Answers to Common Questions about Accident Benefit Claims

Who can receive no-fault accident benefits?

These are benefits available regardless of who is at-fault for an accident.  You could be the driver of a car involved in a single car crash, or a pedestrian or cyclist who was struck by a car and still receive no-fault accident benefits.  If you were injured in an accident that arose directly out of the use or operation of an automobile then you are entitled to no-fault accident benefits.

I have long term disability benefits available through my employer’s insurance plan.  Can I still receive no-fault accident benefits?

Yes.  The law in Ontario requires you to apply to those other insurance policies first and the no-fault accident benefits insurer then pays for amounts above that paid by the other policies.  This applies to all private and work insurance policies for dental and health benefits as well as short term and long term disability benefit policies.  Wallace Smith LLP can co-ordinate these insurance policies for you.

How do I access accident benefits?

You must notify your insurance company within seven days of the accident of your intent to apply for accident benefits. The insurance company will send you a package of documents to complete and return within 30 days after receiving them.  No benefit is payable until the insurance company has received the completed forms.  Most insurance companies will accept the forms beyond the 30 day timeline but to avoid delays it is best to submit them as early as possible.  Make this application even if you have benefits available to you through other plans since there will be a limited amount of funding available to you through those other policies.  Accident benefits may “top up” the difference.

 

Medical & Rehabilitation Benefits

 What types of treatment are covered?

Examples of medical and rehabilitation benefits include:

  • Treatment provided by medical and rehabilitation professionals (such as physiotherapy, chiropractic care and psychological counselling)
  • Medications
  • Assistive devices (such as wheelchairs)
  • Transportation to medical appointments
  • Employment counselling and re-training
  • Modifications to your home and car

 

How much money is available to pay for my treatment?

Generally, you are entitled to receive up to a combined maximum of $65,000 (together with attendant care benefits) for these benefits, unless optional coverage was purchased.  These benefits are available where the treatment and rehabilitation are not covered by OHIP or some other health or disability plan and the expense is incurred within 5 years from the date of the accident or until age 28 for minors.

If you have suffered catastrophic injuries then you are entitled to receive up to a combined maximum limit of $1,000,000 (together with attendant care benefits) over your lifetime for these benefits, unless additional coverage was purchased to increase that amount.

In some cases involving very minor injuries, the benefit is capped at $3,500.  Wallace Smith LLP can assist in recovering money for your expenses beyond this amount if you qualify.

What do I need to do to get treatment?

There are particular insurance forms called treatment plans that are required.  An insurance company is entitled to deny payment for treatment unless a treatment plan is completed by a health professional or social worker.

 

Attendant Care Benefits

 How do I know if I am eligible for this benefit?

If you are no longer able to do certain personal care activities without some help (such as bathing, dressing, and feeding) then you may receive an amount of money to pay someone to assist you with this care.  You are entitled to receive an attendant care benefit even while you are in hospital if family members or friends have assisted you and even if you have not paid the person, provided that you have promised to pay for the service in the future.

Since September 1, 2010, the person assisting you has to ordinarily be employed as an aide or attendant or experience an economic loss because they have provided you care.  The type of information that insurance companies accept as proof of economic loss may be wide ranging and Wallace Smith LLP can assist you in providing that information.

How much can I receive?

You can receive up to $3,000 per month to a combined maximum limit of $65,000 (together with medical and rehabilitation benefits).  The benefit is available for 5 years or to age 28 for minors.  If optional coverage was purchased then the benefit may be higher.

If you have catastrophic injuries then you can receive up to $6,000 per month to a combined maximum of $1,000,000 (together with medical and rehabilitation benefits) and there is no time limit imposed.  If optional coverage was purchased then the amount of this benefit may be higher.

 

Income Replacement Benefits

 How do I know if I am eligible for this benefit?

Income replacement benefits are intended to partially compensate you for your loss of income.  You are entitled to receive weekly income replacement benefits for up to two years (excluding the first week) after the accident if one of the following applies to you:

(1)  You were employed or self-employed on the date of the accident but you are substantially unable to perform the essential tasks of your employment or self-employment.

