Accident Benefits

Every automobile insurance policy contains mandatory accident benefits coverage. A list of available benefits is set out in the Statutory Accident Benefits Schedule. Please note that on September 1, 2010, mandatory Accident Benefits have changed in Ontario.
  1.   Do I have to be a passenger in an automobile to be eligible for accident benefits?
  2.   Are accident benefits paid automatically after I have an automobile accident?
  3.   If I miss the deadline of 30 days can I still apply for benefits?
  4.   Is the injured accident victim the only one covered for Statutory Accident Benefits?
  5.   What if you have a private insurance policy?
  6.   What is your auto insurer required to pay for medical and rehabilitation benefits?
  7.   How much are you entitled to receive for medical and rehabilitation benefits?
  8.   What do you need to submit to your insurer to obtain a medical and/or rehabilitation benefit?
  9.   Is your insurer required to pay for an aide or attendant and how much can you receive for attendant care?
  10.   Can I arrange for my own medical or rehabilitation assessment to determine what treatment I need?
  11.   Is your insurer required to pay for funeral expenses?
  12.   Is your insurer required to pay death benefits?
  13.   How do you qualify for death benefits?
  14.   When are you entitled to receive weekly income replacement benefits?
  15.   When can you begin receiving income replacement benefits?
  16.   What is the maximum amount of income replacement benefits you can receive?
  17.   Can self-employed persons receive income replacement benefits?
  18.   How long can you receive income replacement benefits?
  19.   When are you entitled to receive non-earner benefits?
  20.   What is the maximum amount of non-earner benefits you can receive?
  21.   When are you entitled to receive care giver benefits?
  22.   What is the maximum amount of care giver benefits you can receive?
  23.   Can you receive income replacement benefits, non-earner benefits and care giver benefits at the same time?
  24.   What if I am employed and also a care giver? Which benefit do I choose?
  25.   When can the insurer stop payment of your weekly benefits?
  26.   How will attempting to return to work affect my weekly benefits?
  27.   When is your insurer not obligated to pay benefits?
  28.   Who is entitled to receive payment for visiting expenses that incur while you are injured?
  29.   When are you entitled to receive payment for lost education expenses?
  30.   What is the maximum amount you can receive for lost education expenses?
  31.   What is the maximum amount you can receive for housekeeping and home maintenance expenses for a minor injury?
  32.   How long can you receive payment for these expenses?
  33.   What other expenses can you receive payment for from your insurer?
  34.   What constitutes a catastrophic impairment?
  35.   What if your injury is catastrophic, as defined by the Insurance Act?
  36.   Can the insurer require me to go to its doctor or other health care worker for a physical or psychological examination?
  37.   What if you have optional benefits?
  38.   What steps must you take when claiming benefits?
  39.   Do I need a lawyer for my accident benefits?

Answers

  1.   Do I have to be a passenger in an automobile to be eligible for accident benefits?
  A.   No. Pedestrians and cyclists are also entitled to accident benefits so long as an automobile was also involved in the accident.
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  2.   Are accident benefits paid automatically after I have an automobile accident?
  A.   No. You must notify your insurer within 7 days after the accident, or as soon as practical after the accident, that you wish to apply for accident benefits. Your insurer must then promptly give you application forms. To avoid delays in processing your application, you must file the completed application forms with your insurer within 30 days after receiving them from your insurer.
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  3.   If I miss the deadline of 30 days can I still apply for benefits?
  A.   Yes. Insurers must accept late applications if you have a reasonable explanation for the delay. However, if you do not have a reasonable explanation for the delay, the insurer is allowed to delay up to 45 days in processing your application. It is always best to meet the 30-day time limit. No benefit is payable until a complete application is sent and approved by the insurer.
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  4.   Is the injured accident victim the only one covered for Statutory Accident Benefits?
  A.   No. Any member of your immediate family may also be entitled to benefits if he or she suffers psychological or mental injury as a result of your accident.
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  5.   What if you have a private insurance policy?
  A.   Accident benefits only pay for losses that are not covered by some other private policy or employment benefit plan. If these other benefit plans cover only part of the expenses, accident benefits may pay the balance.
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  6.   What is your auto insurer required to pay for medical and rehabilitation benefits?
