_ed02E. Ontario accident benefits

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1 _ed02E Ontario accident benefits TM

2 Trademark used under licence from Northbridge Financial Corporation. All rights reserved. No part of this publication may be reproduced, stored in retrieval systems or transmitted in any form by any means electronic, photocopying, recording or otherwise without the prior written permission of Northbridge Financial Corporation. * Policies underwritten by Northbridge Commercial Insurance Corporation. 2 Ontario accident benefits

3 Table of contents What is an accident? 4 Which insurer pays the claim? 5 What statutory accident benefits are available in Ontario? 8 How do statutory accident benefits interact with other systems? 11 What is loss transfer? 13 What s available? 14 3 Ontario accident benefits

4 1.0 What is an accident? In Ontario, statutory accident benefits are only payable if the act that caused injury to the insured person meets the policy definition* of accident. Over time, the Courts have broadened the interpretation of the definition of accident to include many common scenarios one would not typically characterize as a motor vehicle accident. Collision with another car or object is not required in order for an accident to have occurred. For example, if a driver is standing upon and washing the top of his tanker trailer and falls to the ground, his consequent injuries will likely be covered by statutory accident benefits. In fact, contact with the automobile at the time of injury is no longer necessary for the incident to be deemed an accident. For example, if a driver slips and falls during his circle check or while fuelling his truck and injures his back, his injury will more than likely be found to be caused by an automobile accident and he will be eligible to claim statutory accident benefits. Similarly, if a piece of cargo falls from a flatbed trailer and strikes and injures a nearby pedestrian, that pedestrian will be eligible to claim statutory accident benefits. Did you know? Accident means an incident in which the use or operation of an automobile directly causes an impairment. 4 Ontario accident benefits

5 2.0 Which insurer pays the claim? The insurer most responsible for paying accident benefits to a person injured in an automobile accident is the one that insures the person, his spouse or someone upon whom he is dependent as a Named Insured or Deemed Named Insured. If the injured person is not a Named Insured (or spouse of, or dependant upon someone who is) on a policy, the insurer most responsible for paying accident benefits to the person is that which lists him as a driver on a policy. If the injured person is not a listed driver on any auto policy, the insurer most responsible for paying accident benefits to him is the insurer of the vehicle that he occupied at the time of the accident. If the injured person was a pedestrian or occupied a vehicle that was uninsured at the time of the accident, the insurer most responsible for paying accident benefits to him is the insurer of the vehicle that struck him (in the case of the pedestrian) or the insurer of any other vehicle involved in the accident (in the case of the uninsured vehicle). In the event the vehicle that struck the pedestrian or any other vehicle involved in the accident is uninsured, the insurer most responsible for paying accident benefits is the Motor Vehicle Accident Claims Fund. Did you know? A person is a Deemed Named Insured in respect to an auto policy if, at the time of the accident: 1) the individual had regular use of the insured vehicle; and, 2) the vehicle was being made available to the individual by any company These rules apply no matter which vehicle the injured person is in at the time of the accident and/or which vehicle was at fault for the accident. 5 Ontario accident benefits

6 For example, if the dependant child of a company driver who regularly uses one of a fleet s vehicles was injured in an accident while taking a taxi ride, the trucking company s insurer would be responsible for paying the accident benefits claim in the event the company driver did not have any insurance of his own. This is in spite of the fact that the dependant child is neither a company employee nor was using company equipment at the time of the accident. Similarly, if one of a carrier s insured vehicles is involved in an accident with an uninsured vehicle and the driver of the uninsured vehicle is injured and has no spouse, or is not dependant upon someone who has insurance, that carrier s insurer would be responsible for paying the (reduced) accident benefits of the uninsured driver. In the past, if an Owner-operator is injured in an accident while driving his tractor and had a valid private passenger vehicle policy at the time, his own insurer would be responsible for paying him accident benefits, as he did not have regular use of a company vehicle and is therefore not a Deemed Named Insured under the carrier s policy. This law recently changed and currently, under Ontario law, the company s insurer would be responsible for paying the accident benefits. It is currently being appealed. 6 Ontario accident benefits

