Accident Benefits Claims
Accident benefits, also referred to as Statutory Accident Benefits (SABS), are for motor vehicle accident victims and are a no-fault insurance benefit that is a compulsory part of every automobile insurance policy in Ontario. Benefits are paid to eligible individuals regardless of who was at fault in a car accident. These payments compensate victims for lost earnings, medical expenses, and other economic losses incurred as a result of the accident. The amount of SABS funds and the categories under which an individual can claim benefits largely depends on the nature and extent of the injury, if the insured was employed, and other factors. To receive full accident benefits for your accident, you will need the assistance of an experienced accident benefits lawyer from Affinity Law.
Who is Eligible for SABS?
A person who suffers an impairment as a consequence of the use or operation of a motor vehicle is eligible for benefits. This includes the insured’s spouse, children and any other dependent under the applicable policy of insurance. You are not eligible for income replacement, non-earner benefits, lost educational expenses, visitor expenses, house-keeping and home maintenance expenses, however, if you were driving and lacked a valid driver’s license at the time of the accident, did not possess auto liability insurance, were driving while intoxicated or otherwise impaired or were found guilty of any other criminal offense while driving.
Which Policy Pays the SABS Benefits?
Normally, the applicable policy to seek SABS benefits is the one covering the injured person. This can include a family member within the household such as a spouse or child. If you are a passenger and not insured, you look to the policy of the owner of the car in which you were riding. If that person was uninsured, then you can still seek benefits from the policy of any other car involved in the accident.
If no accident insurance is available, then you can still collect benefits under the Motor Vehicle Accident Claims Fund or MVACF. This program provides compensation for SABS as well as for property damage and personal injury. MVACF is only available if you are a resident of Ontario and the accident occurred in this province.
How an Accidents Benefits Lawyer Can Help
The SABS application process is a complex one. Your accident benefits lawyer from Affinity Law can assist you with completing the application and ensuring that all documentation has been provided. The process has continuing obligations, meaning that you need to continually provide receipts, medical bills, employment and medical records if you are to continue receiving benefits. There are deadlines as well that your Affinity personal injury lawyer can keep you apprised of and to assure are timely met.
Your lawyer can also ensure that your full benefits to which you are entitled are being paid by the insurer. It is not unusual for an insurer to suddenly dispute a benefit or claim that your impairment or condition is not as serious as alleged or that you sufficiently recovered so that benefits may be reduced or terminated. There are significant differences in the available coverage depending on how your injury has been classified. Having an experienced accident benefits lawyer advocating for you is essential to meeting any challenge or dispute from the insured and to prevent any delay in receiving income replacement, non-earner benefits and for paying for essential medical services.
Another consideration is if your car accident occurred in the United States. If so, you can elect to receive benefits under SABS or those of the state in which your accident occurred. Your election of benefits can have a significant effect on the benefits available to you. Having a personal injury lawyer from Affinity Law to represent you is vital to receiving all the benefits and compensation to which you are entitled.
How to Apply for SABS Benefits
To apply for SBS benefits from your own or the applicable insured’s policy, follow these steps:
- Complete an OCF-1 form, or Application for Accident Benefits Form and submit it to the insurer
- Submit an OCF-3 form, or Disability Certificate that must be completed by a physician or health care professional as defined in the SABS who confirms and certifies that the insured was in an accident and that his/her injuries fit the criteria for the disability tests as set forth in the Statutory Accident Benefits Schedule
- Your employer submits an OCF-2 or Employer’s Confirmation of Income for income replacement benefits that sets forth the amounts you were paid over the 4 to 52 weeks before the accident. If you were self-employed, submit your business records for proof of income to the insurer who will confirm your gross income
- Keep all receipts for visits and all other out-of-pocket expenses related to your care and submit them to the insurer as soon as possible and on a regular basis
To apply for MVACF benefits, take the following steps:
- Complete the OCF-1 form, or Application for Accident Benefits
- Sign a Consent for collection, use, and disclosure of personal information
- Complete Form 3 or Application for Statutory Accident Benefits
- Obtain and submit a police report confirming the accident
- Submit a letter confirming that you are not a named insured or spouse or dependent of an insured
What are the SABS Benefits?
