Motor Vehicle Accidents
If you have been injured in a motor vehicle accident, you can claim accident benefits according to the Statutory Accident Benefits Schedule (SABS). In most cases the insurance company will require you to have a referral from a physician for rehabilitation. Rehabilitation may consist of physiotherapy, massage therapy, chiropractic and/or occupational therapy. For more information, contact your insurance company or visit the Financial Services Commission of Ontario (FSCO) website. Below is a more detailed explanation of No-fault accident benefits and your entitlements.
No-fault accident benefits
You are entitled to no-fault accident benefits regardless of who is at fault in the accident.
Who do you claim no-fault accident benefits from?
- If you have an automobile policy or are a driver on someone's policy, you can claim accident benefits through that policy, even if you weren't in that car at the time.
- If you don't have a car, and aren't listed as a driver on a policy, but are riding in a car at the time of the accident, you claim under the owner's policy.
- If you don't have a car and weren't riding in a car at the time (i.e., cyclist or pedestrian) you claim through the policy of the owner of the car that was involved in the collision with you. If that car didn't have valid insurance on it, or didn't remain at the scene (hit and run), you may claim Accident Benefits through any other car involved in the accident that did have valid insurance.
- If none of the above situations apply, for example in a hit and run accident between a cyclist and a car, you must claim through the "last resort," which is the Motor Vehicle Accident Claims Fund. This is administered by the provincial government, and the claims are handled for them through an independent adjusting firm. Legally, if you have nowhere else to claim Accident Benefits, you are entitled to the same benefits through the MVAC Fund.
The address of the fund is:
Motor Vehicle Accident Claims Fund
P.O. Box 85, 5160 Yonge St.
Toronto ON M2N 6L9
(416) 250-1422
1-800-268-7188
How to Claim Accident Benefits
Accident Benefits coverage is provided by law under every automobile insurance policy in Ontario. Because the regulations (Statutory Accident Benefits Schedule or SABS) are provincially mandated, the coverage provided is standard among insurance companies.
When making a claim for accident benefits, you must first notify the insurance company within 7 days or as soon as practical after the accident occurred.
The insurance company will then send you an Application package which you must complete within 30 days after receiving the forms and return them to the insurance company. No benefits will be payable until you complete the application and if it is outside the 30 days you will have to provide a reasonable explanation. If you have a private insurance policy or an employment benefits package, you should apply for these benefits as well since accident benefits only pay for what is not covered under these types of plans.
Detailed instructions are on the Application Form and the timelines are also listed. The Application will include a Disability Certificate that must be completed in order to qualify for a number of benefits. The Disability Certificate, which is prepared by a health practitioner, must be submitted within 10 days of the Application. This is a very short timeline and our physiotherapists will complete and fax this form in a timely matter directly to the insurance company.
In order to receive medical and rehabilitation treatment, a health professional will be required to prepare, sign and submit a Treatment Plan. A Treatment Plan is a prescribed form that must be used. In cases involving certain soft tissue injuries (grade I/II whiplash injuries) there are Pre Approved Framework Guidelines that may apply and a fixed package of benefits is provided without the need of submitting treatment plans.
If you require an aide or attendant to help you, attendant care benefits are available, however special forms must be completed by an occupational therapist or physician to obtain these benefits.
If you are seeking payment for income replacement benefits you must have your employer submit an Employers Confirmation Form in addition to the Disability Certificate described above.
It is very important that you read the Application carefully and review all the benefits that may be available to you.
Once the insurance company receives your papers, they are required to respond to your application within 14 days. The insurance company may require that you undergo an insurer's medical assessment at the insurer's expense. The insurance company must give you notice that includes: the reasons for the examination; the type of examination that will be conducted and whether your attendance is required during the examination; the name of the person or persons who will conduct the examination, the regulated health professions to which they belong and their titles and designations indicating their specialization, if any, in their professions; and if your attendance is for more than one day to provide the above information for the subsequent days. Following the assessment, you will be entitled to a report setting out the findings of the assessment. If your benefit is being denied, you are entitled to obtain a rebuttal report from your treating professional subject to certain restrictions and timelines.
If your insurance company makes a decision to deny your benefit and you disagree with it, you may dispute the outcome and file an Application for Mediation to the Financial Services Commission ("Commission") of Ontario within two years of the insurer's refusal. If the issue is not resolved at the mediation you may then file: 1. An Application for Arbitration with the Commission within 2 years of the refusal to pay the benefit or within 90 days of the date of the Report of the Mediator; or 2. Start a law suit against the insurance company. In either case, you should contact a lawyer for a consultation.
