accident benefits coverage in ontario

8/6/2019 Accident Benefits Coverage in Ontario

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Accident Benefts

Coverage in Ontario


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Accident Benefts Coverage in Ontario


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This document is intended as an overview o the accident benefts available to you under Ontarioinsurance laws. It does not contain every detail o the auto insurance legislation. For the precisewordings o the law, you should consult the Ontario Insurance Act and the Statutory AccidentBenefts Schedule (SABS) made under that act.

With appropriate acknowledgement, this publication may be reproduced and may be used inwhole or in part, provided that such reproduction is intended or personal or educational useand not or monetary gain o any kind. Recommended acknowledgement: In ormation providedcourtesy o Insurance Bureau o Canada.

Contents

I You Are in a Motor Vehicle Collision ........................................................2

Specifed Benefts ..............................................................................................4

Death and Funeral Payments ..........................................................................8

Medical, Rehabilitation and Attendant Care Benefts ..............................10

Payment o Other Expenses .......................................................................14

Getting the Process Started ...........................................................................16Paralegals (SABS Representatives) ...............................................................18

Right to Sue ......................................................................................................19

Additional In ormation and Help ................................................................21


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I You Are in a Motor Vehicle CollisionWho is eligible or benefts?Any person who is injured in a motor vehicle collision or certain relativesor dependants o any person who is injured in a motor vehicle collisionmay be eligible or benefts.

I you are insured under more than one policy, there are special rulesthat determine under which policy you are eligible to receive benefts.You should contact the insurance company that you believe is liable.

You are not eligible to receive income replacement benefts, non-earnerbenefts, lost education expenses, expenses o visitors and housekeepingand home maintenance benefts i you were in contravention o the lawat the time o the collision. Some examples o this would be:

driving without a valid drivers licence; driving a vehicle when you knew or should have known you were

driving without the owners consent; being a passenger who knew or should have known that the driver

did not have the owners consent to drive the vehicle; driving when you knew or should have known you did not have valid insurance;

driving while impaired or re using to provide a breath sample; using an automobile in connection with criminal activity; and having knowingly misrepresented in ormation when you applied

or auto insurance.

What are the benefts?Ontarios standard auto insurance policy provides you with benefts i you are injured in a motor vehicle collision regardless o who is at ault.Tese benefts are defned by regulation the Statutory Accident BeneftsSchedule (SABS) under Ontarios Insurance Act. You have the choiceo purchasing additional accident benefts to customize your policy toyour needs. Tese additional benefts are potentially available to you, yourspouse and any dependants i you or they are injured in a motor vehiclecollision. When making a claim, ascertain whether you are covered undera standard benefts policy or a policy with additional benefts.

You may be eligible or the ollowing types o benefts. For detaileddescriptions and to determine i you are eligible or any o these benefts,you should contact your insurance broker, agent or adjuster.


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INCOME REPLACEMENT BENEFITI you cannot work because o the injuries caused by a motor vehiclecollision and i you are eligible, this beneft will partially compensateyou or the loss o your income.

NON-EARNER BENEFITI you su er a complete inability to carry on your normal activitiesbecause o the injuries caused by a motor vehicle collision and i youare eligible, this beneft will compensate you.

CAREGIVER BENEFITI you cannot continue as a primary caregiver and i you are eligible,this beneft will reimburse you or expenses you incur.

MEDICAL AND REHABILITATION BENEFITTis beneft will pay or reasonable and necessary medical andrehabilitation expenses that are not covered by a government health planor a private health plan that you may have through work or your spouse.

NOTE: The auto insurance industry in Ontario pays about $150 million

per year to the Ontario Health Insurance Plan (OHIP) to ofset the cost o treating persons injured in motor vehicle collisions. You may access anyavailable OHIP service to help you recover rom your injuries.

ATTENDANT CARE BENEFITI you are unable to carry out certain personal care activities (such asbathing, toileting, dressing or eeding yoursel ) as a result o severeinjuries sustained in a motor vehicle collision and i you are eligible,this beneft will pay reasonable and necessary expenses or an aide,attendant or long-term care acility.

OTHER EXPENSES BENEFITI you are eligible, this beneft may pay or expenses such as losteducational expenses, the cost o certain people visiting you duringtreatment and recovery and reasonable costs related to housekeepingor home maintenance required due to injuries sustained in a motor vehicle collision. You may also be covered or repairing or replacingcertain items o your clothing that were lost or damaged in the collision.