The available benefits are listed below:
- Medical and Rehabilitation Benefits: $50,000 payable over 10-years
- Attendant Care Benefits: Up to $3,000 per month to a maximum of $36,000 payable over no more than 104 weeks or until the $36,000 is exhausted, whichever occurs first
However, the combination of these benefits cannot exceed a total of $65,000
- Income replacement benefit of up to $400 weekly or 70% of weekly gross income, whichever is lower, to be paid until age 65 at which time the benefit will be reduced
- Lost educational benefits of up to $15,000
- Visitor expenses for up to 104 weeks
- Non-earner benefits of $185 per week with a 4-week waiting period with payments up to 2-years
Optional benefits for non-catastrophic injuries are:
- Medical and Rehabilitation Benefits: $100,000 for up to 5-years for adults
- Attendant Care Benefits: $72,000 for up to 5-years for adults
- Income replacement coverage can be increased to $600, $800, or $1,000 per week
However, the combination of these benefits cannot exceed a total of $130,000. An option is to purchase $1,000,000 coverage for all injuries, but you cannot purchase non-catastrophic and all injuries coverage together.
Non-earner benefits (NEB) are for those insureds who are not employed and do not qualify for income replacement benefits but who are unable to “completely carry on a normal life” because of their injuries. To be completely unable to carry on a normal life does not necessarily mean that you must be a paraplegic, bed-ridden, or suffer from some other totally incapacitating injury or illness. Rather, you must suffer from an impairment that continuously prevents you from engaging in substantially all of the activities for which you normally engaged in before the accident.Statutory Accident BenefitsSchedule Section 3 (7)(a). An impairment can also be a high level or degree of pain that prevents you from practically engaging in those activities.
Catastrophic injuries are for the most serious and permanently injured persons such as paraplegics, quadriplegics, the blind, amputees, and persons with significant brain trauma and psychological impairments. You can be classified as having a catastrophic injury that qualifies you for enhanced benefits by combining impairments that results in a 55% whole body impairment. A psychological impairment can be used in combination with others to determine a whole-body impairment.
Total blindness is not required to be considered catastrophic. If your loss of vision is extensive enough so that you are unable to perform your usual employment, it qualifies.
Other examples are second and third degree burns that cover more than 25% of your body, or third degree burns that cover more than 5% of your face and hands.
Catastrophic injury victims are entitled to the following:
- Medical and Rehabilitation Benefits: $1,000,000 over the recipient’s lifetime
- Attendant Care Benefits: $1,000,000 with payments of up to $6,000 per month until the benefit is exhausted. However, the combined total for these benefits cannot exceed $1,000,000
- Housekeeping and home maintenance: $100 per month over the recipient’s lifetime
- Caregiver benefit of $250 per week for the first-person needing care and $50 per week for the second and subsequent persons needing care. This is available for 104 weeks unless the insured sufferer is totally incapacitated or unable to continue living a normal life at which point the benefit is paid for life
- Visitor expenses for life
- Lost educational expenses up to $15,000
- Non-earner benefits of $185 per week with 4-week waiting period with payments up to 2-years
Optional Coverage for Catastrophic Injuries
- All injuries coverage–$2,000,000
- A combination of all injuries and catastrophic coverage–$3,000,000
- Income replacement coverage may be increased to $600, $800, or $1,000 per week
Minor Injuries (MIG)
If your injuries are minor, you are still entitled to limited benefits. These include $3,500 for medical and rehabilitation expenses only. No attendant care benefits apply. You may still be eligible for income replacement if you meet the SABS test, which requires that you be substantially unable to engage in your employment tasks.
Under some circumstances, you can be removed from this category and into the non-catastrophic where you are eligible for more and higher benefits. For instance, your medical provider could find that the accident has caused you deep depression and anxiety, post-traumatic stress disorder, and other non-physical conditions that are the predominate cause of your disability rather than the minor physical injuries you sustained.
