Ontario’s Accident Benefits are governed by the Statutory Accident Benefits Schedule (the “SABS”). Accident Benefits allow for a person insured under the Insurance Act of Ontario to obtain benefits after a motor vehicle accident regardless of who was at fault.
How do I apply for accident benefits?
Following a motor vehicle accident, you will need to contact your insurance company in order to fill out the necessary forms to obtain benefits. It is important to note that your insurer will not always automatically forward these documents to you.
You must first complete and submit an “OCF-1– Application for Accident Benefits Form” to your own insurer. Next, you will need to visit a health care provider in order to complete the “OCF-3– Disability Certificate” and the “OCF-18– Treatment and Assessment Plan”. These forms must indicate that you were in an accident and that you meet the relevant disability test as set out in the SABS. If you are eligible for and choose to apply for income replacement benefits, an “OCF-2– Employer’s Confirmation of Income Form” must be submitted to your insurer once completed by your employer. Other forms that may be relevant to you include the “OCF-10– Election of Income Replacement, Non-earner or Caregiver Benefit”, “OCF-23– Treatment Confirmation Form”, the “OCF-19– Application for Determination of Catastrophic Impairment” and the “OCF-6– Application for Expenses Form”.
What benefits can I get from SABS?
Medical and rehabilitation costs
The medical and rehabilitation benefit will cover reasonable expenses that are not covered by your government or private health plan. These expenses range from ambulance care to physiotherapy treatment. There are various limits that apply to this benefit depending on the severity of your injuries.
An insurer can deny paying medical and rehabilitation benefits if they believe the expenses you have incurred are not reasonably associated with the injuries from which you are suffering. The SABS defines what they consider to be a “cost incurred” in a three-part test that you must fulfill to obtain the benefit. First, you must receive the goods or services to which the expense relates. Next, you must have paid the expense, promised to pay the expense or are otherwise legally obligated to pay the expense. These first two components of the test are generally fulfilled without issue. The last component requires the person providing the goods or services to you to do so during his or her regular occupation or profession or to sustain an economic loss as a result of providing their goods or services.
The last component of the test prescribed in the SABS to determine whether you are eligible to obtain medical and rehabilitation benefits can create issues. In Josey v. Primmum Insurance Co., 2014 CarswellOnt 16385, the arbitrator held that the claimant’s spouse could not receive benefits for attendant care as she was not providing care in the course of her profession nor suffering an economic loss. The reasoning was the finding of legislative intent to exclude family members from being reimbursed for attendant care services in the absence of an economic loss. The SABS offers potential relief for the strict definition given to the word “incurred” by giving arbitrators and judges the discretion to decide what qualifies as a “cost incurred” under certain circumstances.
Housekeeping and home maintenance benefit
The housekeeping and home maintenance benefit is meant to assist you if you are unable to complete housekeeping tasks due to the injuries from which you are suffering. This benefit covers the cost of housekeeping services for up to $100 per week if you have suffered catastrophic injuries. It is an optional coverage for those suffering from minor or non-catastrophic injuries.
Weekly indemnity benefit
If you qualify for more than one weekly indemnity benefit, you must choose which benefit you wish to receive within 30 days of receiving the notice from your insurer. This decision is irreversible pursuant to subsection 35(1) of SABS.
There are three types of weekly indemnity benefits:
- Caregiver benefits
The caregiver benefit is meant to assist you if you are no longer able to continue as a primary caregiver by covering the costs of hiring someone to help you care for your family. Generally, it is offered to those who have dependents such as young children or aging parents. This benefit is paid at a rate of $250 per week plus $50 for each additional person in need of care. It is offered to those suffering from catastrophic injuries only, however, those suffering from minor or non-catastrophic injuries can obtain this coverage at an additional cost.
As per subsection 13(1) of the SABS, you must live with the person for whom you are caring in order to receive this benefit. However, the courts have previously ruled otherwise. In L (V) v. TD Meloche Monnex, the arbitrator decided that the issue of residence must be determined on a case-by-case basis to properly reflect different family arrangement and dynamics. In that case, the applicant who lived on his own 900 meters away from his parents was awarded caregiver benefits. (see s. 13 of SABS)
- Income replacement benefits
The income replacement benefit is calculated on a basis of 70% of your gross income to a maximum of $400 per week. In order to qualify for this benefit, you must be able to establish a substantial inability to perform your employment tasks. To continue receiving the benefit after the two-year post-accident mark, you must be completely unable to engage in any suitable employment based on your education, training or experience. (see s. 4-11 of SABS)
- Non-earner benefits
In order to qualify for non-earner benefits, you must suffer a “complete inability to carry on a normal life”. The SABS indicates that this two-year benefit is available at a rate of $185 per week, minus any other income replacement assistance, and only begins four weeks after the onset of the complete inability to carry on a normal life. (see s. 12 of SABS)
Which benefits am I entitled to under SABS regardless of my type of injury?
The injuries you have sustained in an accident will be designated under one of three categories in the SABS: a minor injury, a non-catastrophic injury, or a catastrophic impairment injury. The benefits available to you under the SABS depend on the designation of your injuries. That said, however, the following general benefits are offered independently of the designation of your injuries:
- Income replacement benefits (sections 6 and 7) – Available as a weekly benefit in cases where you are unable to return to work or self-employment—paid at 70% of gross income to the maximum of $400 per week. The benefit is not payable until the second week post-accident and terminates at 104 weeks unless you are completely unable to engage in any suitable employment based on education, training or experience;
- Non-earner benefits (section 12) – Available as a weekly benefit of $185 where you have suffered a complete inability to carry on a normal life;
- Benefits for damage to clothing and medical devices (section 24) – Available to reimburse items damaged in the accident. There is no monetary limit to this benefit;
- Lost educational expenses (section 21) – If you were enrolled in school at the time of the accident and unable to continue with your program, you may be eligible to obtain up to $15,000;
- Visitor’s expenses (section 22) – Available to reimburse immediate family members for their travelling expenses visiting you;
- Transportation expenses (sections 15 & 16) – Available to reimburse certain costs relating to travel for medical examinations or treatments;
- Death benefits (section 26) – In cases of fatality, a benefit of $25,000 is available to the spouse, $10,000 to a supported former spouse and $10,000 per dependant;
- Funeral benefits (section 27) – In cases of fatality, a basic benefit of $6,000 is offered.
Can I get WCB and weekly indemnity under SABS?
An insurer is not required to pay you benefits if, as a result of an accident, you are entitled to receive benefits under the Workplace Safety and Insurance Act, 1997 S.O., c 16, or any other workers’ compensation law or plan.
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