Accident Benefit (No-Fault) Claims in Ontario
If you are injured in a motor vehicle accident, you are entitled to apply for certain medical, economic and other benefits, regardless of fault. These benefits, sometimes termed “no-fault benefits” or benefits under the Statutory Accidents Benefits Schedule are provided through insurance, or if none is available, through the Ontario Motor Vehicle Accident Claims fund. Note that these benefits are in addition to what may be available from the at fault driver’s insurance.
The type and amount of benefits available varies, depending both upon the classification of your injuries, and also whether optional benefits were purchased. Injuries are classified as minor, non-catastrophic and catastrophic. When injuries are classified as minor, very limited benefits are available.
Minor injuries are defined by the Financial Services Commission of Ontario as:
“A sprain, strain, whiplash associated disorder, contusion, abrasion, laceration or subluxation and any clinically associated sequelae. This term is to be interpreted to apply where a person sustains any one or more of these injuries.”
In determining whether the Minor Injury Guidelines (MIG) applies, insurers must consider whether the injured motorist has been referred to any specialists or for any diagnostic testing. Significantly, the recent decision by the Financial Services Commission of Ontario in Arruda v. Western Assurance (FSCO A13-003926) was significant, in that it held that:
- The insurer has an ongoing duty to assess and reassess a claim as new information becomes available.
- While a claim may initially be within the Minor Injury Guideline, it may not always be so.
- A diagnosis of chronic pain falls outside the Minor Injury Guidelines.
The following benefits may be available to a person after an accident:
Financial (you may claim entitlement in one of the following 3 categories):
- Income replacement benefits, to a maximum of $400 per week (unless your purchased optional benefits), if you are unable to do your job. Benefits are calculated as 70% of your gross income before the accident, capped at the $400.00 maximum. Benefits commence one week following the loss and continues for up to two years provided you remain unable to do your own job. Benefits continue after the two year mark only if you are unable to do any job, to age 65, after which a decreased amount is available.
- Non-earner benefits, of $185.00 per week, commencing 26 weeks post-accident, if you are unable to ‘carry on a normal life,’ and do not qualify for the income replacement benefit or the caregiver benefit. If you were in school at the time, or in certain situations, had graduated less than one year prior to the accident, the non-earner benefit increases to $320.00 per week after two years.
- Caregiver benefits – if you were the caregiver to someone before the accident, i.e. children, disabled relatives, but can no longer provide that care post accident, you may be entitled to receive $250.00 per week for the first person, and $50.00 per week for each additional person you are no longer able to provide care for. This benefit is available for the first two years following an accident where you suffer a substantial inability to engage in caregiving activities. After two years, this benefit continues only where you suffer a complete inability to carry on a normal life. After the law was changed in 2010, this benefit is only available to people who have sustained a catastrophic injury or who purchased optional benefits.
Medical and Rehabilitation Benefits
Medical and rehabilitation benefits cover medical expenses not covered by OHIP, such as massage therapy, physiotherapy, chiropractic treatment, acupuncture, medications, assistive devices and necessary home and vehicle alterations. The amount of coverage for these services varies depending on how the insurer classifies your injuries. For injuries classified as minor, only $3,500.00 is available. For injuries classified as non-catastrophic, $50,000.00 is available, over a 10 year time limit. For catastrophic injuries $1,000,000.00 is available, with no time limits. These amounts may have been increased, if you purchased optional benefits.
Case Manager Services
Where there has been a catastrophic injury (or optional benefits have been purchased), a case manager is provided to co-ordinate medical, rehabilitation and attendant care benefits.
Attendant Care benefits
Coverage is provided for expenses incurred by a homecare attendant or at a medical facility, where a non-catastrophic or catastrophic injury has been sustained. Where a non-catastrophic injury has been sustained, benefits are capped at $36,000.00 over 2 years, and further limited to a maximum of $3,000.00 per month. Where a catastrophic injury has been sustained, benefits are capped at $1,000,000.00, and further limited to a maximum of $6,000.00 per month, for the duration of the catastrophic injury. Amounts may be increased through optional benefits.
Reimbursement is provided for travel expenses incurred as a result of an accident. For non-catastrophic injuries, the first 50 kilometres of each trip are ineligible for reimbursement.
Lost Educational Expenses
Where someone is injured in an accident, and cannot continue in their educational program, reimbursement is available, up to a maximum of $15,000.00.
Where someone is injured in an accident, reimbursement is available to cover costs incurred by certain family members and close relatives to visit that person. These costs must be incurred within 104 weeks of the injury, unless a catastrophic injury has been sustained.
Housekeeping and Home Maintenance
Where a catastrophic injury has been sustained, housekeeping and home maintenance benefits are available, up to a maximum of $100.00 per week for the duration of the injury.
Damage to clothing
Compensation is available where clothing, prescription glasses, dentures, hearing aids, prosthesis and other medical assistive devices are lost or damaged in an accident. For anything you replace at your expense, keep receipts.
Assessments and Examinations
Where an insurer requires medical providers to complete forms to determine and/or pay benefits, the insurer covers the cost of same, up to a prescribed limit.
In Home Assessments and Examinations
In Home Assessments may be required in cases of non-catastrophic and catastrophic injury, and are used to determine whether an injured party requires assistive devices (i.e. a cane, walker, etc.), attendant care and/or housekeeping assistance.
Death and Funeral Benefits
Where someone is killed in an automobile accident, the no-fault insurer will pay compensation as follows:
- Death Benefit $25,000.00 – payable to the spouse – where there is no spouse, this amount is divided amongst the dependants
- $10,000.00 – to a supported former spouse
- $10,000.00 – per dependant
- Funeral Benefit Up to $6,000.00
Depending on the circumstances of your case, you may be entitled to some, all, or none of the no-fault benefits listed above. If prior to your accident you purchased optional benefits, the amount of benefits to which you may be entitled may be higher than the amount indicated above. The information contained above is only summary in nature, and your entitlement to benefits may differ. Call me today at 647-495-8995 or email me today to discuss your case.