Eligible surviving family members may receive:
- $25,000 to the spouse
- $10,000 to each dependent
- $10,000 to be split among those persons in respect of whom the decedent was a dependent
- $6,000 as a funeral benefit
These can be increased with the purchase of optional coverage to:
- $50,000 to the spouse
- $25,000 to each dependent
- $25,000 to be split among those persons in respect of whom the decedent was a dependent
- $8,000 funeral benefit
Depending on the seriousness of your injuries, you may have a team of medical and care providers to care and support you. Medical providers and those providing therapy and other services should be advocates for you and be willing and available to communicate with you, your other providers on the team, and your lawyer. Reports and records are vital to establishing the nature and extent of your injuries, what care is needed, and if you are substantially unable to perform your pre-injury work duties so as to be eligible for income replacement or non-earner benefits.
Case managers are assigned for catastrophic injury cases to coordinate care and services for the injured party. For non-catastrophic cases, an occupational therapist or OT takes care of services and support and assesses the need for attendant services and home maintenance requirements. The OT does need to first submit a Treatment and Assessment Plan, form OCF-18, to the insurer before beginning the process. Once received, the insurer has the right to have the client examined by a physician of their choosing, referred to as a Section 44 Insurer’s Examination, to determine if the client needs to be assessed and if the requested treatment and care is reasonable and necessary. The cost of the assessment by an OT and of the examination cannot exceed $2,000. This cost is deducted from the $50,000 available for medical and rehabilitation benefits for non-catastrophic injuries.
There can be other medical and rehabilitation providers as part of a treatment team. Any assessment done by a professional must first be approved and the request submitted through a Treatment and Assessment Plan. The inclusion of these professionals depends on the nature and extent of your injuries. These individuals may include:
- Social worker—who handles the emotional and psychological issues following a traumatic accident
- Chiropractor—deals with physical issues such as back and neck pain
- Psychologist—if depression and anxiety are especially severe
- Personal support worker—person who handles attendant care
- Massage therapist—for ongoing or chronic physical issues that massage can alleviate
- Speech and Language therapist—if brain damage caused cognitive issues
Rehabilitation Support worker—person who assists with the implementation of various care and for re-integration into the community
The OT or case manager can determine with the assistance of these professionals what assistive devices are necessary and what workplace and home modifications are needed to accommodate the client. The insurer is obligated to pay for any modifications or assistive devices. Examples are walkers, canes, guardrails, handheld showerheads, ergonomic keyboards, ramps, wheelchairs, and other specially designed chairs.
It is not unusual for an insurer to categorize your injuries as non-catastrophic or as minor even if you and your medical provider dispute this. Insurers will also dispute the reasonableness or necessity of certain treatments and deny consent or refuse to provide payment for care already rendered. Your Toronto car accident injury lawyer from Affinity Law can help by ensuring that your medical provider and treatment team offer the necessary documentation to support your injury. But if the dispute is unresolved, you can bring the issue before the License Appeal Tribunal (LAT) for resolution.
If you have been receiving SABS benefits for some time, the insurer may approach you with a settlement offer. Any settlement offers, though, cannot be extended until one year after your accident that precipitated the payments. Any offer will be for a fixed amount. If you do decide to accept it, you will not be able to collect any further SABS benefits from this accident regardless if your injuries worsen or further medical treatment is necessary such as surgery and therapy. You should be cognizant that any settlement you do accept could affect any third party claim you have against the party or parties who were responsible for your accident.
CONTACT AFFINITY LAW
It is highly recommended that if you do not have a lawyer already, you at least consult with a Toronto Accident Benefits lawyer from Affinity Law to understand what options you have and what would be a fair and reasonable settlement amount. One of our knowledgeable Toronto personal injury lawyers can negotiate a reasonable settlement for you and represent you on a third party claim. Most accident benefits claims are settled after the one-year period.
Call us today for a free consultation at (647) 846-2037.