7 HIGHEST PRIORITY Named Insured spouse & dependants Deemed Named Insured spouse & dependants Listed Driver Insured Vehicle Occupied Other Vehicle Involved LOWEST PRIORITY MVACF 7 Ontario accident benefits

8 3.0 What statutory accident benefits are available in Ontario? A person insured under an Ontario automobile policy has access to a comprehensive set of benefits if they are injured in an automobile accident. Every valid motor vehicle liability policy in Ontario provides its insureds with statutory accident benefits the coverage is not optional. In addition, full benefits are available to insured persons whether or not they are at fault for the accident. The following benefits are available under the new Statutory Accident Benefits Schedule (SABS) in Ontario, effective as of September 1, 2010: Medical and rehabilitation Subject to fee guidelines, this benefit pays for all reasonable and necessary expenses incurred by the insured person, as a result of the accident, for medical goods and/or services and for measures undertaken to reduce or eliminate the effects of any disability. This includes workplace, home and/or vehicle modifications, and vocational or academic training. The limit on this coverage is $50,000 for 10 years, or in the event of a catastrophic injury, $1,000,000 for a lifetime. There are optional benefits available to increase the limits from $50,000 to $100,000 or $1,100,000 for medical and rehabilitation benefits, including assessment costs. Income replacement, caregiver, or non-earner Weekly disability benefits are payable for the period of time the insured person is, as a result of the accident, unable to return to work; unable to perform the normal care-giving duties he performed prior to the accident; or suffering a complete inability to carry on a normal life. The income replacement and non-earner benefits are not payable if the injured person: knew, or ought reasonably to have known, they were operating a vehicle without valid insurance or without the consent of the owner; was operating the vehicle without a valid driver s licence; or, at the time of the accident, was engaged in an act for which the person is convicted of a criminal offence. Only one of these benefits is payable in the event the insured person qualifies for two or more weekly benefits 8 Ontario accident benefits

9 The income replacement benefit is limited to the lesser of 70 percent of an insured person s pre-tax income, or $400 per week. There is a one-week elimination period. The benefit is payable for a period of two years, at which point the benefit is only payable if the insured person is unable to return to any form of work. There are optional benefits available that allow the weekly limit to be increased to $600, $800 or $1,000 per week. The caregiver benefit does not apply unless the optional benefit has been purchased. If it has been purchased, the caregiver benefit is limited to $250 per week for the first person in need of care, and $50 per week for each additional person in need of care. The benefit is not payable beyond two years, unless the insured person suffers a complete inability to carry on a normal life. In the event the insured person was not employed at the time of the accident, and as a result of the accident suffers a complete inability to carry on a normal life, coverage is provided for a non-earner benefit. The benefit is limited to $185 per week, or if the insured person was a student at the time of the accident, $320 per week. There is a 26-week elimination period. Attendant care Coverage is provided for all reasonable and necessary expenses incurred by the insured person, as a result of the accident, for services provided by an attendant or long-term care facility. This coverage is limited to $3,000 per month for two years or $36,000 (whichever comes first). In the event of a catastrophic injury, the benefit is increased to $6,000 per month, to a maximum of $1,000,000 for a lifetime. Examination costs Subject to fee guidelines, this benefit pays for all reasonable fees charged by a health professional for conducting an assessment or examination, and for preparing a report if the assessment or examination is reasonably required in connection with a benefit being claimed. Prior to September 1, 2010 there was no monetary or time limit to the benefit. Following the changes on September 1, 2010 these costs currently come out of the Medical and Rehabilitation limits. 9 Ontario accident benefits