DEATH AND FUNERAL PAYMENTS BENEFITTere are lump-sum payments available or survivors o a person killedin a motor vehicle collision and to help pay or a uneral.


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Applying or beneftsYou must tell your insurance company within seven days o theoccurrence o a motor vehicle collision, or as soon as possible, that youwish to apply or benefts. Te insurer will promptly provide you with abenefts application package. You must send this application or beneftsback to the insurer within 30 days o receiving the application orms.

I you are not sure which benefts you may apply or, contact your insurerto discuss what you are eligible to claim.

Where does the application go?You should contact the insurance company that you believe is liable.

If you have your own automobile insurance or believe that you arecovered under someone elses policy, return the completed applicationto that insurance company.

If you do not have your own insurance policy, return the completedapplication to your spouses insurance company or to the insurancecompany o the person you are dependent on.

If you do not have access to insurance as described above , send theapplication to the insurer o the car in which you were an occupant or,i you were a pedestrian, the insurer o the car that hit you.

If you were an occupant of an uninsured vehicle or if you were apedestrian struck by an uninsured vehicle , return the application tothe insurer o any other vehicle involved in the collision. I you believethat there is no insurance company responsible or processing theclaim, call the Motor Vehicle Accident Claims Fund at 1-800-268-7188

(or 416-250-1422 in the oronto area).

Specifed BeneftsOntarios auto insurance lawsI you have been injured in a motor vehicle collision and, as a result, youare not able to work or carry on your normal activities as be ore, thereare important acts you need to know when applying or benefts underyour automobile insurance. Tis document will help you understand theOntario laws concerning the payment o benefts to people injured inmotor vehicle collisions, including:

people who have been employed or sel -employed;


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people who have no income rom employment or sel -employment(non-earners); or primary caregivers.

Income replacement beneftI you are eligible, this beneft will partially compensate you or the losso your income i you cannot work because o your injuries.

Tis beneft is or people who were employed at the time o the collisionor, subject to certain conditions, during the year prior to the collision.You may be eligible to receive a payment at least every two weeks topartially replace the income you have lost i , as a result o the motor vehicle collision, you su er a substantial inability to per orm the essentialtasks o your job. Tis beneft is available i you continue to su er asubstantial inability to per orm the essential tasks o your job or up to104 weeks rom the onset o the disability. You may quali y or beneftpayments i you can answer yes to the ollowing questions:

Did I su er physical or psychological impairments as a result o amotor vehicle collision and, as a result, am I unable to work?

Do any o the ollowing statements apply to me? I was employed or sel -employed at the time o the motor vehicle

collision. I worked or at least 26 o the 52 weeks immediately prior to the

motor vehicle collision. I was receiving Employment Insurance (EI) benefts at the time

o the motor vehicle collision. I was not employed but was at least 16 years old or was excused

rom attending school at the time o the motor vehicle collision.However, i you answered yes to the above questions and are qualifedto receive an income replacement beneft but are eligible and elected toreceive a non-earner beneft or caregiver beneft instead, then you will bedisqualifed rom receiving the income replacement beneft.

HOW MUCH CAN YOU RECEIVE?As long as you are eligible, you will receive a payment at least once every

two weeks o 70% o your gross income based on your employmentincome history be ore the collision, minus income replacement assistancepayable rom other sources, such as your employer, to a maximum o $400 per week. I you continue to quali y or the beneft a er 104 weeks,your minimum weekly beneft will be $185. Te frst seven days o yourdisability will not be covered.


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When you bought your car insurance, you may have purchased theadditional income replacement beneft rom your insurance agent orbroker, which pays up to $600, $800 or $1,000 per week depending onyour selection at the time o purchase. Please check to see i you are

eligible to receive this increased beneft.Your gross income is your income prior to deductions and taxes.

Te amount you will receive will be calculated on the in ormation youincluded on your application orm. In general, benefts are calculatedas ollows:

I you are employed at the time o the collision, the incomereplacement is based on gross income earned either:

in the 52 weeks be ore the collision; or in the our weeks be ore the collision multiplied by 13.

I you are sel -employed at the time o the collision, the incomereplacement beneft is based on income earned:

in the last 52 weeks; or in the last fscal year completed be ore the collision.

