Accident Benefits Coverage in Ontario

Transcription

1 Accident Benefits Coverage in Ontario June 2007

2 Accident Benefits Coverage in Ontario Table of Contents If You Are in a Car Crash...1 Specified Benefits...3 Death and Funeral Payments...7 Medical, Rehabilitation and Attendant Care Benefits...9 Professional Services Guideline Getting the Process Started Paralegals (SABS Representatives) Payment of Other Expenses Right to Sue Additional Information and Help This document is intended as an overview of the accident benefits available to you under Ontario insurance laws. It does not contain every detail of the auto insurance legislation. For the precise wordings of the law, you should consult the Ontario Insurance Act and the Statutory Accident Benefits Schedule made under that act. With appropriate acknowledgement, this publication may be reproduced and may be used in whole or in part, provided that such reproduction is intended for personal or educational use and not for monetary gain of any kind. Recommended acknowledgement: Information provided courtesy of Insurance Bureau of Canada.

3 If You Are in a Car Crash Who is Eligible for Benefits? Any person who is injured in a car crash or any person who suffers psychological injuries because of a car crash that has injured certain relatives or dependants may be eligible for benefits. If you are insured under more than one policy, there are special rules that determine from which policy you are eligible to receive benefits. You are not eligible to receive income replacement benefits, non-earner benefits, lost education expenses, expenses of visitors and housekeeping and home maintenance benefits if you were in contravention of the law at the time of the accident. Some examples of this would be: driving without a valid licence; driving a vehicle when you knew or should have known you were driving without the owner's consent; being a passenger who knew or should have known that the driver did not have the owner's consent to drive the vehicle; driving when you knew or should have known you did not have valid insurance; driving while impaired or refusing to provide a breath sample; using an automobile in connection with criminal activity; and having knowingly misrepresented information when you applied for auto insurance. What Are the Benefits? The following are brief descriptions of the types of benefits for which you may be eligible. For more complete descriptions and to determine if you are in fact eligible for any of the following benefits, you should contact your insurance broker, agent or adjuster, who will have more detailed information for you about the various benefits. INCOME REPLACEMENT BENEFIT If you are eligible, this weekly benefit will partially compensate you for the loss of your income if you cannot work because of your injuries. NON-EARNER BENEFIT If you are eligible, this benefit will begin to compensate you 26 weeks after the onset of your complete inability to carry on your normal activities. CAREGIVER BENEFIT If you are eligible, this weekly benefit will reimburse you for expenses you incur if you cannot continue as the main caregiver for a member of your household who is under 16 or who is over 16 and suffers from a disability

4 MEDICAL AND REHABILITATION BENEFIT This benefit will pay for reasonable and necessary medical and rehabilitation expenses not covered by a government health plan or a supplementary health plan you may have. ATTENDANT CARE BENEFIT This benefit will pay reasonable and necessary expenses for a caregiver or attendant whom you require if you are unable to carry out certain self-care activities as a result of severe injuries sustained in the accident. OTHER EXPENSES BENEFIT This benefit will pay for other expenses such as lost educational expenses, expenses of visitors, and the reasonable cost of housekeeping or home maintenance necessary due to injuries you sustained in the accident. Repairing or replacing certain items of your clothing lost or damaged in the accident may also be covered. DEATH AND FUNERAL PAYMENTS BENEFIT There are lump-sum payments available for survivors of a person killed in an accident and to help pay for a funeral

5 Specified Benefits Ontario's Auto Insurance Laws You have been injured in a car crash and, as a result, you are not able to work or carry on your normal activities as before. There are important facts you need to know when applying for Weekly Benefits through your automobile insurance. This document will help you understand the Ontario laws concerning the payment of benefits to people injured in car crashes. This includes: people who have been employed; caregivers; and people who have no income (non-earners). You must tell your insurance company within 7 days of the crash, or as soon as possible, that you wish to apply for benefits. You must send your application for benefits within 30 days of receiving the application forms. Income Replacement Benefit If you are eligible, this benefit will partially compensate you for the loss of your income if you cannot work because of your injuries. This benefit is for people who were employed at the time of the accident. You may be eligible to get a payment every two weeks to partially replace the income you have lost if, as a result of the car crash, you can no longer work at the same level or pace as before. This benefit is available, if you continue to be unable to work at the same level or pace, for up to 2 years after the car crash. You may qualify overall for benefit payments if you can answer "yes" to the following questions: 1. Did I suffer physical or psychological injuries as a result of a car crash and, as a result, am I unable to work? 2. Do any of the following statements apply to me? a. I was employed or self-employed on the day of the car crash. b. I worked for at least 26 of the 52 weeks immediately prior to the car crash. c. I was receiving Employment Insurance (EI) benefits on the day of the car crash. How Much Might I Receive? As long as you are eligible, you will receive a payment at least once every two weeks of 80% of your net pay based on your income history before the accident, minus net income benefits payable from other sources such as your employer, to a maximum of $400 per week. The first seven days of your disability is not covered. Your net pay is the total of your annual income minus Employment Insurance premiums, Canada Pension Plan payments and the income tax you would normally have deducted from your pay

