
- You must suffer a complete inability to carry on a normal life as a result of and within 104 weeks after the accident.
You must not qualify for an income replacement benefit. Alternatively, NEBs are payable if you were enrolled in educational pursuits on the date of your accident or within one year of the accident, and you meet the disability test.
Effective June 1, 2016, the age requirement for the payment of NEBs was raised from 16 to 18 years of age, the waiting period also changed from 26 weeks to four weeks, and NEBs are now only payable for 104 weeks as opposed to the age of 65 years old. If you’re found eligible, after June 1, 2016, NEBs are only payable at the rate of $185 per week for a maximum of 104 weeks.
After September 1, 2010, if no option was purchased, caregiver benefits (“CGBs”) are only available if you are found to be catastrophically impaired.
Pursuant to the SABS 34/10, in order for you to be found eligible for CGBs, you must live with a person in need of care and be the primary caregiver for the person in need of care, and not receive any payment for caregiving activities. The SABS 34/10 defines a “person in need of care” as one who is under 16 years of age or who requires care because of physical or mental incapacity.
Further to the disability test as outlined in the SABS 34/10, you must suffer a substantial inability to engage in the caregiving activities in which you were engaged in at the time of your motor vehicle accident for the first 104 weeks. After 104 weeks, the test becomes stricter and is the same as that for NEBs – a complete inability to carry on a normal life.
There is no waiting period for CGBs. So, if you’re eligible, you receive $250 per week for the first person in need of care and $50 per week for each additional person in need of care. This amount is reduced as your children turn 16 and are no longer in need of care.
If you elect IRBs or NEBs, and later you’re found to be catastrophically impaired, then the SABS 34/10 allows you to re-elect to the CGB. Elections are otherwise considered final.
The Disability Certificate (OCF-3) Form
If you want to claim any of the aforementioned weekly disability benefits, then your insurer will require you to complete the mandatory Disability Certificate (OCF-3) form. You fill in Part 1 through to 3 of the OCF-3 form, and then give it to your healthcare provider, such as, but not limited to, the following:
- Nurse practitioner;
- Occupational therapist;
- Psychologist; or a
- Speech language pathologist.
Only an authorized healthcare provider can complete the OCF-3 form.
At Rudder Law Group, we understand that after sustaining severe and permanent injuries and impairments following a motor vehicle accident or car accident, and experiencing a devastating, unforeseen loss, you want to optimize your level of independent living and be able to pay for the exorbitant costs of future care, so as to avoid undue stress and hardship. That’s why we are committed to fighting on your behalf to ensure that we increase your auto insurance policy limits to the highest tier of medical rehabilitation benefits in your accident benefits claim, as well as obtain just compensation in your tort action or lawsuit. We fight to accomplish this goal so you can pay for the exorbitant future costs of care, in order to gain access to the necessary multidisciplinary treatment, care services, and support needed to optimize your level of independent living, and your full mental, physical, social and vocational ability. We are committed to this in order to facilitate the optimization of your social and economic inclusion, and participation in all aspects of your life in society.