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What you need to know if you have been in a Car Accident
Whether you were a driver, passenger, cyclist, or pedestrian in a car accident, or a witness to one, you are eligible for assistance via the Statutory Accident Benefits Schedule under the Ontario Motor Vehicle Insurance Policy. Some coverage is even available to the immediate family of the injured victim without them even having been involved in the incident themselves.
Have I been in an “accident” as defined by the policy?
As long as the ordinary (and not in any way illegal or improper) use or operation of a motor vehicle is the root cause of why you have become injured, you are likely eligible for assistance under the Accident Benefits (Section B) portion of your Ontario Automobile Insurance Policy. Should you hurt yourself while filling your vehicle with gas, scraping off the ice or even attaching a trailer to it, you are just as eligible for help as if you had been involved in a collision with someone else.
NO. If you are in a single vehicle incident by yourself, or if you cause a motor vehicle collision, you are still eligible for assistance. Your coverage(s) may be limited or somewhat curtailed if you are charged with a criminal offence however, and you should consult a qualified legal representative immediately to understand how and what you can do to try and fix the problem.
If you are in an accident with a vehicle you use for work, talk to your employer. If it is your personal vehicle, contact your broker or insurance company directly and as soon as possible. If you are a pedestrian, cyclist or a passenger in someone else’s car, you will seek help from your own insurance policy. If you do not have an insurance of your own, you would seek help from the insurer of the vehicle that you were in or one of the vehicle(s) involved that led to your injury (if you are a pedestrian or cyclist). If that information is not given to you by the other party, contact the police whom investigated the accident to obtain a copy of the Accident Report, where that information will be listed. If you are a minor, student or simply dependant on someone else who owns a car, you can also make a claim through that policy (usually your parents or a spouse). If you are a pedestrian hit by an uninsured driver, you can obtain some assistance from Ontario’s Motor Vehicle Accident Claims Fund.
Will making a claim affect my premiums?
NO. Accident Benefit claims are non-ratable by Insurers. DO NOT DELAY in contacting your Insurance Company to tell them of an injury to you or a loved one over fear of your rates going up, as any unreasonable delay could affect your coverage(s). Even if you subsequently need to cancel your policy because your vehicle is destroyed or you can no longer afford it, or if you decide to change insurance carriers, your accident coverage(s) remains preserved regarding the incurred loss.
What kind of assistance is available to me?
Accident Benefits are limited indemnity coverages that, subject to you passing the respective disability test for each benefit type, provide you modest funds for reimbursement of wage loss and for help you need getting well again, both physically and emotionally. You can also obtain domestic and child-care assistance if you are substantially disabled from carrying on with your pre-accident responsibilities and tasks. Some of the key benefits include:
Specified Weekly Benefits such as:
- Income Replacement Benefits calculated as 80% of your net pre-accident wages providing you are employed at the time of the accident or have been employed for at least 26 of the last 52 weeks immediately preceding the accident. Coverage is capped @ $400/week, unless you have pre-purchased an optional increased weekly allowance, and there is a 1 week waiting period/deductible. This sum is reduced by any post-accident wages or collateral short/long-term disability benefits coverage you have available to you, including CPP disability benefits. After 104 weeks of disability, the entitlement test becomes more severe and focuses on whether a person can return to any job for which they are suitable and not just their pre-accident employment.
- Caregiver Benefits allowed as $250 for your first child or dependant (whom lives with you) and $50 for each additional party as long as you were their primary caregiver pre-accident and are substantially disabled from resuming your caregiving duties and responsibilities. Eligible children must be under 16 years of age and benefits are not paid automatically but instead as a reimbursement for the help that you are determined to need and receive or should have received after medical evaluation. After 104 weeks of disability, the entitlement test broadens its focus to look at all of a person’s pre-accident activities of daily living and not just parenting or support of a dependant. This coverage can also assist people whom live with and care for compromised adult children, parents or spouses, if that person is categorized as under medical or physiological disability.
- Non-Earner Benefits allowed at $185/week, but not until one turns 16 years of age, and if that criteria is satisfied already, not for the first 26 weeks of disability. Students or recent graduates (adult or youth having been enrolled or attending full-time in a recognized education program) whom finished their studies not more than 1 year pre-accident are bumped up to $320/week after 104 weeks from the onset of their disability. This benefit is really designed for youth, the elderly and the unemployed and is subject to a stringent ‘complete inability’ test that looks at whether one’s key critical pre-accident lifestyle, vocational plans and general activities are derailed and continuously compromised post-loss.
Housekeeping and Home Maintenance Benefits: For up to 104 weeks post accident and subject to you being identifiably substantially disabled from those duties, you can obtain no more than $100/week in reimbursement for the services of family, friends or professionals in assuming and then performing your pre-accident domestic chores whilst you are incapacitated.