I you are unemployed at the time o the collision but receiving EIbenefts, or had worked at least 26 weeks o the 52 weeks be ore thecollision, the income replacement beneft is based on income earnedin the 52 weeks be ore the collision including EI benefts.

I you are over the age o 65, benefts are payable or up to 208 weeksand are gradually reduced over the period.

I you reach age 65 while receiving benefts, the beneft is converted

at that time to a li etime pension at a reduced rate.Non-earner beneftYou may quali y or the non-earner beneft i you su er a completeinability to carry on your normal li e and i :

you do not quali y or the income replacement beneft; you were at least 16 years o age and a ull-time student at the time

o the motor vehicle collision; or at the time o the motor vehicle collision, you had completed your

education in the previous year but had not yet secured employmentrelated to your education.


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HOW MUCH CAN YOU RECEIVE?Te frst 26 weeks o your disability are not covered. A er this period,you may be eligible to receive:

a weekly payment o $185, less the total o all other income

replacement assistance; and i more than 104 weeks have elapsed since the onset o the disability

and you continue to quali y or the beneft, the amount will increaseto $320 or each week that you are eligible to receive the beneft, lessthe total o all other income replacement assistance.

I you are over the age o 65, benefts are payable or up to 208 weeks andare gradually reduced over the period. I you reach age 65 while receiving

benefts, the beneft is converted at that time to a li etime pension at areduced rate.

Caregiver beneftA caregiver is someone who, prior to the collision, was the primary personresponsible or looking a er others, such as a dependent child or an adultin need o care.

You may quali y or the caregiver beneft under Ontarios automobileinsurance legislation i you are an insured person and, as a result o themotor vehicle collision, you have sustained a catastrophic impairmentand are substantially unable to carry out the caregiving activities youpreviously carried out. Te law also says that at the time o the collision,you must:

be living with a person in need o your care; and

be the primary caregiver or the person in need o care and notbe receiving any payment or engaging in caregiver activities.

HOW MUCH CAN YOU RECEIVE?Te caregiver beneft reimburses you or the expense o purchasingcaregiving services or your dependants i , due to injuries you sustainedin the motor vehicle collision, you are unable to care or your dependantsas you did be ore the collision. I eligible, you will receive $250 per week

or the frst person and $50 per week or each additional person in yourhousehold or whom you were the main caregiver at the time youwere injured.

As a caregiver, you may receive benefts or up to 104 weeks while you aresubstantially unable to per orm your caregiver activities. Your insureris not obligated to pay a caregiver beneft or any period longer than 104


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weeks o disability unless, as a result o the motor vehicle collision, youare completely unable to carry on a normal li e.

When you bought your car insurance, you may have purchased theadditional caregiver beneft rom your insurance agent or broker,

which pays the beneft even i your injury is not catastrophic but youare substantially unable to per orm your caregiver activities. You may have also purchased the additional dependant care beneft, which coversexpenses or caring or your dependants i you are injured in a motor vehicle collision, employed at the time o the collision and not receivingcaregiver benefts. Te amount available is $75 per week or the frstdependant and $25 per week or each additional dependant toa maximum o $150 per week. Check with your insurer to determinei you are eligible to receive these optional additional benefts.

I you re use treatmentPlease note that your beneft(s) may cease i you re use to participatein rehabilitation or treatments that are reasonable or, in the case o theincome replacement beneft, i you are able to return to work or to obtainother employment or which you are trained but do not make a reasonable

e ort to do so.

Which beneft is right or you?You may be eligible or more than one type o beneft; however, you mustchoose only one. I your application or benefts discloses that you quali y

or more than one beneft, your insurance company will noti y you.

Death and Funeral PaymentsOntarios auto insurance lawsTere are important acts you need to know when applying or survivorbenefts under your automobile insurance i you have lost your spouse, adependant or someone on whom you have been dependent, as the resulto a motor vehicle collision.

What are the death beneft and uneral beneft?Te death beneft is a lump-sum payment made to you i you have lostyour spouse, a dependant or someone on whom you were dependent;the uneral beneft provides reimbursement or uneral expenses.