6 The amount you will receive will be calculated on the information you included on your application form. In general, benefits are calculated as follows: For persons employed at the time of the accident, the income replacement is based on income earned in the 4 or 52 weeks before the accident. For persons self-employed at the time of the accident, the income replacement benefit is based on income earned in the last 52 weeks, or the person s last fiscal year completed before the accident. For persons unemployed at the time of the accident but receiving Employment Insurance benefits, or those who had worked at least 26 weeks in the 52 weeks before the accident, the income replacement benefit is based on the income earned in the 52 weeks before the accident including Employment Insurance benefits. For persons over the age of 65, benefits are payable for up to four years on a declining basis. For persons who reach age 65 while receiving benefits, the benefit is converted at that time to a lifetime pension at a reduced rate. If you can produce a written contract that provides evidence you were to start work after the date of the accident, the income replacement benefit will be based on the annual income you would have received. The payments will begin within 10 days after your completed application is received by your insurance company. If your disability continues, a payment will follow at least once every two weeks. If your application is questioned or refused, you will be given a written explanation within 10 business days. Caregiver Benefits A caregiver is someone who is responsible for looking after others. You may qualify for caregiver benefits under Ontario's automobile insurance legislation if you are an insured person who, as a result of the car crash, is substantially unable to carry out the caregiving activities you previously carried out. The law also says that you must: be living with a person in need of your care; and be the primary caregiver for the person in need of care and not be receiving any payment for engaging in caregiver activities. How Much Might I Receive? The caregiver benefit reimburses you for the expense of purchasing caregiving services for your dependants if, due to injuries you sustained in the automobile collision, you are unable to care for them as you did before the collision. If eligible, you will receive $250 per week for the first person and $50 per week for each additional person in your household for whom you were the main caregiver at the time you were injured. As a caregiver, you may receive benefits for up to 104 weeks while you are substantially unable to perform your caregiving activities. Your insurer is not obligated to pay a caregiver benefit for any period longer than 104 weeks of disability, unless as a result of the car crash, you have a complete inability to carry on a normal life

7 When you bought your car insurance, you may have purchased the optional caregiver and dependant care benefit from your insurance agent or broker, which pays a higher benefit of $325 per week for the first person and $75 per week for each additional person. Please check to see if you are eligible to receive these increased benefits. Non-earner Benefits You may qualify for non-earner benefits if: you do not qualify for income replacement benefits; you no longer qualify for caregiver benefits; you were a full-time student at the time of the car crash; or at the time of the car crash, you had completed your education in the previous year but had not yet secured employment related to your education. To qualify for this benefit, you must suffer a complete inability to carry on your normal activities. How Much Might I Receive? The first 26 weeks of your disability are not covered. After this period, you may be eligible to receive a weekly payment of $185 every two weeks. If more than 104 weeks have elapsed since the onset of the disability and you continue to qualify for the benefit, the amount will be increased to $320 for each week that you are eligible to receive the benefit. Housekeeping and Home Maintenance Benefit You may qualify for housekeeping benefits if, as a result of the car crash, you sustain an impairment that results in a substantial inability to perform housekeeping and home maintenance that you normally performed prior to the car crash. How Much Might I Receive? The amount payable for this benefit will be up to $100 per week; the benefit will not be paid for more than 104 weeks after the onset of the disability. If You Refuse Treatment Please note that your benefit(s) may cease if you refuse to participate in rehabilitation or treatments that are reasonable or, in the case of the income replacement benefit, you are able and do not make a reasonable effort to return to work or to obtain other employment for which you are trained. Where Does the Application Go? If you have your own automobile insurance or are covered under someone else's policy, return the completed application to that insurance company. If you don't have insurance, return the completed application to your spouse s insurance company or the insurance company of someone you are dependent on. If you do not have access to insurance that way, send the application to the insurer of the car in which you were an occupant or, if you were a pedestrian, the insurer of the car that hit you. If there

