Accident Benefits
In this section, we will describe the accident benefits available since November of 1996. If your accident occurred before this time, please contact us with your questions.
As you read about the benefits below, keep in mind that you can purchase higher levels of benefit coverage from your insurer to give you greater protection should you later become involved in a car accident. If your insurer or broker has not advised you of this option, insist that they give you full details so that you can make an informed choice.
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Income Replacement: If your were employed at the time of the accident, or for at least 26 weeks out of the previous year, you may claim a benefit equal to 80% of your net income (80% of your take home pay). Why do they base the benefit on net income? The benefit is not taxable, so the insurer is not going to pay you money that would have gone to the government anyway. Why 80%? The government and insurers figure if they pay you less than your full loss, you will have an incentive to get back to work as soon as possible. If you have disability insurance privately or through work, the insurer gets to deduct what you receive - or could receive if you apply. The car insurer now also gets to deduct Canada pension disability payments if you qualify.
The benefit is based on your average weekly income over the previous 4 or 52 weeks (whichever gives a higher average). If you are self employed, you must use the previous 52 weeks or last fiscal year. The current law requires that income be reported to the tax authorities in order to be included in this calculation.
Unless you had purchased optional higher coverage, the most the insurer has to pay you is $400 per week, even if 80% of your net income is higher than this amount.
If you were not employed for the time stated, you might be eligible for a caregiver benefit if you are the primary caregiver for someone, and have to hire help in looking after that person because of your injuries. Alternatively, there is non-earner benefit for those who suffer a "complete inability to carry on a normal life" - a very difficult test to meet!. The amount is not payable for the first 26 weeks after the accident, and after that is only $185 per week if you meet the test.
Be aware: Did you know that if you are not complying with the limitations on your license when you are involved in an accident, you will probably not be able to claim any weekly benefits? This is particularly important for those with G1 and G2 licenses, as there are significant restrictions that must be complied with. Recent arbitration decisions from the Financial Services Commission of Ontario have denied injured drivers income loss benefits for driving in violation of the license restrictions.
Medical and Rehabilitation Expenses: This covers things like physiotherapy, chiropractors, medication, medical devices, home modifications, rehabilitation programs, retraining etc. if "reasonable and necessary" because of the accident. For non-catastrophic injuries, coverage extends for a period of ten years with an overall financial limit of $100,000. If you sustain "catastrophic injuries" as defined in the regulation, the total coverage is up to a million dollars of expenses, and there is no time limit.
Attendant care: this is to cover the cost of things like nursing services, and other personal care necessary because of the injuries. If your injuries are non-catastrophic, the coverage is only for two years, with a monthly maximum of $3,000 and total payout of no more than $72,000. If your injuries are catastrophic, there is no time limit but the monthly amount is limited to $6,000 and total lifetime limit is $1,000,000. While this may sound like a lot of money, for some situations such as brain injury cases, these limits will fall far short of the cost involved with some care facilities.
Other expenses: there is coverage for housekeeping/home maintenance up to two years at $100 per week (for non-catastrophic cases); lost educational expenses; visitor expenses; and damage to clothing or other items such as glasses caused by the accident.
Death benefits: If death results from an accident, amounts are payable to spouses and dependents. There is also coverage for funeral expenses up to $6,000.
To link to a copy of the most current schedule of accident benefits click here. This version contains changes that will come into effect October 1, 2003 as noted. As further changes come into effect, this link will provide an up to date consolidation of the regulation.
PROCEDURAL QUESTIONS
There are time limits for applying for benefits. Notify your insurer within 7 days. Submit the Accident Benefit forms within 30 days. Now any benefit application, or expense claimed is to be submitted within 7 days. Delay may lead to denial of a benefit.
Your insurer is entitled to medical and income information as long as it is reasonably necessary in order to assess and calculate entitlements. Your insurer is entitled to have you examined by doctors of their choosing, as often as is reasonable.
Disputes frequently occur in accident benefit claims. The insurer may refuse to pay disability benefits because they don't believe you are disabled. They may refuse to pay for treatment because they don't accept as reasonable and necessary because of the accident.
What can you do? Prior to March 1, 2006, injured persons were entitled to request a medical examination at a Designated Assessment Centre. These were health care providers in your community that have been authorized by the Ontario government to conduct what are supposed to be neutral examinations. If they agreed that your injuries entitle you to the benefit claimed, the insurer must pay. However if they support the insurer's position, you could still fight for your benefit. However, as of March 1, 2006, there is no more right to a DAC for any accident since November 1996. The insurer still has a right to their own doctors conducting examinations and rendering opinions, and the injured person theoretically has a right to have their own doctor write a rebuttal. However this is not binding. In fact there is nothing to require the insurer to pay short of an arbitration or court order!
The first step is "mediation" through the Ontario Financial Services Commission. A "mediator" designated by the government will meet with you and the insurer, either in person or by telephone conference to explore whether settlement possibilities.
If you and the insurer cannot agree, you have a right to sue your insurer, or to have a hearing conducted by an arbitrator at the Financial Services Commission to decide your rights.