Understanding Automobile Insurance and Rehabilitation in Ontario: Common Sense Definitions and Explanations

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1 Understanding Automobile Insurance and Rehabilitation in Ontario: Common Sense Definitions and Explanations clinical excellence human focus 15 Barrie Blvd., St. Thomas, ON N5P4B9 Ph: Fx:

2 Understanding Automobile Insurance and Rehabilitation in Ontario: Common Sense Definitions and Explanations Introduction At Novus Rehabilitation we understand that navigating the claims process after an automobile accident can be challenging, especially when you or a loved one needs care or rehabilitation. Sometimes trying to understand the process, the terminology and the various definitions can be an unwanted stressor. In this free e-book we have summarized definitions/descriptions of various processes, legislation and services you may encounter as you navigate the claims process after an injury from an automobile accident. These definitions are designed to help you to better understand, in a common sense way, some of the terms you might encounter. This document does not cover every definition or term that you might encounter and for many you might want to learn more information. If that is the case, you could review the Insurance Act and the associated Statutory Benefits Schedule (SABS) or call us in the office at (or and we ll be happy to help. Please note: The content and definitions in this document may be reproduced only for your own personal or educational use. This material is copyrighted and must be appropriately referenced and acknowledged as the intellectual property of Novus Rehabilitation. We recommend that any acknowledgement read: Information provided courtesy of Novus Rehabilitation. The information contained in this document may not be copied or otherwise reproduced for any commercial use or application. Novus Rehabilitation 2014 All Rights Reserved 2

3 Part 1: Helping You Understand the Process I ve been injured in a motor vehicle accident in Ontario. How do I get coverage for services I might need? In order to be covered for any services that you might need after being injured in a motor vehicle accident in Ontario you must contact your insurance company and report your claim. They will generally send you a package which contains a number of forms: OCF 1 Application for Accident Benefits (you complete this form) OCF 2 Employer s Confirmation of Income (your employer completes this form) OCF 3 Disability Certificate (your doctor most commonly completes this form) OCF 5 Permission to Disclose Health Information (you complete this form) OCF 23 - Treatment Confirmation Form (if you are seeking treatment the service provider completes this form if you fall under the Minor Injury Guidelines or MIG). These forms, as a whole, serve to open your file with the insurance company so that you are eligible for the benefits that you may be entitled to receive. I think that I need some treatment and care. How do I access it? In order for you to access treatment and care following an automobile accident the service provider (i.e., health care professional) who you wish to work with must complete an OCF 18 Treatment and Assessment Plan. Before you can receive their services the OCF 18 must be approved by the insurance adjuster assigned to your file. In some urgent instances assessments and/or treatments may proceed with verbal approval from the adjuster. Once approval is received from the adjuster you may proceed with the requested treatment or care for the duration specified in the OCF 18. If your OCF 18 is declined the adjuster may request an Insurer s Examination (IE) in order to obtain a second opinion related to your need for this treatment or care. Novus Rehabilitation 2014 All Rights Reserved 3

4 Part 2: Key Definitions FSCO The Financial Services Commission of Ontario (FSCO) is responsible to oversee the insurance and pension industries in Ontario. FSCO makes the rules that govern the insurance industry in Ontario. SABS Part of the Insurance Act, the Statutory Accident Benefits Schedule is a regulation that defines what benefits you are entitled to after an accident in Ontario. MIG Minor Injury Guideline If your injuries are primarily soft tissue in nature (i.e., sprains, strains) then your coverage would fall under the Minor Injury Guideline or MIG. Benefits under the MIG are restricted to $3500 for medical and rehabilitation services. Non Catastrophic Impairment If the nature of your injuries are more severe than the Minor Injury Guideline (MIG) but not immediately considered Catastrophic in nature then a Non Catastrophic Impairment classification would apply. Accordingly, you would be entitled to various benefits at the Non Catastrophic Impairment level. For example, as an adult you would be entitled to fifty thousand dollars in Medical and Rehabilitation Benefits over a ten year period and/or your entitlement to Attendant Care Benefits would be limited to a two year period (104 weeks). In the case of minors the duration of benefit coverage may exceed ten years depending upon their age at the time of the accident. Catastrophic Impairment Depending on the nature and severity of your injury (i.e., brain injury, spinal cord injury, amputation etc.) your impairments may be deemed to be catastrophic in nature. If this is the case the length of time and the overall dollar value of your benefits increase. For example, your Medical and Rehabilitation Benefit would be one million dollars over the course of your lifetime (vs. fifty thousand dollars over a ten year period if your injuries are noncatastrophic). Claims Adjuster (Adjuster) A Claims Adjuster is responsible to adjust or oversee your insurance claim on behalf of the insurance company. Novus Rehabilitation 2014 All Rights Reserved 4

