By Junior Libby [CC0], via Wikimedia Commons

by our Toronto Personal Injury Lawyer

All drivers in Ontario must be insured and all insurance policies provide for Accident Benefits, which are meant to provide car accident victims with quick access to certain necessities, such as medical treatment and income replacement for unlucky individuals who cannot return to work following a car accident.  These benefits are generally available to all car accident victims, regardless of who caused the car accident, hence the term “no fault”; it does not matter whose fault it is, nearly all car accident victims can make a claim for these benefits.

In a perfect world, the Accident Benefits claim system was meant to be user friendly, and accessible to the public without the need for legal representatives to serve as go-betweens for victims and insurance companies. However, if you take a look at the Statutory Accident Benefits Schedule, you’ll see a big gap between the vision and the reality; the claims system can be complicated and a qualified legal professional – a lawyer or paralegal – can serve as a trusted guide to guide you through the claims process.

This article will set out the various types of benefits included in a Standard Automobile Insurance policy, as well as the policy limits – how much money is available – under each heading. You should know that auto insurance policy holders can change their policies by making it easier to access certain benefits or increasing the amount of benefits.  They may elect to pay a higher monthly premium to bump-up the policy limits or amount of weekly benefits payable.  If a heading has a asterix (“*”) next to it, you’ll know that policy holders can enhance or change these benefits. What we will discuss here is the standard baseline benefits available to all eligible claimants.

Income Replacement*, Non-Earner, and Caregiver* Benefits

A person who cannot return to work as a result of a car accident may be eligible for income replacement benefits (IRBS), which pay accident victims 70% of their gross income up to a maximum of $400.00 per week. Generally speaking, this benefit is only available to people who were employed on the date of the accident or were working at least 6 of the 12 months immediately preceding the accident.  This benefit is payable so long as an accident victim is unable to return to their own job. However, two years after the accident, the benefit will only be payable if a person is unable to return to any job. Otherwise, the benefit is payable indefinitely, with adjustments made as claimants reach age 65.

A person who was not employed at the time of the accident, but who nonetheless suffers a complete inability to carry on a normal life as a result of the car accident may be entitled to a non-earner benefit of $185.00/week. This benefit is not payable until six months from the date of the car accident. So long as a claimant qualifies for this benefit, it remains payable, with certain adjustments made as claimants reach age 65.

Finally, primary caregivers unable to care for their children may be eligible for caregiver benefits, which will reimburse claimants for expenses they incur hiring others to care for their dependents up to a maximum of $250.00/week for the first child and an additional $50.00 for each subsequent child. Under a standard auto insurance policy, this benefit is only available to people who have suffered a catastrophic impairment. This benefit is payable for two years following the auto accident, following which time, it is only payable if the caregiver suffers a complete inability to carry on a normal life, in which case it may be payable for the duration of an accident victim’s entire life.

Lost Educational Expenses

An insurance company may pay up to $15,000.00 to reimburse car accident victims for tuition, books, equipment and room and board if they have incurred these expenses as part of an education program that they can no longer participate in as a result of the car accident.

Benefits for Damage to Personal Property

Standard policies include provisions that reimburse accident victims for reasonable expenses incurred to repair or replace personal items such as clothing, dentures, hearing aids, prescription eye wear, and any other items a person was wearing that were damaged in an accident.

Attendant Care* and Housekeeping* Benefits

Car accident victims unable to carry out personal care activities, such as grooming, bathing, meal preparation, etc., may apply to have the car insurance company pay for expenses incurred to hire an attendant to assist accident victims with these activities. In order to qualify for this benefit, car accident victims must (1) suffer more than a mere “Minor Injury”; and (2) have an occupational therapist assess a victim’s attendant care needs and submit an assessment and accompanying form to the auto insurance company.

Under standard automobile insurance policies, car accident victims who have not been catastrophically impaired may be entitled to up to two years worth of attendant care benefits of $3,000.00 a month and not more than $36,000.00 in total. Catastrophically impaired claimants may access up to $6,000.00 a month for incurred expenses relating to attendant care up to a maximum of $1million for the duration of their life.

Housekeeping benefits provide reimbursement for expenses incurred for housekeeping services rendered to car accident victims who are unable to complete their pre-accident housekeeping duties. Under standard policies these benefits are only available to car accident victims who have suffered a catastrophic impairment. In that case, the auto insurer may be obligated to pay up to $100.00/week for incurred housekeeping expenses.

Medical and Rehabilitation* Benefits

Car accident victims are entitled to payment of all reasonable and necessary medical and rehabilitation expenses not covered by a private health plan or OHIP. This may include physiotherapy, massage, chiropractic, or psychiatric treatment; a gym membership and sessions with a personal trainer; occupational or vocational therapy; assistive devices such as long handed brooms, shower stools or adjustable beds; and generally any other good, service or treatment that may be reasonable and necessary to reduce or eliminate the effects of an accident related disability or to facilitate a car accident victim’s reintegration into his or her family, society and the labour market.

The Ontario government has determined “most persons injured in car accidents in Ontario sustain minor injuries” and have therefore passed the Minor Injury Guideline (pdf), which limits medical rehabilitation benefits to $3,500.00 for all victims who have sustained a “Minor Injury”, as defined in the Guideline.

Car accident victims that sustain more than a Minor Injury, or are able to convince the insurance company that they are not bound by the Minor Injury Guideline, are eligible to receive up to $50,000.00 in medical and rehabilitation benefits. Catastrophically impaired accident victims may have access to $1 million in medical rehabilitation benefits over the course of their lifetime.

Death and Funeral Expenses

Sadly, car accidents sometimes cause fatalities. When they do, eligible spouses may be entitled to a lump sum payment of $25,000.00. Dependents of the deceased may be eligible to receive lump sum payments of $10,000.00 each.  The auto insurer may also contribute up to $6,000.00 towards a funeral.

Visitors Expenses

Insurers may repay reasonable and necessary expenses incurred by (immediate) family members, including grandparents and grandchildren, to visit the accident victim. Generally, this benefit is only payable for the first 104 weeks following an accident, unless the victim has been catastrophically impaired.

Sounds Simple, right?…

In this article, an attempt was made to make Accident Benefits as simple as possible to understand. In reality, the claims process is not so simple.  Accident victims must first fill out initial applications and make elections with respect to what weekly benefits they may claim, if any, often without knowing much about the process.

Next, submitting claims and receiving repayment for incurred expenses is complicated and takes time, and often, a claimant has already paid money out of pocket and is waiting weeks if not months (or years!) for the insurer to pay them back. More complicated still are the insurers rules regarding proof that expenses are incurred; in the case of housekeeping, caregiving and attendant care, claimants must first be eligible for the benefit (i.e. have purchased enhanced benefits or convinced the insurer that they have more than a Minor Injury), and then have to meet a whole other set of qualifying rules too complex to discuss here.

Similarly, claims for medical and rehabilitation expenses must be made on approved forms prior to receiving any goods, services or treatment. Once submitted, insurers have a right to scrutinize the applications and send claimants for assessments to determine whether the requested goods or services are reasonable and necessary. Then, once claims are denied, car accident victims must navigate the dispute resolution process, which involves mediation and then arbitration or lawsuits, if necessary.

Put simply, there’s rarely anything simple about the claims process and an experienced car accident lawyer can help explain the process to you and provide valuable assistance and advocacy in the event that the insurance company denies any of your claims.

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