Accident Benefits

What are “accident benefits”?

Every automobile insurance policy (including all the vehicles described in Motor Vehicle Accidents) includes certain “accident benefits” that your insurance company will pay, depending upon your needs following an accident.

Accident benefits are available to you regardless of fault. It does not matter how the accident happened, or whether any other vehicle was involved.

Accident benefits are available regardless of whether you were the driver, the passenger, or even a pedestrian. If an automobile was involved in the accident (and this includes all the vehicles described in Motor Vehicle Accidents), these benefits will usually be available.

Accident benefits are also available even if you do not have your own insurance policy. (See below for further information.)

Accident benefits may include the following: weekly benefits, medical and rehabilitation benefits, attendant care benefits, housekeeping and home maintenance benefits, and miscellaneous benefits. Each of these are explained in the information below.

Who can get accident benefits?

Accident benefits are typically available to anyone who has been injured in an accident involving an automobile (including all of the vehicles described in Motor Vehicle Accidents). Whether specific benefits are available will depend on the nature and extent of your injuries.

Family members are also entitled to receive accident benefits, even if they are not involved in the accident, but they suffer from a mental or psychological condition as a result of the injuries to the family member who was involved in the accident.

What about my lost income?

Income that you lose during the course of your recovery may be compensated for by weekly benefits. Weekly benefits are divided into three types:

• Income replacement benefits
• Caregiver benefits
• Non-earner benefits

If you were employed or self-employed at the time of the accident and cannot fully return to work as a result of your injuries, you may qualify for an income replacement benefit. This benefit will compensate you for 70% of your lost gross income, up to a maximum amount set out in your policy. Typically, the maximum is $400 per week, but it may be as high as $1,000.00 per week. No benefit is paid for the first 7 days after the accident.

If you provided care to someone else at the time of the accident (a child or someone with special needs), and your injuries prevent you from providing that care, then you may qualify for a caregiver benefit. This benefit will compensate you for costs you incur in having someone else provide that care for you while you recover. Typically, the maximum amount for this benefit is $250 per week for the first person you care for, and an additional $50 per week for each additional person. In many cases, caregiver benefits will only be available to those who are determined to have sustained a “catastrophic impairment”, however, this will depend on your policy.

If you fall within more than one of these categories, then you may have the right to choose the benefit you receive. It is strongly recommended that you seek legal advice prior to making such a decision.

The availability and duration of each weekly benefit will depend upon the nature of your injuries, the extent of your limitations, and the speed of your recovery.

What about my treatment costs?

Treatment costs that are not covered by OHIP, or from some other source, may be covered by medical and rehabilitation benefits.

Medical and rehabilitation benefits are intended to pay for treatment you need to recover from your injuries and return to a normal life. These typically include: physiotherapy, massage therapy, chiropractic therapy, assistive devices (such as walkers, wheelchairs, etc.), modifications to your home, and psychological treatment.

The amount of medical and rehabilitation benefits that are available will depend on the nature and extent of your injuries. In most cases the benefits will pay for up to $65,000 in treatment over the course of 10 years. If you have been found to have suffered a “minor injury”, then your benefits may be limited to $3,500 in treatment. Conversely, if you are found to have suffered a “catastrophic impairment”, the maximum might increase to $1,000,000 over the course of your lifetime. However, these amounts may change depending on the optional benefits that you may or may not have purchased with your insurance policy.

Medical and rehabilitation benefits generally need to be pre-approved by the insurance company before you receive the treatment. You will need to have your doctor or other treatment provider complete forms that are then sent to the insurance company for approval.

Depending on the nature and extent of your injuries, you may require an attendant to help you with personal hygiene, dressing, and other daily care. Attendant care benefits may be available to help pay for these costs.

Attendant care benefits will typically pay up to $3,000 per month, for up to 2 years after the accident, but only to a maximum of $36,000. In the case of very serious injuries, the benefit may be increased to $6,000 per month, and to a maximum of $1,000,000 over the course of your lifetime. However, these amounts may change depending on the optional benefits you may or may not have purchased with your insurance policy.

What if I need help around the house?

Depending on the nature and extent of your injuries, you may not be able to do your regular tasks around the home. Depending on the optional benefits you may or may not have purchased with your insurance policy, you may be entitled to receive a housekeeping and home maintenance benefit to help you cover the costs of having someone else do these tasks for you.

If this benefit is available, it will typically pay up to $100 per week, for the first 104 weeks. If you are found to have sustained a “catastrophic impairment”, then this benefit may be payable for a longer period of time.

What other benefits might be available?

Depending on the severity of your injuries, and the optional benefits you may or may not have purchased with your insurance policy, you may be entitled to the services of a case manager, who will coordinate your treatment.