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Do you quali y or payments?Be ore you can receive the death beneft or reimbursement or uneralexpenses under an automobile insurance policy, your situation mustquali y under the statutory accident benefts coverage. You may quali y

or payments i , as a result o the motor vehicle collision, one o theollowing persons dies within 180 days o the motor vehicle collision

(or within 156 weeks i the injury sustained resulted in a continuousdisability during that period):

your spouse (or ormer spouse rom whom you were receivingmaintenance or support under a domestic contract or court order); or

the person on whom you were dependent; or a person dependent on you.

HOW MUCH CAN YOU RECEIVE?Te amount o the death beneft you will receive depends on yourparticular situation.

I you are the spouse o a person killed in the motor vehicle collision,you may be entitled to a payment o $25,000, or $50,000 i the additional

death and uneral beneft was purchased. I the deceased person had nospouse, the dependants o the deceased person will be entitled to share$25,000 equally.

In addition, i you were dependent on the person who died, or i theperson who died was obliged under a domestic contract or court orderto provide support to you, you will be entitled to a beneft o $10,000,or $20,000 i the additional death and uneral beneft was purchased.

I a dependant died as a result o a motor vehicle collision, the $10,000payment will be made to the dependants fnancial support or careprovider or, in the case that this individual has died, to the spouse o thefnancial support or care provider i the spouse was the primary caregivero the dependant. I the fnancial support or care provider and spousedo not survive or 30 days a er the collision, the $10,000 is shared by alldependants who survive or these 30 days.

Funeral expenses are reimbursed to a maximum o $6,000, or $8,000 i the additional death and uneral beneft was purchased.


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Medical, Rehabilitationand Attendant Care Benefts

Ontarios auto insurance lawsI you are injured in a motor vehicle collision and you require treatmentor your injuries, the insurer responsible to pay medical, rehabilitation

and attendant care benefts is also responsible to ensure that any claimmade on your behal is reasonable and necessary and that the goodsand services being recommended have a good chance o improvingyour health.

What is the medical beneft?Te medical beneft includes payments or reasonable and necessary expenses that are not covered by another health plan, such as OHIPor an extended health policy, and that are incurred by you or on yourbehal as a result o a motor vehicle collision in which you were injured.

Te coverage includes reasonable and necessary expenses or:

medical, surgical, dental, optometric, hospital, nursing, ambulance,audiometric and speech-language pathology services; chiropractic, psychological, occupational therapy and

physiotherapy services; medication; prescription eyewear; dentures and other dental devices;

hearing aids, wheelchairs or other mobility devices, prostheses,orthotics and other assistive devices;

transportation to and rom treatment including transportationor an aide or attendant; and

other required goods and services o a medical nature that are notcovered elsewhere.

NOTE: Your insurance company is not obliged to pay or any goods orservices that are considered experimental.


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What is the rehabilitation beneft?Te rehabilitation beneft is the payment o expenses incurred by you oron your behal , as a result o injuries caused by a motor vehicle collision.Te beneft is to reimburse you or payments you have made

or reasonable and necessary measures to: reduce and eliminate the e ects o the disability resulting rom the

injury; or assist you in reintegrating into a amily role or the labour market

(i you had a labour orce attachment) and also your community.Te coverage includes reasonable and necessary expenses or:

li e skills training; amily, social rehabilitation, fnancial and employment counselling; vocational assessments; workplace, home and vehicle modifcations; transportation to and rom counselling and training sessions

including transportation or an aide or attendant; and other goods and services required that are rehabilitative in nature.

Do you quali y or the medical andrehabilitation beneft?It is important to understand that the expense incurred must be as a resulto the injury you sustained in the motor vehicle collision, as well as beingreasonable and necessary. Tere are three classes o injury: (1) minorinjury; (2) non-minor injury; (3) catastrophic injury.

Generally speaking, minor injuries, which are defned by the SABS,include sprains and strains, cuts and bruises. Catastrophic injuries, alsodefned by the SABS, include amputation o a limb, spinal cord injuriesand severe brain damage. Non-minor/non-catastrophic injuries areeverything in between. Tese in between injuries would include brokenbones or some kinds o internal organ damage, such as a ruptured spleen.

I it is determined that you have sustained a minor injury, your healthcare practitioner (such as your amily doctor, physical therapist orchiropractor) can access immediate treatment without needing theinsurance companys approval. o obtain pre-approved treatment, yourhealth practitioner must submit a reatment Confrmation Form, calledan OCF-23, which will permit you to start treatment right away. It is


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up to your health practitioner to decide, with your in ormed consent,specifcally what kinds o treatment you will receive.