  A.   The insurer may be required to pay all of the reasonable and necessary expenses incurred by or on behalf of the insured as a result of the accident for:
  1. medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services;
  2. chiropractic, psychological, occupational therapy and physiotherapy services;
  3. medication;
  4. prescription eyewear;
  5. dentures and other dental devices;
  6. hearing aids, wheelchairs or other mobility devices, prostheses, orthotics and other assistive devices;
  7. transportation for the insured person to and from treatment sessions, including transportation for an aide or attendant;
  8. other goods and services of a medical nature that the insured person requires, other than goods or services for which a benefit is otherwise provided in this Regulation.
Also:
  1. life skills training;
  2. family counseling;
  3. social rehabilitation counseling;
  4. financial counseling;
  5. employment counseling;
  6. vocational assessments;
  7. vocational or academic training;
  8. workplace modifications and workplace devices, including communications aids, to accommodate the needs of the insured person;
  9. home modifications and home devices, including communications aids, to accommodate the needs of the insured person, or the purchase of a new home if it is more reasonable to purchase a new home to accommodate the needs of the insured person than to renovate his or her existing home;
  10. vehicle modifications to accommodate the needs of the insured person, or the purchase of a new vehicle if it is more reasonable to purchase a new vehicle to accommodate the needs of the insured person than to modify an existing vehicle;
  11. transportation for the insured person to and from counseling and training sessions, including transportation for an aide or attendant;
  12. other goods and services that the insured person requires, except or in other words not including (i) services provided by a case manager, (ii) housekeeping and care giver expenses, and (iii) any goods or services for which a benefit is otherwise provided in this Regulation.
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  7.   How much are you entitled to receive for medical and rehabilitation benefits?
  A.   For a "Minor Injury" - You are entitled to receive up to $3,500 maximum, which can be increased to $50,000 if there is compelling evidence that a pre-existing medical condition will prevent the insured person from achieving maximal recovery with access to only $3,500.
     For a Non Catastrophic Impairment - You are entitled to receive up to Maximum of $50,000 available for 10 years or until the person is 25 years old (Prior to Sept. 1/10 this was a $100,000 maximum)
     For a Catastrophic Impairment - as defined by the legislation, you are entitled to receive up to $1,000,000.00 for medical rehabilitation expenses incurred over your lifetime.
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  8.   What do you need to submit to your insurer to obtain a medical and/or rehabilitation benefit?
  A.   You must submit a treatment plan to the insurance company. This should be done before any treatment commences. The treatment plan must be prepared by a health professional and signed by one of the following health practitioners:
  1. physician,
  2. psychologist,
  3. physiotherapist,
  4. dentist,
  5. optometrist,
  6. chiropractor.
     Insurers are entitled to refuse to pay for treatment unless a treatment plan is completed.
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  9.   Is your insurer required to pay for an aide or attendant and how much can you receive for attendant care?
  A.   If you have been injured in an accident your insurer may be required to pay the cost of providing for an aide or attendant.
     For a "Minor Injury" - Attendant Care is not available.
     For a Non Catastrophic Impairment - $3,000 per month maximum (total maximum of $36,000) for up to 2 years post (as determined by OT or RN)** (Pre-Sept 1/10 - was a total maximum of $72,000 and there was no restriction on who could complete a Form 1)
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  10.   Can I arrange for my own medical or rehabilitation assessment to determine what treatment I need?
  A.   YES; however, All fees and expenses for conducting assessments, examinations and preparing reports are to be paid out of medical and rehabilitation limits (excluding insurer examinations and accounting reports for income replacement benefits) (these expenses were formerly paid by the insurer out of separate category of benefits with no monetary limit)
     Also: Absolute cap of $2,000 for fees and expenses associated with any assessment or examination, including the cost of preparing reports (and including insurer examinations), along with a prohibition on an insurer paying for a future care or similar plan (there was never a cap on assessment costs-the criteria for recovery was simply 'reasonable and necessary')
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  11.   Is your insurer required to pay for funeral expenses?
  A.   When an insured person dies as a result of a motor vehicle accident, the insurer may be required to pay funeral expenses incurred to a maximum of $6,000.
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  12.   Is your insurer required to pay death benefits?