8 is no insurance on that vehicle, return the application to the insurer of any other vehicle involved in the accident and failing that, call the Motor Vehicle Accident Claims Fund at (or in the Toronto area). Which Benefit is Right for Me? You may be eligible for more than one type of weekly benefit; however, you must choose only one. If your application for benefits discloses that you qualify for more than one benefit, your insurance company will notify you

9 Death and Funeral Payments Ontario's Auto Insurance Laws If, as the result of a car crash, you have lost your spouse, dependant or someone on whom you have been dependent, there are important facts you need to know when applying for survivor benefits through your automobile insurance. You must tell your insurer within 7 days of the person's death, or as soon after that as possible, that you wish to apply for payments. Your insurer will supply you with the necessary forms and any other information you need. You must file your application for payment of death and funeral benefits within 30 days of receiving the application forms. What are Death Benefits and Funeral Benefits? Death benefits are lump-sum payments to you if you have lost a spouse, dependant or someone on whom you were dependent. Funeral benefits provide reimbursement for funeral expenses to a maximum of $6,000, unless you have purchased the optional extra amount. Do I Qualify for Payments? Before you can receive death benefits or reimbursement for funeral expenses under an automobile insurance policy, your situation must qualify under the statutory accident benefits coverage. You may qualify for payments if, as a result of the car crash, one of the following dies within 180 days of the car crash (or within 156 weeks if the injury sustained was continuous during that period): your spouse (or former spouse or same-sex partner from whom you were receiving maintenance or support under a domestic contract or court order); or the person on whom you were dependent; or a person dependent on you. How Much Might I Receive? The amount of the death benefit you are to receive depends on your particular situation: 1. If you are the spouse or same-sex partner of a person killed in the car crash, you may be entitled to a payment of $25,000 ($50,000 if the optional death and funeral benefit was purchased). If the deceased person had no spouse, the dependants of the deceased person will be entitled to share $25,000 equally. 2. In addition to the amount identified in #1, if you were dependent on the person who died, or if the person who died was obliged under a domestic contract or court order to provide support to you, you will be entitled to a benefit of $10,000 ($20,000 if the optional death and funeral benefit was purchased)

10 3. You should be aware that if a dependant is killed as a result of a car crash, the $10,000 payment will be made to the surviving provider or, in the case that this individual is dead, to the spouse or same-sex partner of the provider if the spouse or same-sex partner was the primary caregiver of the dependant. If the provider and spouse or same-sex partner do not survive for 30 days after the accident, the $10,000 is shared by all dependants who survive for these 30 days. 4. Funeral expenses are reimbursed to a maximum of $6,000, or $8,000 if the optional death and funeral benefits was purchased. Where Does the Application Go? If the deceased had his or her own insurance or was covered under someone else's policy, return the completed application to that insurance company. If the deceased did not have insurance, return the completed application to your spouse s insurance company or the insurance company of someone you are dependant on. If you do not have access to insurance in that way, send the application to the insurer of the car in which the person was an occupant or, if he or she was a pedestrian, the car that hit him or her. If there is no insurance on that vehicle, return the application to the insurer of any other vehicle involved in the accident and failing that, call the Motor Vehicle Accident Claims Fund at (or in the Toronto area)

11 Medical, Rehabilitation and Attendant Care Benefits Ontario s Auto Insurance Laws You are injured in a car crash and you require treatment for your injuries. There is information you should know about medical, rehabilitation and attendant care benefits. What are Medical Benefits? Medical benefits include payments for reasonable and necessary expenses that are not covered by another health plan, such as OHIP or an extended health policy, and that are incurred as a result of a car crash in which you were injured. The coverage includes reasonable and necessary expenses for any of the following items, if they are necessary as a result of the injuries you sustained in the accident: medical, surgical, dental, optometric, hospital, nursing, ambulance, hearing testing and speechtherapy services; chiropractic, psychological, occupational therapy and physiotherapy services; medication; prescription eyewear; dentures and other dental devices; hearing aids, wheelchairs or other mobility devices, prostheses, orthotics and other medical devices; transportation to and from treatment including transportation for an attendant; and other required goods and services of a medical nature. NOTE: Your insurance company is not obliged to pay for any goods or services that are considered experimental. What are Rehabilitation Benefits? Rehabilitation benefits are for the payment of expenses incurred by you or on your behalf, as a result of injuries caused by a car crash. The benefit is to reimburse you for payments you have made for reasonable and necessary measures to: i reduce and eliminate the effects of the disability resulting from the injury; or ii assist you in reintegrating into a family role or the labour market (if you had a labour force attachment) and also your community. The coverage includes reasonable and necessary expenses for: life-skills training; family, social rehabilitation, financial and employment counselling; vocational assessments; workplace, home and vehicle modifications; and other goods and services required that are rehabilitative in nature. Page 9

