Accident Benefit Claims
Learning About Accident Benefits in Ontario, Canada
If you are hurt in a motor vehicle accident in Ontario, you can rely on financial assistance through Accident Benefits—a requirement of all basic auto policies sold in the province. The benefits are meant to assist with paying your medical bills, lost wages, and other expenses, no matter who is responsible for the accident.
This coverage is regulated by Ontario's Statutory Accident Benefits Schedule (SABS) of the Insurance Act, R.S.O. 1990, c. I.8. Whether you are a driver, passenger, pedestrian, or cyclist, you qualify for these benefits if the accident involved an automobile in Ontario.
Most Notable Features of Ontario's Accident Benefits No-Fault System:
You can qualify for benefits even if you were responsible for causing the accident.
In civil law, you don't have to establish guilt "beyond a reasonable doubt" as you would have to in a criminal trial. You just need to establish the case on a balance of probabilities—i.e., more probably than not that the defendant was to blame
- Broad Eligibility: Covers all the victims of injury, e.g., occupants, drivers, passengers, cyclists, and pedestrians.
- Family Access: There are certain instances when the family members are also eligible.
Types of Accident Benefits in Ontario
Income Replacement Benefit (IRB)
If you cannot work because of accident injuries, you can get up to 70% of your gross weekly income, up to $400 per week (more if you took increased coverage). This begins after 7 days of disability.
Medical and Rehabilitation Benefits
Pays for treatments not covered by OHIP, such as:
- Physiotherapy
- Chiropractic treatment
- Massage therapy
- Psychological counselling
The standard benefit is:
- $65,000 over 5 years for non-catastrophic injuries
- $1 million for a lifetime of catastrophic injuries
Attendant Care Benefits
When you require assistance with activities of daily living like bathing, dressing, or eating, this benefit covers a personal support worker. Limitations are:
- $3,000/month in non-catastrophic injuries
- $6,000/month in catastrophic injuries
(up to the same maximums as Medical & Rehab Benefits)
Caregiver Benefits
When you were a full-time caregiver and are no longer able to do so due to injuries, you can receive:
- $250/week for the first dependent
- $50/week for each additional dependent
(Available only in the case of catastrophic impairments unless optional benefits were purchased.)
Non-Earner Benefit
If you were not employed when the accident occurred but your injuries render you unable to continue your usual life (e.g., students, homemakers), you may be entitled to:
- $185/week, beginning 4 weeks from the date of the accident
- Payable for up to 2 years
Death and Funeral Benefits
In case of death due to an accident, relatives may be entitled to:
- Up to $25,000 for spouse
- $10,000 per dependent
- Up to $6,000 for funeral costs
Other Benefits
Other benefits that may be added are:
- House maintenance and housekeeping services (up to $100/week for catastrophic impairment)
- Transportation to medical appointments
- Visitors’ costs
Who Can Make a Claim for Accident Benefits?
You can apply if:
- • You were in a motor vehicle accident in Ontario as a driver, passenger, cyclist, or pedestrian.
- • You are a family member of someone injured or killed in the accident and have suffered psychological trauma or other secondary effects.
How to Apply for Accident Benefits in Ontario
1. Report the Accident to Your Insurer
You must notify your insurance company within 7 days of the accident (or as soon as you’re able). You’ll need to provide:
- Date, time, and location
- People and vehicles involved
- Description of your injuries
2. Fill Out and Return the Application Package
You will be given an Accident Benefits Application Package, which consists of:
- OCF-1: Application for Accident Benefits
- OCF-2: Confirmation of the Employer (if IRB applies)
- OCF-3: Certificate of Disability (dated and signed by a medical practitioner)
- OCF-18: Treatment and Assessment Plan (signed by your doctor)
Return the completed forms within 30 days. Delay can impact your eligibility.
3. Go for Medical Exams (if required)
Your insurance company may order an Independent Medical Examination (IME) to evaluate your injuries. You are required to show up or lose your benefits. Your insurance company is required to provide you with reasonable notice, such as the purpose of the examination.
4. Keep in Touch
Stay involved with your claim. Return any further paperwork in a timely manner to prevent delays.
Typical Pitfalls (and How to Deal with Them)
- Delays in Processing: If your claim is inordinately delayed, maintain records in proper sequence and contact often. You might need services of an attorney.
- Denials of Claim: When benefits are denied by your insurance company, a complaint can be filed with the Licence Appeal Tribunal (LAT). It is advisable to consult with a personal injury lawyer.
- Too Low Coverage: You can appeal benefit levels or ask for extra medical opinions to support your case.
Do Family Members Get Benefits Even If They Were Not in the Accident?
Yes. Relatives may be offered some benefits (such as psychological counseling or death benefits) if they experience emotional distress following the serious injury or death of a loved one. But only accident victims themselves may be evaluated for catastrophic impairment, which determines qualification for extended benefits.
Do I Need to Deal with the Insurance Company Myself?
No. If you have a lawyer for personal injuries, they will deal with the insurance adjuster, draft documents, and represent you throughout the process. You will still get updates from your insurer, but your lawyer will respond.
Having a lawyer on your side means you can concentrate on healing while professionals fight for your complete compensation. Some lawyers have excellent track records for winning in court—insurers take careful note of that when deciding settlements.
Smooth Claim Process Tips
- Notify early: Don’t wait to contact your insurer.
- Complete forms carefully: Incomplete or inaccurate information can slow down or ruin your claim.
- Keep records: Record all treatments, charges, and communication.
- Follow your doctor’s advice: Adhering to prescribed treatment shows you’re committed to recovery.
- Stay organized: Maintain a file with all paperwork related to your claim.
If you’ve been injured in a car accident in Ontario, don’t delay to determine your right to benefits under the law. The process can be complicated, but with the proper information—and perhaps legal help—you can receive the assistance you need to recover.