10 Housekeeping As of September 1, 2010, housekeeping is only available to those that have either purchased the optional benefit or those that have suffered a catastrophic injury. This coverage is limited to $100 per week for two years, or in the event of a catastrophic injury, for a lifetime. Visitor s expenses This benefit pays for the reasonable and necessary expenses incurred by specific people who visit the insured person during his treatment or recovery; namely, the insured person s spouse, children, grandchildren, parents, grandparents, brothers and sisters. There is no monetary limit to the benefit, which is payable for the first two years following the accident, or in the event of a catastrophic injury, a lifetime. Repair or replacement of damaged clothing, glasses, hearing aids, etc. This benefit pays the cost of repairing or replacing the following items that were lost or damaged as a result of the accident: clothing worn by the insured person at the time of the accident; prescription eyewear; dentures; hearing aids; prostheses; and other medical or dental devices. Death and funeral In the event an insured person dies as a result of the accident, this benefit pays a maximum of $6,000 towards incurred funeral costs and a one-time payment of $25,000 to the insured person s spouse and $10,000 to each of his dependants. Medical & Rehabilitation Damaged Clothing Income Replacement Visitor s Expenses Ontario Statutory Accident Benefits Attendant Care Examination Costs Death & Funeral Housekeeping These benefits are not payable if the injured person: knew, or ought reasonably to have known, they were operating a vehicle without valid insurance or without the consent of the owner; was operating the vehicle without a valid driver s licence; or at the time of the accident, was engaged in an act for which the person is convicted of a criminal offence. 10 Ontario accident benefits

11 4.0 How do statutory accident benefits interact with other systems? By virtue of the nature of the trucking business, an automobile accident almost always occurs during the course and scope of the injured person s employment. There s also a good chance that the accident will have occurred outside of Ontario, and that the injured person will have purchased supplementary coverage from a private disability carrier to cover such incidents. The Ontario Automobile Policy details how the accident benefits coverage it provides will interact with other insurance, such as workers compensation, collateral policies, and the policies of other jurisdictions. Workers compensation As long as an injured person is entitled to receive benefits from a workers compensation plan, they are not eligible to receive accident benefits, without exception. Contrary to popular belief, the injured person is not afforded the choice to receive either workers compensation or accident benefits. Rather, the injured person is offered the choice to receive workers compensation benefits or take legal action against a party involved with the incident. In the event they choose the latter course of action, they will no longer be entitled to receive workers compensation benefits. Because they are no longer entitled to workers compensation benefits, the injured person thereby becomes eligible to receive accident benefits. Did you know? If a person is entitled to workers compensation benefits as a result of an accident, they are barred from claiming statutory accident benefits, unless they choose to pursue a legal action in connection with the incident. 11 Ontario accident benefits

12 Collateral policies Unlike the example above, an injured person can, in respect to one incident, be eligible for both benefits available under a collateral policy and accident benefits however, in that case, the collateral policy becomes the first payer. This means that all claims must first be presented to the collateral insurer, and only those portions not covered may be submitted to the accident benefits insurer for consideration. It is important to note that there are a great number of benefits offered in the accident benefits schedule that are rarely, if ever, offered under a collateral policy. Some examples include the attendant care, housekeeping, and assessments and examinations benefits. The existence of a collateral policy will not exempt the accident benefits insurer from having to pay any benefits. Finally, the offset experienced by an accident benefits insurer when a collateral policy exists does not apply to claims for death or funeral benefits. Other jurisdictions In the event a person is injured in an automobile accident outside of Ontario, they are required to choose between receiving accident benefits offered under the Ontario Automobile Policy, or benefits in the same amounts and subject to the same conditions as offered in the accident jurisdiction. No matter what choice the injured person makes, the Ontario insurer is responsible for paying the claims. It is important to note that there are, in fact, a number of jurisdictions whose accident benefits schemes are richer than those offered in Ontario. In Michigan, for example, there are no monetary or time limits on medical, rehabilitation and attendant care benefits available to an injured person. A person who is injured in an accident outside of Ontario will be provided the choice of receiving his policy s statutory accident benefits, or the no-fault benefits available in the accident jurisdiction. Either way, his insurer is responsible for paying whatever benefits level is chosen Did you know? Benefits available to an injured person under a collateral policy offset that person s available accident benefits. 12 Ontario accident benefits