5 Accident Benefits Accident benefits is the term used in the auto insurance world when referring to the variety of benefits you may be entitled to if you are injured in an automobile/motor vehicle accident. Types of accident benefits may include, but are not limited to: income replacement benefits, medical and rehabilitation benefits, caregiving benefits, housekeeping benefits and/or attendant care benefits. Income Replacement Benefit (IRB) This is a part of your standard automobile insurance coverage; it is intended to cover your lost income if you are off work due to your injuries. The amount of the income replacement benefit depends on your specific coverage. It is possible to purchase a higher level of income replacement benefit when you are buying an auto insurance policy. Note: If Income Replacement Benefits do not apply to you then you may be entitled to Non-Earner Benefits or Caregiver Benefits. Non-Earner Benefit If you are not employed you may be eligible to receive Non- Earner Benefits if you meet the criteria that you suffer a complete inability to carry on a normal life as defined in the SABS. Caregiver Benefit If your primary role is as the caregiver to your children or adult parents and you are unable to participate in these tasks due to your injuries you may be entitled to receive Caregiver Benefits rather than Income Replacement Benefits. Medical and Rehabilitation Benefit You are entitled to Medical and Rehabilitation Benefits to cover a wide variety of costs associated with your medical care, related medications, therapy/rehabilitation services, equipment or home modification needs and eligible transportation costs. Attendant Care Benefit Your entitlement to Attendant Care Benefits must be assessed by an Occupational Therapist or Registered Nurse and documented on the Form 1 reflecting your need for assistance in managing your own personal care tasks. Such tasks might include, but are not limited to: bathing, dressing, grooming, mobility, dining, taking medications etc. These funds may be used to pay for someone to come into your home and assist you with those tasks that you are unable to safely or independently manage due to your injuries. The Attendant Care Benefit does not encompass housekeeping needs. Novus Rehabilitation 2014 All Rights Reserved 5

6 IE (Insurer s Examination) Under Section 42 of the Statutory Accident Benefits Schedule (SABS) your insurance adjuster may seek an unbiased opinion about recommendations related to your care. In this situation, the adjuster may select a health care professional to perform an Insurer s Examination (IE) of professional recommendations for treatment, services or equipment requested. It is expected that this evaluator should have the knowledge and experience to provide an unbiased opinion related to your unique clinical needs. The Insurer s Examination assessor is not to provide treatment and results of their clinical analysis must be reported back to the referring insurance adjuster generally within ten working days. If recommendations are made related to treatment or equipment you must be notified of your right to select your preferred therapist to follow through. Should you disagree with the findings of the IE you have the right to apply for mediation. FAE A Functional Abilities Evaluation (commonly referred to as an FAE) is an objective assessment of your abilities and limitations. This type of assessment looks at your physical and cognitive abilities such as strength, endurance and movement dexterity. The data obtained in completing the FAE allows for comparisons to be made in various contexts; quite often, FAE data is used in supporting analysis of safe return to work and related to what type of accommodations or supports may be needed. There are various FAE methods utilized in the industry. JSA A Job Site Analysis (commonly referred to as a JSA) is a multi-faceted assessment typically involving a physical demands analysis (an assessment of the physical demands at your job). Following the completion of a JSA a report will be generated and it should include information and/or recommendations to support your safe return to work given your physical issues or impairments. This may include, but is not limited to, ergonomic, environmental/design recommendations as well as posture, movement or technique recommendations. PDA A Physical Demands Assessment (typically referred to as a PDA) is an objective analysis of your occupation/job and all of the responsibilities and tasks involved in its completion. Often, your employer has a record of the physical demands of each job at your workplace. Novus Rehabilitation 2014 All Rights Reserved 6

7 Mediation If you have requested treatment or services and have, following an Insurer s Examination (IE) been refused then one option is to apply for Mediation. Mediation is a confidential process that helps to resolve disputes between you and your insurance company using a mediator from the Financial Services Commission of Ontario (FSCO). If the more informal mediation process does not resolve your concerns then the next step is the formalized Arbitration process. Arbitration If the mediation process proves unsuccessful then Arbitration is the next step. A neutral arbitrator will hear the arguments of both sides and usually makes a final decision. Motor Vehicle Accident Claims Fund (MVACF) If you are injured and neither you nor the other party involved in the accident have insurance coverage then the Motor Vehicle Accident Claims Fund (MVACF) is considered to be the payer of last resort. Practically, this means that coverage for your accident benefits claim will be provided through this fund. Novus Rehabilitation 2014 All Rights Reserved 7

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