Attendant Care Benefits: For up to 104 weeks post accident and subject to you being identifiably substantially disabled from those personal activities, you can obtain limited reimbursement for the services of family, friends or professionals in helping you with basic life tasks such as cooking you a meal, feeding you, dressing you, dispensing medication, assisting you with bathing and other defined activities from a specific list in the policy during critical times of your illness, usually occurring right after your accident. A cap of $3000/month is applied.
Medical & Rehabilitation Benefits: For up 10 years post accident you have the right to submit claims for consideration that are of a medical nature. There are a large range of services one might need to heal post accident and return to their pre-existent lifestyle, including activities at home, at school and in the workplace. Most commonly, the insurer will assist with partial reimbursement to health professionals for services like physiotherapy, chiropractic care, massage therapy or psychological counseling at proscribed and capped rates set by the Financial Services Commission of Ontario. With serious injuries, alterations to homes, cars or the provision of wheelchairs and other medical devices is also addressed at market rates. Medication(s) coverage is available as well, but transportation assistance is quite limited and comes with a 50km round-trip deductible. All medical servicing is subject to being vetoed by the insurer whom one must usually seek pre-approval from before obtaining the assistance. Should one reach the maximum $100,000 claim limit for medical and rehabilitation services, coverage ceases even if 10 years has not yet passed.
Is there an enhanced level of coverage I can access?
YES. You can pre-purchase optional levels of assistance from your insurer to increase your medical/rehabilitation limits, raise your weekly income benefit and index your assistance to inflation so that benefits keep pace with the cost of living. There are other coverage(s) too and you should contact your broker or insurer for a full listing.
Additionally, your accident injuries may be so severe immediately or worsen more progressively over time, such that you are initially identified or later medically determined to be “CATASTROPHICALLY” impaired as defined under the policy. In such instances you gain access to enhanced assistance for a greater duration, notably including: an increase in Attendant Care Benefits up to $6000/month with lifetime access or until $1,000,000 is incurred; Medical & Rehabilitation Coverage available to you past 10 years post-loss and for the balance of your natural life or until you exhaust $1,000,000 in expenses; the right to have a medical case-manager appointed to plan, coordinate and ‘quarter-back’ the provision of services to you; and further extension of Housekeeping and Home Maintenance coverage(s) beyond 104 weeks post loss and for the balance of your life.
What benefits are available for my family?
When you are hurt in a motor vehicle accident the effects are felt by your loved ones too. There are certain benefits designed for people other than the initial victim but if a spouse, sibling, grandchild, grandparent or dependent of the first physically injured person is traumatized to the point that they suffer a psychological or mental injury, they also become eligible for a full range of benefit assistance through their own automobile policy’s accident benefit coverage. This often happens with grave, fatal and grossly upsetting injuries that cause loved ones to miss work, have difficulty functioning in everyday life and need to seek out emotional support through professional counseling.
Visitor’s Expenses can be reimbursed to the immediate nuclear family of the injured person for those reasonable costs they incur in rushing to that person’s bedside be they air, rail or any variety or mode of transport, and can additionally include temporary housing costs (such as hotels) during those visits be they immediately after the accident or for subsequent visits conducted in the first 104 weeks post-loss, when specifically checking in on a loved one whom remains disabled by their accident injuries.
Death & Funeral Expenses are available as limited and immediate compensation and partial indemnity, to deal with the direct, causal loss of life of a loved one in a motor vehicle accident. Enhanced coverage can be purchased from your insurer to raise the basic limits of up to $6000 in reimbursement for Funeral and related burial costs as well as a $25,000 payment to a surviving spouse as defined under the Insurance Act. Further payments of up to $10,000 for the loss of a dependent child or legally separated dependant spouse, or conversely $10,000 to each child or dependant, when a parent is killed, are also available as long as the deceased passes from accident related injuries that kept them continuously disabled for that self-same period of no greater than 156 weeks (3 years) post-loss.
Where can I find further information or get help?
While it is the responsibility of the Insurer paying your accident benefits to explain all coverage(s) and provide you with the forms to make claims, the regrettable truth is that such advice is often delivered only in writing and the adjuster is too busy to return your call in a timely way. You can visit the Financial Services Commission of Ontario website (www.fsco.gov.on.ca) for some basic consumer information, but the wealth of forms and procedures can be overwhelming to most healthy people, let alone someone who is suffering the effects from a car accident or struggling to look after an injured loved one.
If you are seeking legal advice, ensure that you talk to a representative that is happy to speak to you without obligation and respond to your questions with straight answers you can understand – no insurance lingo or confusing legalese. Ask the right professionals to help you make fair, timely and appropriate submissions for the assistance you are entitled to so you can concentrate on getting better, and getting back to your life.
Ross Baker, Paralegal - Gillis-Zago Personal Injury Lawyers