I it is determined that you have a non-minor injury, your health careprovider will submit a reatment and Assessment Plan, called an OCF-

18, which will include a description o the injury and resulting disability,i any, and a list o the goods and services and price o the goods andservices to be used in the treatment. You must sign this orm. Yourinsurer will respond to the reatment and Assessment Plan within10 business days o receiving it. I the plan meets the criteria o beingreasonable, necessary and non-experimental, the insurer will pay orexpenses within 30 days o receiving invoices.

NOTE: Do not sign a blank orm. To ensure that you are aware o howyour policy dollars are being spent, never sign a blank OCF 23 or OCF 18.

HOW MUCH CAN YOU RECEIVE FOR TREATMENT?I you sustain a minor injury, as defned by the SABS, you could receiveup to $3,500 in the medical and rehabilitation beneft.

I your injury is not minor and not catastrophic, as defned by the SABS,the medical and rehabilitation beneft payments could be up to $50,000.I your injury is catastrophic, the beneft payments could be up to$1,000,000.

You may have purchased additional benefts with higher limits. Contactyour insurance representative, broker or agent or the amounts that apply to you.

Cost o examinationsSometimes your doctor or treatment provider may seek a second opinionabout your condition or the treatment that you require. Te costs o theseexaminations are part o your medical and rehabilitation beneft. Inaddition, sometimes the insurer may seek a second opinion, but in thiscase, the costs are not part o your beneft.

Insurers are liable to pay reasonable ees, up to $2,000, or healthpro essionals to conduct an assessment or examination. Tis $2,000must include all associated costs, such as the cost o preparing a report.

Unless you have su ered a catastrophic impairment, travel expenses areonly paid i you have to travel more than 50 kilometres, and then only orthe amount in excess o 50 kilometres.


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Your insurer will not pay or an in-home assessment i you sustain aminor injury.

What is the attendant care beneft?

In some cases, your injuries that resulted rom the motor vehicle collisionare such that you are no longer able to take care o yoursel , and yourequire assistance or activities such as bathing, toileting, grooming,

eeding and dressing. Te attendant care beneft may reimburse you orreasonable and necessary expenses incurred to purchase personal careservices supplied by:

an aide or attendant; or

a long-term care acility, including a long-term care home orchronic-care hospital.

Do you quali y or the attendant care beneft?Persons who sustain minor injuries are not eligible or attendantcare services.

I you have sustained a non-minor or catastrophic injury, the expensesmust be reasonable and necessary and required as a result o the motor vehicle collision.

Either a registered nurse (RN) or an occupational therapist (O ) may assess how much assistance you need. Tey will complete and sign anAssessment o Attendant Care Needs orm, called a Form 1, to veri y your needs. Once the RN or O has sent in the Form 1, the insurer has 10business days during which they must respond to the orm. I the insureris persuaded that the services are reasonable and necessary, the insurer isrequired to pay or the expenses within 30 days o receiving invoices.

HOW MUCH CAN YOU RECEIVE?For non-minor injuries, attendant care beneft payments may be up to$3,000 per month and up to a total o $36,000 or expenses incurredwithin 104 weeks o the collision.

For persons with a catastrophic injury, beneft payments may be up

to $6,000 per month and $1,000,000 total with no time limit.You may have purchased additional benefts with higher limits.Contact your insurance representative, agent or broker or amountsthat apply to you.


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Maximum ees or pro essional servicesTe Financial Services Commission o Ontario (FSCO) has set maximum

ees and hourly rates that are payable by insurers or health services.Insurers are not required to pay more than the amounts listed in FSCOsPro essional Services Guideline, Attendant Care Hourly Rate Guideline,and Minor Injury Guideline.

What i there is a dispute with your insurer concerningmedical, rehabilitation or attendant care benefts?Discuss your concerns with your insurance representative or adjuster.I the issue in dispute remains unresolved, there is a dispute resolutionprocess available through FSCO. An application or mediation can beobtained rom your insurance company.

For mediation inquiries, contact 1-800-517-2332 ext. 7210(or 416-590-7210 in the oronto area).

For arbitration inquiries, contact 1-800-517-2332 ext. 7202(or 416-590-7202 in the oronto area).