13 5.0 What is loss transfer? In 1990, the government of Ontario introduced a No Fault scheme, in which people were paid benefits by their own insurer without consideration of fault. Prior to this No Fault scheme, people were paid directly by the at-fault driver. As a result of this change, a law was subsequently created in Ontario called Loss Transfer (Section 275 of the Insurance Act). Loss Transfer was implemented due to the fact that disproportionate benefits were being paid by insurers of Private Passenger Vehicles (PPVs), compared to those who insure heavy commercial vehicles. The main rule behind Loss Transfer is that if the at-fault party is a heavy commercial vehicle, its insurer would reimburse the PPV s insurer. This is based on the fact that, in many cases, if a small PPV was hit by a truck, the driver of the PPV may be seriously injured while the truck driver may be uninjured. For Loss Transfer to apply, the atfault vehicle must be over 4500 kg [this includes cargo, vehicle attachments, and even the weight of the driver] and the notat-fault vehicle must be below 4500 kg. 13 Ontario accident benefits

14 6.0 What s available? As of September 1, 2010, if you are buying a new policy or renewing an existing one, you have the following options with respect to Statutory Accident Benefits: Coverage Coverage under policies initiated before Sept. 1, 2010 Coverage under new standard auto insurance policy Options available to increase benefits Medical, rehabilitation and attendant care benefits - for non-catastrophic injuries $100,000 for medical and rehabilitation benefits; $72,000 for attendant care benefits. $50,000 for medical and rehabilitation benefits, including assessment costs; $36,000 for attendant care benefits. $100,000 or $1,100,000 for medical and rehabilitation benefits including assessment costs; $72,000 or $1,072,000 for attendant care benefits. Medical, rehabilitation and attendant care benefits - for catastrophic injuries $1,000,000 for medical and rehabilitation benefits; $1,000,000 for attendant care benefits. $1,000,000 for medical and rehabilitation benefits including assessment costs; $1,000,000 for attendant care benefits. An additional $1,000,000 for medical, rehabilitation and attendant care benefits including assessment costs. Caregiver benefit Up to $250 per week for the first dependant plus $50 for each additional dependant; available for all injuries. Up to $250 per week for the first dependant plus $50 for each additional dependant; available only for catastrophic injuries. Up to $250 per week for the first dependant plus $50 for each additional dependant; available for all injuries. Housekeeping and home maintenance expenses Up to $100 per week, available for all injuries. Up to $100 per week, available only for catastrophic injuries. Up to $100 per week, available for all injuries. Income replacement benefit 80 percent of net income up to $400 per week 70 percent of gross income up to $400 per week Weekly limit can be increased to $600, $800 or $1000 per week Dependant care benefit Not provided. Not provided. Up to $75 per week for the first dependant and $25 per week for each additional dependant to a maximum of $150 per week. Death and funeral benefits $25,000 lump sum to an eligible spouse; $10,000 lump sum to each dependant; maximum $6,000 funeral benefits $25,000 lump sum to an eligible spouse; $10,000 lump sum to each dependant; maximum $6,000 funeral benefits. $50,000 lump sum to an eligible spouse; $20,000 lump sum to each dependant; maximum $8,000 for funeral benefits. Indexation benefit applicable to income replacement benefit, non-earner benefit, caregiver benefit, attendant care benefit or medical and rehabilitation benefit Not provided. Not provided. Annual adjustment according to the Consumer Price Index for Canada. Source : 14 The information in this brochure is only an outline of the coverage available and is subject to the terms, conditions and exclusions of the policy. Please refer to the policy wording for complete details.

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