If you were enrolled in an education program at the time of the accident, and your injuries prevent you from continuing in that program, you may be entitled to a lost educational expenses benefit. This benefit will reimburse incurred expenses for tuition, books, equipment, etc. up to a maximum of $15,000.

Family members who visit you during the course of recovery may be entitled to compensation for the expenses that they incur during these visits, for the first two years after the accident. In the case of very serious injuries, this benefit may be paid for a longer period of time.

If any of your clothing, prescription glasses, dentures, hearing aids, prostheses, or other medical or dental devices were damaged in the accident, then you may be entitled to recover the costs of either repairing or replacing these items.

Additional benefits, or increased amounts of benefits, may be available if purchased with the automobile insurance policy.

What if the person dies as a result of the accident?

If the person involved in the accident dies either in the accident itself, or shortly after the accident as a result of injuries they suffered in the accident, then the surviving family members may be entitled to a death benefit.

Typically, the amount of this benefit is as follows:

• The spouse of the deceased person may receive a $25,000 benefit (if the deceased person did not have a spouse, then this benefit is divided amongst any dependants)
• Each dependent of the deceased person may receive a $10,000 benefit
• If the deceased person was dependant on someone else, that person (or their spouse or any dependant) may be entitled to receive a $10,000 benefit
• If the person involved in the accident dies as a result of injuries they suffered in the accident, then the family is entitled to recover a benefit to help pay for the costs of the funeral. This benefit will typically pay for incurred expenses up to $6,000.

Where do I get accident benefits?

• If you own an automobile, even if it was not involved in the accident, you will look first to your own insurer for accident benefits.
• Accident benefits are available even if you do not have your own insurance policy, and even if you were not an occupant of a vehicle at the time of the accident.
• If you were an occupant of a vehicle involved in the accident, the following order will determine which insurance company will pay for your accident benefits:
  
  • Your own automobile insurance company. This includes any insurance company that provides you with coverage, such as your spouse or parent’s insurance company
  • The insurance company for the vehicle you were in at the time of the accident
  • The insurance company for any other vehicle that was involved in the accident.
• If you were not an occupant of a vehicle involved in the accident, then the following order will determine which insurance company will pay for your accident benefits:
  
  • Your own automobile insurance company. This includes any insurance company that provides you with coverage, such as your spouse or parent’s insurance company
  • The insurance company for the vehicle that struck you
  • The insurance company for any other vehicle involved in the accident.
• If you do not have access to any insurance policy, and none of the vehicles involved in the accident were insured, you can still receive accident benefits from the Motor Vehicle Accident Claims Fund.

How do I claim accident benefits?

You must contact the insurance company as soon as possible, within 7 days of the accident. It is strongly recommended that you seek legal advice with respect to the various requests that will come from your insurance company and that are listed below:

• The insurance company will provide you with a package of forms that need to be completed, including an Application for Accident Benefits form. This form needs to be completed within 30 days of the accident. In some circumstances, you may still be able to apply for benefits later than 30 days after the accident.
• Depending on the benefits that you may be entitled to receive, the insurance company will also need various other forms to be completed by your doctors, other treating professionals, and your employer. Different forms will be due at different times, so it is important to have these forms completed as soon as possible.
• The insurance company may request various documents from the hospital, your business if you are self-employed, or your family doctor. These documents will have to be obtained as soon as possible, and you may be required to sign authorizations for these forms to be released.
• During the course of your claim, the insurance company will likely request that you participate in various assessments by doctors, occupational therapists, or other professionals. If you are self-employed, you or the insurance company may retain an accountant to help calculate your income. Depending on the circumstances, there can be significant consequences for failing to cooperate, which can include the suspension or termination of benefits.
• The insurance company may also request an interview, a sworn statement about the accident and your claim, or even that you submit to questioning under oath.
• Over the course of your claim, there may be disputes with the insurance company over whether or not you are entitled to certain benefits. A dispute resolution process is available to resolve these disputes, but that process must be initiated within 2 years of any denial of benefits.

What if I have other insurance policies available to me, or was injured during the course of work?

If you have other insurance coverage (short-term disability, long-term disability, or medical coverage), it may affect the accident benefits available to you. Depending on the nature of the coverage, you may have to apply for those benefits before you can receive applicable accident benefits.

If the accident happened while you were in the course of your employment, you may be entitled to receive benefits from the Workplace Safety and Insurance Board (WSIB).

If WSIB benefits are available to you, you will have to make a choice as to which benefits you wish to receive. It is strongly recommended that you seek legal advice with respect to any such decision, as it can have serious effects on your rights to compensation.

What if my accident happened outside of Ontario?

Different provinces have different insurance schemes to deal with automobile accidents. If you are involved in an accident outside of Ontario, but are insured in Ontario, then you may have an election as to which provincial insurance scheme will apply. It is strongly recommended that you seek legal advice prior to making that decision.