For appeal inquiries, contact 1-800-517-2332 ext. 7222(or 416-590-7222 in the oronto area).

Payment o Other ExpensesOntarios auto insurance lawsI you have been injured in a motor vehicle collision, you may be eligible

or the ollowing benefts: lost educational expenses; expenses o visitors; damage to clothing, glasses, hearing aids, etc; and housekeeping and home maintenance expenses i you have sustained

a catastrophic impairment or purchased the additional coverage.

Lost educational expensesTis beneft is available i , at the time o the collision, you wereenrolled in an elementary, secondary, postsecondary or continuingeducation program and, as a result o the collision, are unable tocontinue the program.


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Te beneft covers expenses incurred be ore the collision or tuition,books, equipment or room and board. Te expenses must be related tothe program that you can no longer continue and or the school termin which you were enrolled at the time o the collision, to a maximum

o $15,000.Your insurer may periodically require you to urnish a disability certifcate to continue receiving this beneft.

Expenses o visitorsI you su er impairment as a result o a collision, your insurance company will pay or reasonable and necessary expenses incurred by the ollowingpeople when they visit you during your treatment or recovery:

your spouse, children, grandchildren, parents, grandparents, brothersand sisters;

an individual who was living with you at the time o the collision; an individual you are treating as a child o your amily; and in the case o an injured child, an individual who is treating that

child as part o the individuals amily.

Tere is a maximum o 104 weeks a er the collision during which theseexpenses can be claimed, unless the impairment is catastrophic.

Damage to clothing, glasses, hearing aids, etc.Your insurance company will pay or reasonable expenses incurred by you to repair or replace clothing you were wearing at the time o thecollision, and prescription eyewear, dentures, hearing aids, prostheses

and other medical or dental devices that were lost or damaged as a resulto the collision.

Housekeeping and home maintenance beneftYou may quali y or the housekeeping and home maintenance benefti , as a result o the motor vehicle collision, you sustain a catastrophicimpairment that results in a substantial inability to per orm housekeepingand home maintenance that you normally per ormed prior to the motor vehicle collision. Te amount payable or this beneft will be up to $100per week.

When you bought your car insurance, you may have purchased theadditional housekeeping and home maintenance beneft rom yourinsurance agent or broker, which pays the beneft or up to 104 weekseven i your injury is not catastrophic but results in a substantial inability


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to per orm housekeeping and home maintenance that you normally per ormed prior to the motor vehicle collision. Check to see i you areeligible to receive this optional beneft.

Getting the Process StartedHow do you apply or accident benefts?A er you report the motor vehicle collision to your insurer, your insurerwill send you an Application or Accident Benefts Package.

NOTE: You may not need to complete all the orms you receive.

Check with your insurer to determine which orms you must complete.

Te ull package will include the ollowing:

Application or Accident Benefts (OCF-1); Employers Confrmation o Income (OCF-2); Disability Certifcate (OCF-3); Permission to Disclose Health In ormation (OCF-5); and reatment Confrmation Form (OCF-23).Some o the orms will require you to visit your amily doctor or otherhealth care practitioner, such as a chiropractor, physical therapist oroccupational therapist.

Once you and your chosen health practitioner have completed andreturned the appropriate orms to your insurer, you will be notifed within10 business days o the insurers decision to do one o the ollowing: pay the beneft(s), request more in ormation, or request that you undergo anexamination by a health practitioner designated by your insurer; this iso en re erred to as an insurer examination.

I you have sustained a minor injury, your health practitioner can approveand submit the reatment Confrmation Form to quickly enter you intothe pre-approved Minor Injury Guideline treatment process.

What is an insurer examination?An insurer examination is a way or an insurer to get a second opinionon your condition and/or the treatment that you require to get better.Tese examinations are conducted by regulated health pro essionals,such as doctors, medical specialists, physical therapists, chiropractors or


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occupational therapists, or by someone with vocational expertise i thereare questions related to your pre-collision job or your ability to return towork. Te examiner is chosen by your insurance company and per ormseither a fle review or a physical exam.

What happens i your insurer requests an insurerexamination?I an insurer examination is requested, you will be notifed o the

ollowing:

the reason or the examination; whether your attendance will be required and, i so, the day, time

and location o the examination (your insurer must provide youwith at least fve business days notice); and

in ormation about who will be conducting the exam, including theregulated health pro essionals qualifcations and accreditations.