  A.   If the deceased was married, a sum of $25,000 would be payable to his or her spouse. If the deceased was not married but was survived by a dependant(s), the $25,000 is divided equally among the dependants. If the deceased was a dependant at the time of the accident, $10,000 would be payable to the person upon whom the deceased was dependent.
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  13.   How do you qualify for death benefits?
  A.   In order to qualify for death benefits, the deceased must have died within 180 days from the accident, or, if the deceased was continuously disabled as a result of the accident, within 156 weeks of the day of the accident.
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  14.   When are you entitled to receive weekly income replacement benefits?
  A.   You are entitled to receive weekly income replacement benefits for up to the first 104 weeks (excluding the first week) after a collision in the following circumstances:
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  15.   When can you begin receiving income replacement benefits?
  A.   You will not receive income replacement benefits for the first 7 days after a collision. Then, as long as you qualify, you can receive 70% of your gross income (less any benefits you may be entitled to from other insurance policies or employment plans).
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  16.   What is the maximum amount of income replacement benefits you can receive?
  A.   If unable to return to work, paid at 70% of gross income to a maximum of $400 per week** (not payable for first week and qualifying test changes at two year anniversary) (was paid at 80% of net)
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  17.   Can self-employed persons receive income replacement benefits?
  A.   Yes. Self-employed persons are entitled depending on their income and expense situation. Usually an accountant will be necessary to determine eligibility and quantum
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  18.   How long can you receive income replacement benefits?
  A.   Income replacement benefits are payable for 2 years following the accident so long as you suffer a substantial inability to engage in the essential tasks of your pre-accident employment. To continue to receive benefits beyond the 2-year mark, you must be suffering from a complete inability to engage in any employment for which you are suited by education, training, and experience.
     So long as you continue to satisfy the eligibility criteria, income replacement benefits are available to you up until age 65, at which point they are reduced on a gradual basis.
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  19.   When are you entitled to receive non-earner benefits?
  A.   If, at the time of the accident, you were not working but were enrolled in school or had completed your education during the year prior to the accident and were not employed in a job that reflected your education, you may be entitled to a non-earner benefit. You are only entitled to this benefit if you suffer a complete inability to carry on a normal life and are over 16 years of age.
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  20.   What is the maximum amount of non-earner benefits you can receive?
  A.   If completely unable to carry on a normal life, paid at $185 per week and can be paid at $320 per week 2 years post accident if enrolled in educational pursuits at or shortly before the time of the accident (not available for first 26 weeks)
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  21.   When are you entitled to receive care giver benefits?
  A.   You may be entitled to a care giver benefit if you were living with and were primary care giver for a person in need of care and were not being paid for these activities and you are catastrophic.
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  22.   What is the maximum amount of care giver benefits you can receive?
  A.   Prior to Sept 1, 2010, The maximum amount of the care giver benefit was $250 per week for the first person in need of care plus $50 per week for each additional person. Since Sept 1, 2010, minor injuries and non-catastrophic injuries do not have care giver benefits available anymore.
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  23.   Can you receive income replacement benefits, non-earner benefits and care giver benefits at the same time?
  A.   No. Only one of the income replacement, non-earner and care giver benefits is payable for any given period of time.
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  24.   What if I am employed and also a care giver? Which benefit do I choose?
  A.   You must elect one or the other. Advice from a personal injury lawyer may be of assistance in making the decision that is best for you.
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  25.   When can the insurer stop payment of your weekly benefits?
  A.   Your insurer may stop payment of weekly benefits in the following cases:
  1. If, despite your insurer's request, you fail to provide a certificate from a health practitioner stating that you continue to suffer from the disability, the insurer may stop payment of weekly benefits after 21 days of its request;
  2. If your insurer arranges an assessment by a health practitioner and it is determined that you are no longer disabled, your insurer may stop payment of the weekly benefits. However, you are entitled, within specified time frames, to have a health practitioner of your choice rebut the insurer's decision to stop payment of your disability benefits.
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  26.   How will attempting to return to work affect my weekly benefits?
  A.   You may attempt to return to work at any time during the first 104 weeks of your disability without affecting your entitlement to receive income replacement benefits so long as you cannot continue with the employment because of the accident.
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  27.   When is your insurer not obligated to pay benefits?