What Potential No-Fault Benefits (Accident Benefits) is an injured person entitled to?
An injured person will be entitled to make a claim for accident benefits regardless as to whether or not they were at fault or not when injury arises out of a collision with a car. Depending on various circumstances, the payment of the benefits will be from one's own auto insurer, the insurer for the car involved, or the Motor Vehicle Accident Fund if no insurance is available. Potential no fault benefits available are listed below.
Medical & Rehabilitation Benefits Not Covered by OHIP or other Medical Plan
An injured person is entitled to receive up to $100,000.00 of medical and rehabilitation benefits for expenses, which are not covered by OHIP or some other health or disability plan, incurred up to 10 years after the accident. If a person's injury is catastrophic as defined by the Insurance Act, such as a serious brain injury or spinal cord injury or some other kind of catastrophic injury, a person is entitled to receive $1,000,000.00 in medical and rehabilitation benefits and these are payable over the person's lifetime and not limited to 10 years. If optional increased coverage was purchased by an injured person, the payments discussed in this paragraph may be higher.
Income Replacement Benefits
An injured person is entitled to receive weekly income replacement benefits for up to the first 104 weeks (excluding the first week) after a collision in the following circumstances:
1. If the injured person was employed on the date of the accident and thereafter suffers a substantial inability to perform the essential tasks of his or her employment.
2. If an injured person was not employed at the time of the accident, but worked at least 26 of the 52 weeks before the accident (or was receiving Employment Insurance benefits at the time of the accident) and thereafter suffers a substantial inability to perform the essential tasks of the employment in which the person spent most of his or her time during the 52 weeks before the accident.
3. If an injured person was entitled to start work within one year under a legitimate written contract of employment that was made before the accident and as a result of an accident suffers a substantial inability to perform the essential tasks of that employment.
An injured person can still receive income replacement benefits after 104 weeks if the person suffers a complete inability to engage in any employment for which she is reasonably suited by reason of education, training or experience.
An injured person receives no income replacement benefits for the first 7 days after a collision and thereafter, as long as a person qualifies, he or she will receive 80% of net weekly income (after deducting taxes) and after deducting any benefits the person may be entitled to from other sources such as a disability plan at work. The maximum that can be received is $400.00 per week, unless optional coverage was purchased and, if it was, the maximum a person can receive from his or her auto insurance company is $1,000.00 per week. These benefits are available to you up until age 65 and then they start to reduce on a gradual basis.
Non-Earner Benefits
An injured person who was not working at the time of an accident and who does not qualify for income replacement benefits is entitled to receive $185.00 per week if the person suffers a complete inability to carry on a normal life. Nothing, however, is payable for the first 26 weeks after the accident. If a person was a student at the time he or she was injured or had been a student within one year of being injured and was not yet employed, these benefits increase to $320.00 per week starting 104 weeks after the accident.
Caregiver Benefits
An injured person may be entitled to a caregiver benefit if they were living with and were the primary caregiver for a person in need of care and were not being paid for these activities. The injured person must chose this benefit instead of either an income replacement benefit or a non earner benefit. The maximum amount of the caregiver benefit is $250.00 per week for the first person in need of care plus $50.00 per week for each additional person.
Attendant Care Benefits
An injured person can receive up to $3,000.00 per month for two years (which is a maximum of $72,000.00) for attendant care benefits. In a catastrophic case, an injured person can receive up to $6,000.00 per month to a maximum of $1,000,000.00 and there is no time limit. If optional increased coverage was purchased, these benefits may be higher.
Housekeeping and Home Maintenance Benefits
An injured person can receive $100.00 per week for reasonable expenses incurred for housekeeping and home maintenance, if the injured person suffers a substantial inability to perform these services and the injured person performed these services before the accident. These expenses are paid for 104 weeks unless the injury is catastrophic, in which case they are payable for longer.
Non-Payment of Accident Benefits by Accident Benefits Insurer
Where the payment of specific claims are denied in whole, or in part, by the accident benefits insurance company the injured person then has a right to make an Application for Mediation over the unpaid claim at the Financial Services Commission of Ontario and if the unpaid claim is not resolved at mediation, they then have an option to proceed in one of two ways. The person can make an Application for Arbitration at the Financial Services Commission of Ontario. The other way is that they can start a lawsuit in the Superior Court of Ontario. You should contact a lawyer to help you decide how to proceed.