Are you entitled to a copy o the examination report?Yes. Your insurance company is obligated to send you and your own

regulated health pro essional a copy o the report within 10 business dayso the receipt o the report rom the regulated health pro essional whoconducted the insurer examination.

You should eel ree to ask the examiner to whom you are sent any questions that you may have about the examination, the purpose o theexamination and the fndings.

What happens i you re use the insurer examination?I you re use to comply with the request or an insurer examination, yourinsurer has the right to deny your claim on the basis o non-complianceand will in orm you o such.

Can you choose to resubmit your application a er adenial or non-compliance has been issued?Yes. I your claim is denied or non-compliance, you have the option o complying with the necessary conditions. Your insurer is then obligatedto reconsider the application. Your insurer will be obligated to pay beneftsthat would normally have been paid during the period o non-complianceonly i you provide them with a reasonable explanation or your non-compliance within 10 business days o the original notifcation o non-compliance, or as soon as possible a er that day.


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I your insurer denies your claim a er the insurerexamination, do you have any recourse?Yes. I an insurer examination has been conducted and, as a result o that report, your insurer denies your claim or benefts, you can accessFSCOs dispute resolution services. FSCO oversees several services to helpconsumers and insurance companies settle accident beneft claims airly and without delay.

FSCOs dispute resolution services include mediation, neutral evaluationand arbitration with an internal appeals mechanism. Tese services helpresolve disputes about whether or not you quali y or accident beneftsunder the SABS and how much those benefts should be.

Paralegals (SABS Representatives)Ontarios auto insurance lawsE ective May 1, 2008, there are new requirements or individuals who arenot lawyers and who provide representation to claimants under the SABS.

SABS representatives require a paralegal licence rom the Law Society o Upper Canada and must meet the requirements set out in the regulations.A representative is any person who:

represents an injured person be ore FSCOs dispute resolution services; gives legal advice concerning legal interests, rights or responsibilities

with respect to a proceeding or the subject matter o a proceeding; dra s or assists with dra ing documents or use in a proceeding; and negotiates on behal o a person who is party to a proceeding.In addition to being licensed by the Law Society o Upper Canada,a paralegal must be a graduate rom an accredited postsecondary institution, meet a good character requirement, carry pro essionalliability insurance, comply with payment and trust account rules andabide by the Paralegal Rules o Conduct.

Generally, a person who acts or a amily member or riend, withoutcompensation, does not require licensing and may represent a claimantat FSCOs dispute resolution services.

Additional in ormation about paralegals and legal SABS representativesis available rom the Law Society o Upper Canadas website atwww.lsuc.on.ca.


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Right to SueAll persons injured in motor vehicle collisions have access to accidentbenefts, which are available without having to sue anyone.

In addition to accident benefts, injured persons have the right to sue i the injuries resulting rom the collision were caused by the negligence o another party. Speak to your insurer or your legal representative i youhave questions about your right to sue a third party.

What can you sue or?ECONOMIC LOSSESRecovery o lost income and loss o earning ability is limited to 70% o gross income lost, beginning seven days a er the collision until trial.A er the trial date, recovery will be based on 100% o your gross incomeloss and loss o earning capacity.

Accident benefts and benefts rom other sources, such as incomecontinuation beneft plans, will be subtracted rom court awards.Tese also include:

payments o disability pension benefts under the CanadaPension Plan; periodic payments o insurance or income replacement, i the

insurance is o ered by the insurer, only to persons who are employed at the time the contract o

insurance is entered into; and only on the basis that the maximum benefts payable is limited to an

amount calculated by re erence to the insured persons income romemployment.You may also sue the at- ault party or most other economic lossessu ered by you as a result o the collision and that are not coveredby no- ault benefts.

HEALTH CARE EXPENSESRecovery o health care expenses in excess o what the accident benefts

package pays or is available to seriously injured collision victims whoseinjuries meet a legislated verbal threshold test (see below). Benefts romother sources will be subtracted rom court awards.


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PAIN AND SUFFERINGSeriously injured collision victims whose injuries meet a legislatedverbal threshold test may sue or a pain and su ering (non-economicloss) award. A $30,000 deductible applies.

As well, where the injuries o collision victims meet the verbalthreshold, amily members may also sue or any loss o guidance, careand companionship pursuant to the Ontario Family Law Act. A $15,000deductible applies.