(2)  You were not employed at the time of the accident but:

      •  you worked at least 26 of the 52 weeks before the accident (or were receiving Employment Insurance at the time of the accident) but you are substantially unable to perform the essential tasks of the employment you spent most of your time engaged in during the 52 weeks before the accident, or
      • you are substantially unable to perform the essential tasks of employment in which you spent most of your time during the 52 weeks before the accident, or
      • you were excused from attending school at the time of the accident.

 

Can I receive this benefit for longer than two years?

You can still receive income replacement benefits for longer than two years after the accident if you are completely unable to work in any employment that is reasonable for you taking into consideration your education, training or experience.  Wallace Smith LLP will work with you to determine whether you continue to remain eligible for this benefit.

If you continue to meet the eligibility test then this benefit is available to you until age 65 and at that point the amount is reduced on a gradual basis.

How much will I receive?

You cannot receive income replacement benefits for the first 7 days after a collision.  After that, as long as you qualify you will receive 70% of your gross weekly income (before deducting taxes) and after deducting any benefits you may be entitled to receive from other sources such as a long term disability plan.  The maximum entitlement is $400 per week, unless optional coverage was purchased.

What happens to this benefit if I try unsuccessfully to return to work?

You may attempt to return to work within the first two years without affecting your entitlement to this benefit.  Any income you earn simply reduces the amount of your income replacement benefit during the time you are working.

How do I know which to choose: income replacement or non-earner?

If you are not catastrophically injured then the insurance company may hold you to the first type of benefit you choose (for example income replacement or non-earner benefits).  It is important to understand which is better for you as you may be eligible for both.  Wallace Smith LLP will assist you in making that decision at an early stage to ensure that you are receiving the maximum amount available to you.

 

 

Non-Earner Benefits

How do I know if I am eligible for this benefit?

If you were a student (with some exceptions), not working at the time of the accident and you are completely unable to carry on a normal life then you are entitled to receive this benefit.

How much will I receive?

If entitled, you will receive $185 per week for up to two years, however, no amount is payable for the first 4 weeks.   The amount is reduced by any other income replacement assistance you are receiving from another source.

How do I know which to choose: income replacement or non-earner?

Again, if you are not catastrophically injured then the insurance company may hold you to the first type of benefit you choose (for example income replacement or non-earner benefits).  It is important to understand which is better for you as you may be eligible for both.  Wallace Smith LLP will assist you in making that decision at an early stage to ensure that you are receiving the maximum amount available to you.

 

Caregiver Benefits

How do I know if I am eligible for this benefit?

If, at the time of the accident, you were the primary caregiver for another person but due to your injuries you are substantially unable to provide the same care then you may be eligible for this benefit.  This benefit is available to you only if you have been catastrophically injured.

How much will I receive?

You will be reimbursed up to $250 per week for the first dependant and $50 per week for each additional dependant who you cared for at the time of the accident.

 

Lost Education Expenses

If you are unable to continue in a program that you were enrolled in at the time of the accident then you may be reimbursed for expenses such as tuition, books, equipment, and room and board up to a maximum of $15,000.

 

Visitors’ Expenses

If your family members and others who lived with you at the time of the accident visit you then they may be reimbursed for reasonable and necessary expenses incurred as a result of your treatment or recovery.  There is no payment after two years unless you have sustained a catastrophic injury.

 

Housekeeping and Home Maintenance Benefits

This benefit is available in cases of catastrophic impairment only.  An injured person is entitled to receive up to $100 per week for reasonable expenses incurred for housekeeping and home maintenance.  To be entitled to the benefit, the injured person must have performed the chores before the accident and following the accident is substantially unable to complete those same chores.

 

Funeral and Death Benefits

When a person dies as a result of an accident then the insurance company may have to pay for funeral expenses up to a maximum of $6000.

Each person who was dependant of the deceased is entitled to receive $10,000.  If the person was married then $25,000 is paid to the spouse, however, if the person was not married but had dependants then the $25,000 is divided between the dependants.  If the deceased was a dependant then $10,000 is paid to the person upon the person was dependant.

Greater amounts may be available if you purchased optional benefits.