1. I was injured in a car accident [1]. Am I entitled to compensation?
In addition to the possibility of a lawsuit to recover a money award
or settlement for injuries, pain and suffering and other losses,
Ontario's government requires automobile insurers to provide certain
mandatory benefits to most people who are injured or killed in car
accidents. These benefits are called "statutory accident [2]
benefits". The statutory accident [3] benefits system operates on a
"no-fault" basis. This means that, subject to some limited
restrictions, you may be entitled to compensation even if you are the
one that caused the accident [4].
As an injured party, you may well be entitled to receive benefits
regardless of whether you were a driver, passenger, cyclist or
pedestrian. You, as well as your family members and dependants, can
often receive benefits even if you did not have car insurance at the
time of the accident [5].
There are often disputes about what benefits you are entitled to and
what insurance assessments you are required to attend. It is often a
good idea to consult with a personal injury lawyer to determine what
you are entitled to and what steps you need to take to protect your
interests.
2. What kind of benefits can I receive?
Income Replacement Benefits - these benefits are designed to reimburse
you for some of the money you lose as a result of being unable to work
due to an injury suffered in a car accident [6]. Benefits are not
payable for the first week and you must meet a disability test to
qualify for the benefits. The disability test becomes more difficult
to meet after more than two years have passed since the accident [7].
You can receive income replacement benefits whether you are an
employee or a self-employed individual. The maximum that you can
receive is generally $400 per week, unless other optional increased
benefits are purchased.
If you are self-employed, your income calculation will be more
complicated and insurers often hire accountants to assist them with
these calculations.
Non-earner Benefits - you may receive these benefits if you are 16
years of age or older and have suffered a complete inability to carry
on a normal life as a result of the accident [8] within 104 weeks
after the accident [9]. A lawyer can assist in explaining what
"complete inability to carry on a normal life" means and how that term
has been interpreted by the cases. The benefits are only available to
certain classes of people, ie: unemployed but enrolled in school on a
full-time basis, or have completed your education less than one year
before the accident [10] and not be employed in a job that reflects
your education and training.
The amount of the non-earner benefit is generally $185 per week,
although nothing will be payable for the first 26 weeks of the
disability. However, if your disability has lasted for more than 104
weeks, you will be entitled to receive $320 per week following the
initial 104 week period.
Caregiver Benefits - these benefits may be payable if you (the injured
person) were living with a person in need of care (such as a young
child or an elderly parent) prior to the accident [11] and were not
being paid for these services. You may be able to recover reasonable
and necessary expenses up to a maximum of $250 per week for the first
person in need of care and $50 per week for each additional person.
You should note that when it comes to the income replacement,
non-earner and caregiver benefits, only one of these three benefits
can be paid at any given period of time.
Medical and Rehabilitation Benefits - this benefit deals with
reimbursement for reasonable and necessary expenses such as medical,
surgical, dental, optometric, hospital, nursing, ambulance, audio
metric, speech-language pathology, chiropractic, psychological,
occupational therapy, physiotherapy, medication, prescription eyewear,
dentures, hearing aids, wheelchairs, prostheses, orthotics,
transportation to and from treatment sessions (excluding the first 50
kilometers of the trip in the injured person's vehicle),
workplace/home/vehicle modifications, life skills training,
counseling, and vocational assessments.
Subject to some exceptions set out in the pre-approved framework
guidelines, you must submit a treatment plan to the insurance company
prior to beginning treatment. If you do not submit a treatment plan,
the insurance company could refuse to compensate you for treatment.
The treatment plan must be prepared by a health professional and
signed by one of the following - physician, psychologist,
physiotherapist, dentist, or optometrist.
You can receive a maximum reimbursement of $100,000 for "reasonable
and necessary" expenses acquired in the period of 10 years following
the accident [12]. If you suffered "catastrophic impairment", you may
be entitled to receive up to $1,000,000 incurred over your lifetime.
Attendant Care Benefits - this benefit may provide compensation for
services of an aide or an attendant who is assisting you due to your
injury. This could include services of a family member or other aide
looking after you at home, or services provided by a long-term care
facility including a nursing home, home for the aged or chronic care
hospital.
You may be entitled to a maximum of $3,000 per month for two years
following the accident [13]. If you suffered "catastrophic
impairment", you may receive up to $6,000 per month up to a maximum of
$1,000,000 without a time limit. The insurer may ask you to provide it
with a certificate from a health professional confirming that you
require attendant care services.
Funeral and Death Benefits - when a person dies due to a car accident
[14], his or her estate may be entitled to reimbursement of funeral
expenses to a maximum of $6,000.
The deceased's spouse, dependants and caregivers may also be entitled
to death benefits. Death benefits are usually only payable if the
deceased died within 180 days after the accident [15], or, if the
deceased was continuously disabled as a result of the accident [16],
within 156 weeks after the accident [17]. No benefits will be payable
to a person who dies before the deceased or within 30 days after the
deceased.