You have the option to purchase an endorsement that would reduce thedeductible or threshold claims or pain and su ering to $20,000 and thatwould reduce the deductible or Family Law Act claims to $10,000. See

your insurance representative, broker or agent or the amounts that apply to you.

What is the verbal threshold?o be able to sue or pain and su ering and health costs that exceed the

accident benefts limits, the injury must result in permanent seriousimpairment o an important physical, mental or psychological unction.Tis is re erred to as the verbal threshold.

How do you begin?Te person you are suing must be, to some degree, at ault or thecollision. I this is the case, you (the plainti ) must noti y your owninsurer o the collision and apply or accident benefts. You must alsonoti y the person being sued (the de endant) within 120 days o thecollision that you intend to commence a lawsuit against him or her.

Tat person has the right to in ormation about your insurer and claimsor statutory accident benefts and your medical treatment as a result o

the collision. You may also be required to undergo an examination by the de endants health pro essional. You may be penalized or ailing tocomply with these procedural and disclosure steps.

You must launch your lawsuit against the de endant within one year romthe date o your collision. At any time, either party can request mediation

to help settle the claim.You will be responsible or any legal ees i you hire a lawyer to representyou in the lawsuits. However, i the plainti is success ul in the lawsuit,the court will o en require the de endant to pay part o the plainti slegal costs.


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Additional In ormation and HelpWhether or not you have the right to sue, you may be eligible or accidentbenefts. I you need help understanding accident beneft payments,call Insurance Bureau o Canada at 1-800-387-2880 (or 416-362-9528in the oronto area).

Application or Mediationwww. sco.gov.on.ca/english/ orms/drs/1217E.pd Application or Arbitrationwww. sco.gov.on.ca/ENGLISH/ orms/drs/1218E.pd FSCO Consumer In ormationwww. sco.gov.on.ca/english/insurance/auto/#consumer FSCO Auto Insurance Claims Forms

www. sco.gov.on.ca/english/ orms/auto orms/claims/de ault.asp

FSCO Auto Insurance Policy Application and Endorsement Formswww. sco.gov.on.ca/english/ orms/auto orms/endorsement/de ault.asp

Insurance Bureau o Canada Consumer In ormationwww.ibc.ca/en/Contact_Us.asp E-lawswww.e-laws.gov.on.ca/ FSCO Bulletinswww. sco.gov.on.ca/english/pubs/bulletins/autobulletins

Selected FSCO Bulletins

Changes to Automobile Insurance Regulations No. A-01/10www. sco.gov.on.ca/english/pubs/bulletins/autobulletins/2010/a-01_10.asp

Transition to the New Statutory Accident Benefts Schedule E ective September 1, 20No. A-04/10www. sco.gov.on.ca/english/pubs/bulletins/autobulletins/2010/a-04_10.asp

Auto Insurance Re orms and Policyholder Communications No. A-09/10www. sco.gov.on.ca/ENGLISH/pubs/bulletins/autobulletins/2010/a-09_10.asp

Revision to Auto Bulletin No. A-09/10 on Policyholder Communications Regarding Ne

Business No. A-15/10www. sco.gov.on.ca/ENGLISH/pubs/bulletins/autobulletins/2010/a-15_10.asp

Minor Injury Guideline and Revised Minor Injury Treatment Discharge Report (OCF-2A-10/10www. sco.gov.on.ca/ENGLISH/pubs/bulletins/autobulletins/2010/a-10_10.asp

Revised Pro essional Services Guideline and Revised Transportation Expense GuidelinE ective September 1, 2010 No. A-19/10www. sco.gov.on.ca/ENGLISH/pubs/bulletins/autobulletins/2010/a-19_10.asp

Revised Accident Beneft Claims Forms and New Attendant Care Hourly Rate GuidelinA-13/10www. sco.gov.on.ca/ENGLISH/pubs/bulletins/autobulletins/2010/a-13_10.asp


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Accident Benefts Coverage in Ontario

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QUESTIONS? WERE HERE.

Insurance Bureau o CanadasConsumer In ormation Centre

Tel: 416-362-9528Toll-free: 1-800-387-2880 (Ontario only)

Hours: MF 8:00 a.m. 5:00 p.m.

or visit ibc.ca

accident benefits coverage in ontario

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