12 Do I Qualify for Medical and Rehabilitation Benefits? It is important to understand that the expense incurred must be as a result of the injury you sustained in the car crash, as well as reasonable and necessary. Your insurance company will usually require that the application include a treatment plan prepared by a health-care practitioner. A treatment plan includes a description of the impairment and resulting disability and of the goods and services to be used in the treatment. Your insurer will respond to the treatment plan within 10 business days of receiving it. If the plan is acceptable, the insurer will pay for expenses within 30 days of receiving invoices. Any medical and rehabilitation coverage available to you through other sources must be accessed first. How Much Might I Receive? If your injury is not catastrophic as defined by the regulations, medical and rehabilitation benefit payments could be up to a maximum of $100,000, if your condition and needs warrant. If your injury is catastrophic, benefit payments could be up to a maximum of $1,000,000. You may have purchased benefits with higher limits. See your insurance representative, broker or agent for the amounts that apply to you. What are Attendant Care Benefits? Attendant care benefits are intended to reimburse you for reasonable and necessary expenses incurred by you or on your behalf to purchase the following services, which must be required as a result of injuries sustained in the car crash: services provided by an aide or attendant; or services provided by a long-term care facility including a nursing home, home for the aged or chronic-care hospital. Do I Qualify for Attendant Care Benefits? The expenses incurred must be required as a result of the injury you sustained in the car crash, as well as reasonable and necessary. Your insurance company may require the treating health-care practitioner to sign a form to verify these criteria. Should the expenses continue, your insurer will likely request updated forms. Any attendant care coverage available to you through other insurance sources must be accessed first. How Much Might I Receive? If your injury does not result in a catastrophic impairment as defined by the regulations, attendant care benefit payments will be up to $3,000 per month and $72,000 total for expenses incurred within two years of the accident. If your injury does result in a catastrophic impairment, benefit payments will be up to $6,000 per month and $1,000,000 total with no time limit. You may have purchased benefits with higher limits. See your insurance representative, agent or broker for amounts that apply to you. Page 10

13 Maximum Fees for Professional Services Expenses for health-care services rendered on or after November 1, 2003 are subject to maximum fees payable by automobile insurers who are not liable to pay more than these fees. What if there is a Dispute Concerning Medical, Rehabilitation or Attendant Care Benefits? Discuss your concerns with your insurance representative or adjuster. If the issue in dispute remains unresolved, there is a dispute resolution process available through FSCO at (or in the Toronto area). An application for mediation can be obtained from your insurance company. Page 11

14 Professional Services Guideline THE PROFESSIONAL SERVICES GUIDELINE FROM THE SUPERINTENDENT S GUIDELINE NO. 01/05 IS AS FOLLOWS: Introduction This Guideline is pursuant to section (1) of the Insurance Act for the purposes of subsections 14 (4), 15 (6), 17 (2) and 24 (2) of the Statutory Accident Benefits Schedule Accidents on or After November 1, 1996 (SABS), and applies the expenses for health care services rendered on or after November 1, Purpose This Guideline sets out the maximum fee payable by automobile insurers under the SABS for the services of any of the health care professions or health care providers listed in this Guideline. These maximum fees are applicable to: a medical benefit under clauses 14 (2) (a), (b), or (h) of the SABS; a rehabilitation benefit under clauses 15 (5) (a) to (g) or (l) of the SABS; case management services under subsection 19 (1) of the SABS; or conducting an examination or assessment or provision of a certificate, report or treatment plan under subsection 24 (1) of the SABS. Maximum Fees Automobile insurers are not liable to pay for expenses related to professional services rendered to an insured person that exceed the following maximum hourly rates. These fees change yearly based on the fees charged by Ontario Medical Professionals. Page 12