  A.   Your insurer is not obligated to pay income replacement benefits, non-earner benefits, lost education expenses, expenses of visitors or home maintenance expenses if you were the driver of an automobile at the time of the accident and you;
  1. knew or ought to have known that the automobile was not insured;
  2. were not licensed to drive;
  3. were an excluded driver under the contract of insurance for the vehicle which you were driving at the time of the accident;
  4. were driving a vehicle, or were an occupant of a vehicle, when you ought to have known that the vehicle was being driven without the owner's consent;
  5. were convicted of impaired driving;
  6. were convicted of driving with a blood alcohol level exceeding legal limits,
  7. were convicted of failing to provide a breath sample;
  8. were engaged in a criminal offence, or were an occupant of an automobile that was being used in connection with a criminal offence;
  9. misstated facts to the insurer in order to obtain motor vehicle insurance;
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  28.   Who is entitled to receive payment for visiting expenses that incur while you are injured?
  A.   If your family members and other individuals who were living with you at the time of your accident visit you, they are entitled to payment of all reasonable and necessary expenses incurred as a result of the accident during your treatment or recovery. There is no payment after 104 weeks unless the injury is catastrophic. In the case of catastrophic, the payment is for life.
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  29.   When are you entitled to receive payment for lost education expenses?
  A.   If you are unable to continue in a program that you were enrolled in at the time of the accident, the insurer will pay for lost education expenses.
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  30.   What is the maximum amount you can receive for lost education expenses?
  A.   The maximum amount you can receive is $15,000.
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  31.   What is the maximum amount you can receive for housekeeping and home maintenance expenses for a minor injury?
  A.   You can receive a maximum of $3,500.00 which can be increased to $50,000.00 see answer to question 7 above for details.
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  32.   How long can you receive payment for these expenses?
  A.   Your housekeeping and home maintenance expenses are paid for 104 weeks unless the injury is catastrophic.
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  33.   What other expenses can you receive payment for from your insurer?
  A.   Your insurer may by be obligated to replace or repair clothing damaged in the accident, prescription eyewear, dentures, hearing aids, prostheses, and other medical or dental devices lost or damaged in the accident.
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  34.   What constitutes a catastrophic impairment?
  A.   Some examples of catastrophic impairments are paraplegia or quadriplegia, permanent loss of use of both arms, loss of vision in both eyes, and severe brain injuries. In other cases, once your condition has stabilized or three years has elapsed since the accident, you may make an application to your insurer for a determination that the impairment is catastrophic.
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  35.   What if your injury is catastrophic, as defined by the Insurance Act?
  A.   If your injury is defined as a catastrophic impairment by the Insurance Act you are entitled to a much higher level of medical and rehabilitation benefits and attendant care benefits (a maximum of $1,000,000 for medical and rehabilitation benefits and $1,000,000 for attendant care benefit). These benefits are payable over your entire lifetime.
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  36.   Can the insurer require me to go to its doctor or other health care worker for a physical or psychological examination?
  A.   An insurance company may not but can require an injured person to attend an insurance examination (IE) with respect to an application for a benefit that is provided under the pre-approved framework guidelines.
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  37.   What if you have optional benefits?
  A.   If you have purchased optional benefits from your insurance company, the amount of benefits available to you may be increased. For this reason you must always review your insurance policy and provide a copy to your lawyer to determine if these optional benefits have been purchased.
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  38.   What steps must you take when claiming benefits?
  A.   You must notify your insurer within 7 days from the date of the accident that you wish to apply for benefits and your insurer must then promptly give you application forms. To avoid delays in processing your application, you must file the completed application forms with your insurer within 30 days after receiving them from the insurer. If you cannot do so within 30 days because of the severity of your injuries, the application must be made as soon as reasonably possible.
     If you are having difficulties recovering the benefits to which you are entitled you should consult with a lawyer. Any lawsuit or arbitration proceeding to enforce the payment of these benefits must be commenced within two years from the time the benefit was terminated or denied.
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  39.   Do I need a lawyer for my accident benefits?
  A.   The system that has been established to govern accident benefits is technical and complex. It is advisable that you speak with a lawyer with experience in dealing with personal injury matters to assist you in navigating any issues that may arise.
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