A spouse may receive $25,000 if the deceased was married. If the
deceased was not married, but had dependents, the $25,000 would be
divided equally among the dependents. On top of the $25,000, each of
the dependents and former spouses of the deceased (to whom the
deceased had an obligation to pay spousal support) will be entitled to
$10,000.
If the deceased was himself or herself a dependent at the time of the
accident [18] (ex. if the deceased was a minor child), $10,000 would
be payable to the person upon whom the deceased was dependent (ex.
parent or grandparent) or, if that person is dead, to that person's
surviving spouse or dependents.
Visiting Expenses - if you sustained injury in a car accident [19],
your family members and individuals who were living with you at the
time of the accident [20] may be entitled to reimbursement for all of
their reasonable and necessary expenses incurred as a result of coming
to visit you during your treatment or recovery. The visitors will only
be reimbursed for expenses incurred within 104 weeks after your
accident [21], unless your injury is catastrophic.
Lost Education Expenses - if, due to your injuries, you are unable to
continue in the education program in which you were enrolled at the
time of the accident [22], you may be entitled to claim [23] for your
lost education expenses up to the maximum amount of $15,000. You may
get reimbursed for expenses incurred before the accident [24]
including tuition, books, equipment or room and board.
Housekeeping and Home Maintenance Expenses - you may receive
compensation for reasonable and necessary housekeeping and home
maintenance expenses, if your injury resulted in a substantial
inability to do your housekeeping and home maintenance and you
normally performed home maintenance services before your accident
[25]. Your housekeeping and home maintenance expenses may be paid for
104 weeks to a maximum of $100, unless the injury is catastrophic, in
which case the time-limit does not apply.
Psychological and Mental Injuries - your family members and dependents
(whether related or not) may be entitled to receive benefits if they
have suffered psychological injuries as a result of your accident
[26].
Cost of Examinations - you may be reimbursed for reasonable fees
charged by health care providers in preparing disability certificates,
reviewing and approving treatment plans, preparing applications for
approval of assessments or examinations, preparing assessments of
attendant care needs, and preparing applications for determinations of
catastrophic impairment. You are normally required to obtain consent
of the insurer before incurring examination expenses. However, there
are certain exceptions. Your treatment providers may well be able to
assist you in applying for these benefits
Other Expenses - you may be entitled to be reimbursed for all
reasonable expenses you incurred in repairing or replacing clothing,
prescription eye wear, dentures, hearing aids, prostheses and other
medical or dental devices that were lost or damaged as a result of the
accident [27].
3. How can I claim [28] my benefits?
Compensation will not be paid to you automatically following your
accident [29]. In order to receive benefits, you should notify your
insurer within seven days of the date of the accident [30] that you
wish to submit an application. Late applications are made in many
cases and you could discuss this with a lawyer. The insurer will then
be required to send you the application forms as soon as possible. You
will have to complete the forms and send them back to your insurer
within 30 days. If you will not be able to meet the 30-day deadline
because of the severity of your injuries, it is probably a good idea
for you to advise your insurance company (but you may well wish to
seek legal advice from a lawyer).
4. Which insurance company will provide my statutory accident [31]
benefits?
If you have car insurance or if you are a listed driver on someone
else's auto insurance policy, your own insurer will likely be
responsible for providing you with benefits.
If you do not have auto insurance, and you were injured in a car
accident [32] as a pedestrian or a cyclist, you may be able to apply
to the insurance company that insured the car that hit you. If you
were a passenger, you may well be able to apply to the company that
insured the car in which you were riding.
In some situations, no insured drivers are involved. In such cases,
you may be able to claim [33] compensation from a special government
fund (the "Motor Vehicle Accident [34] Claims Fund") set up to handle
these type of scenarios.
It is important to remember that statutory accident [35] benefits will
generally only compensate you for losses that are not covered by some
other private insurance policy or employment benefits plan. If these
other policies or plans will cover only part of the losses incurred,
the statutory accident [36] benefits can be used to compensate you for
the balance, subject to some limitations.
5. What can I do if the insurance company denied my claim [37] for
benefits?
If you are having problems recovering benefits to which you are
entitled, you may be entitled to sue the insurer in court or try to
enforce payment through arbitration. However, before you can proceed
to court or to arbitration, you are required to mediate the dispute
with the Financial Services Commission. It is extremely important to
initiate mediation within two years from the date that the benefit was
denied. An injury/car accident [38] lawyer can provide further details
with respect to this.
http://www.personalinjurylawlawyer.ca is a website offering free
information about injury law and facilitating free lawyer case
evaluations at http://www.personalinjurylawlawyer.ca
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