Accident benefits: how do I apply?

Residents of Ontario have coverage for financial losses that result from injuries suffered in motor vehicle accidents under their automobile insurance policy. Some of the financial losses for which you may be eligible include: loss of income, medical expenses, family expenses, and the cost of hiring caregiver assistance. The process of applying for these statutory accident benefits is somewhat complicated; there are timelines for completing the applications and medical questionnaires; and unfortunately, insurers are sometimes reluctant to pay claimants the full amount they deserve. A personal injury lawyer has the expertise to enable you to get the maximum benefits you are owed and also to deal with your insurance company if your accident benefits are being denied.

Applying for motor vehicle accident benefits

If you were injured in a car accident, you must report the accident to the police. This is a crucial step if you ever intend to apply for compensation for your injuries.

Anyone who was injured by a motor vehicle can apply for accident benefits from their insurance company. This includes people who were injured as pedestrians, cyclists, motorcyclists or in another vehicle. Under Ontario’s ‘no fault’ insurance, everyone should apply for accident benefits from their own insurance company, even when it was another person that was responsible for your accident. If you are not insured, then you may apply against the insurance policy of your immediate family (for example, if your parents or spouse has insurance) or against the insurer of the driver who caused the accident.

Governed by the Insurance Act, Statutory Accident Benefits (SABS) are available to all Ontario residents, to pay compensation for expenses, such as lost wages and medical treatments that an injured person incurred as a result of their accident. Accident victims are required to inform their insurer of their injuries within seven days of the accident. The insurance company will provide you with an Application for Accident Benefits form which must be completed and returned within 30 days if possible. You are advised to also keep a copy of the completed form for your own records.

Depending on the severity of your injuries and how much they affect your ability to perform necessary daily functions, you may be eligible for the following accident benefits under SABS.

• Income replacement benefit
  If you are unable to work, you may receive 70 per cent of your gross weekly income, not exceeding $400 weekly. You must demonstrate an inability to perform the essential functions of your job in order to qualify for this benefit. Also, to be eligible, you must have been employed at the time of the accident, or employed for at least 26 weeks of the year previous to the accident and were receiving Employment Insurance benefits at the time of the accident. Self-employed persons are also eligible for this benefit.
• Non-earner benefit
  The non-earner benefit is $185 weekly, but increases to $320 weekly if more than 104 weeks elapsed since the injury or disability, and the claimant continues to be unable to unable to carry on a normal life. An insurer must pay this benefit to a person who cannot function normally as a result of their injuries but are not eligible for income replacement. Thus, this benefit is intended for students who were enrolled fulltime at the time of the accident, or graduated within one year of the accident but have not yet found employment.
• Caregiver benefits
  If you sustained a catastrophic injury as a result of your accident and are substantially unable to perform previously done caregiving activities, then you are eligible for this benefit. You must also have been the primary caregiver, living with the person who is in need of care, and not paid for this service. This benefit is $250 weekly for the first dependent person and $50 weekly for each additional person. You are not eligible for this benefit if you are already receiving income replacement or the non-earner benefit.
• Medical benefits
  You are eligible for compensation for any reasonable expenses incurred as a result of the accident. This may include dental, optometric, ambulance, chiropractic, hearing aids and medication. It may also include the cost of transportation to various medical treatments.
• Rehabilitation benefit
  You may receive compensation for necessary and reasonable expenses for services that are intended to reduce the effects of your disability or injury, with the goal of being able to return to as normal a life as was enjoyed prior to the accident. Some of the treatments and services that may be included are: home modifications to accommodate disability needs, transportation to and from counselling, life skills training, vocational training, workplace modifications, financial counselling and family counselling.

Minor injury to catastrophic injury: different medical and rehabilitation maximums apply.

If your injuries were deemed to be ‘minor’, then you are eligible for up to $3500 in combined medical and rehabilitation benefits. The Minor Injury Guideline (MIG) under the Statutory Benefits Schedule refers to injuries such as a sprain, strain, partial dislocation of a joint, whiplash, lacerations and bruises. However, this maximum amount does not apply if you were previously diagnosed with a pre-existing medical condition that prevents you from achieving complete recovery without treatment exceeding the $3500 limit.

• Attendant Care benefits now combined with Medical and Rehabilitation (effective June 1st, 2016)
  If the severity of your injuries is such that you require a care person or need to stay in a long-term care facility, then you may receive attendant care benefits. Effective June 1st, 2016, the maximum allowable benefit for attendant care was combined with medical and rehabilitation benefits (note: before this date, there were separate maximum benefits for attendant care and medical/rehabilitation).

  For non-catastrophic injuries (not considered ‘minor’ under MIG), the injured person may receive up to $65,000 for any one accident, in combined medical, rehabilitation and attendant care benefits. These benefits are payable for up to five years for non-catastrophic injuries, but only as long as the injured person is medically eligible.

  In the case of catastrophic impairment resulting from an accident, the maximum benefit is $1,000,000 combined for medical, rehabilitation and attendant care. There is no time limit for receiving this benefit in the case of a catastrophic impairment.

  On June 1st, the Ontario government also implemented further changes to the optional accident benefits that Ontario residents may purchase under their vehicle insurance policy. One of the amendments is to allow policyholders to purchase combined medical/rehabilitation/attendant care optional coverage for $1 million for catastrophic injuries and $130,000 for non-catastrophic. Unfortunately, there is now a greater need for Ontario residents to purchase this optional coverage to provide protection in the event of a serious injury, since our basic benefits have effectively been cut in half since June 1st.

• Death and Funeral Expenses
  Family members are entitled to receive a death benefit for an accident victim who dies within 180 days of the collision. If the accident victim was continuously disabled as a result of the accident, this benefit is payable up to 156 weeks of the accident. A spouse is eligible to receive $25,000. Also, each dependant may receive $10,000.

The funeral benefit for a person who is fatally injured in an accident is a maximum of $6,000.

Other Benefits

There are various other miscellaneous expenses for which an injured person may be eligible to receive compensation, depending on their circumstances.

• Educational expenses
  Someone who was enrolled in an educational program but was unable to continue due to the accident, may receive a benefit to cover their educational expenses, including books and room and board, in an amount not exceeding $15,000.
• Visitors’ expenses
  Visitors’ expenses may be paid for close family members who visited the accident victim within the first 104 weeks of their treatment.
• Housekeeping and home maintenance
  If a person is unable to do housekeeping or home maintenance due to catastrophic impairment, they are eligible to receive up to $100 weekly for work they normally did before the accident.
• Damage to property
  The injured person is entitled to replacement value for personal items damaged in the accident. This may include such items as clothing, prescription glasses, dental devices, hearing aids and prosthetics.
• Cost of examinations
  Your insurance company is obligated to pay for miscellaneous examination fees that were required due to your injuries and in applying for accident benefits. Some of the fees that would be covered in this benefit are: a disability certificate fee; MIG treatment confirmation and assessment forms; physicians’ fees for written medical assessments; and a nurse’s fees for preparing the attendant care needs assessment.

How can a lawyer help?

Claiming for accident benefits can be a challenging process. There are substantive requirements for medical evidence and assessments before you are approved for benefits, and benefits each have specific qualifying criteria. The Injury Lawyers of Ontario (ILO) are experienced personal injury lawyers who have helped many accident victims get the benefits they are owed. We will represent your interests directly with your insurance company, both in the process of applying for accident benefits, and in the event that benefits are unfairly stopped or denied. Our expert staff can advise you in the completion of the required forms and examinations during the application process. The ILO lawyers in your community will provide compassionate and tailored legal assistance to ensure that you received needed accident benefits with minimal stress and delay for you.