15 Regulated Health Profession or Provider Max. Hourly Rate (as of June/06) Non-Catastrophic/Catastrophic Chiropractors $99.78/$ Massage Therapists $51.47/$78.78 Occupational Therapists $88.23/$ Physiotherapists $88.23/$ Podiatrists $88.23/$ Psychologists and Psychological Associates $132.34/$ Speech Language Pathologists $99.26/$ Registered Nurses, Registered Practical Nurses and Nurse Practitioners Unregulated Health Profession or Provider Case Managers, Kinesiologist, Family Counsellors, Psychometrists, Rehabilitation Counsellors, Vocational Counsellors Fees for Completion of Forms $80.87/$96.63 Max. Hourly Rate (as of June/06) Non-Catastrophic/Catastrophic $51.47/$78.78 Automobile insurers are not liable to pay expenses that exceed the following maximum fees for the completion for certain accident benefit forms by members of the health professions and health care providers listed in this Guideline. (These maximum fees do not apply to the assessments related to the completion of these forms.) Form Max. Payable for Completion of Forms (as of June/06) Disability Certificate (OCF-3) $63.72 Treatment Plan Form (OCF-18) $63.72 Form 1 Assessment of Attendant Care Needs $63.72 Automobile Insurance Standard Invoice (OCF-21) $0 Application for Approval of an Examination (OCF-22/198) $63.72 Page 13

16 Getting the Process Started Effective March 1, 2006, Designated Assessment Centers were eliminated from the Statutory Accident Benefits Schedule and replaced with the insurer s right to request an independent medical examination. These changes streamline the assessment process by allowing you to have a medical assessment done by your own health care provider rather than a Designated Assessment Centre. How Do I Apply for Accident Benefits? After reporting the incident to your insurer you will be sent an application for accident benefits package from your insurer. Not all of these forms must be filled out by every person, so you may wish to speak to your insurance representative or adjuster to determine which forms apply to you. The full package will include the following: Application for Accident Benefits (OCF 1) Employer s Confirmation of Income (OCF 2) Disability Certificate (OCF 3) Permission to Disclose Health Information (OCF 5), and Pre-approved Framework Treatment Confirmation (OCF 23). Once you and your chosen health care practitioner have completed and returned the forms to your insurer, you will be notified within 10 business days of the insurer s decision to do one of the following: pay the benefit(s), request more information, or request you undergo an independent medical examination. What is an Independent Medical Examination? An Independent Medical Examination is conducted by a health care practitioner chosen by your insurance company. It can take one of two forms: a paper review and/or a physical exam. What Happens if my Insurer Requests an Independent Medical Examination? If an Independent Medical Examination is requested by your insurer, you will be notified of the following: the reason for the examination; whether your attendance will be required (if so, you will be informed of the date, time, place and expected length of the examination); information about who will be conducting the exam, including the health care practitioner s qualifications and accreditations; and that the examination will occur within 30 kilometres of your residence (if within the GTA), or within 50 kilometres (if outside the GTA). Am I Entitled to a Copy of the Examination Report? Yes. Your insurance company is obligated to send you and your health care practitioner a copy of the report within 5 business days of the receipt of the report from the health care practitioner who conducted the IME. Page 14

17 What Happens if I Refuse the Independent Medical Examination? If you refuse to comply with the request for an independent medical examination, your insurer has the right to deny your claim, for non-compliance, and will inform you of such. Can I Choose to Resubmit My Application after a Denial for Non-compliance Has Been Issued? Yes. If your claim is denied for non-compliance, you have the option of complying with the necessary conditions. Your insurer is then obligated to reconsider the application. Your insurer will be obligated to pay benefits that would normally have been paid during the period of non-compliance only if you provide them with a reasonable explanation for your non-compliance within ten business days of the original notification of non-compliance, or as soon as possible after that day. If My Insurer Denies My Claim after the Independent Medical Assessment, Do I Have Any Recourse? Yes. If an independent medical examination has been conducted and, as a result of that report, your insurer denies your claim for benefits, you have the right to another opinion or rebuttal examination, typically conducted by the health professional that originally filled out the application form that was used to claim for the benefit. This rebuttal examination, in most cases, will be limited to a paper review of your file and is confined to issues identified by the independent medical examination report that led to the denial. While generally the rebuttal is conducted by the health practitioner who filled out the original form, this is not written in stone. If the independent examiner is not a member of the same health profession as the original provider, or is a member of the same health profession but is a specialist when the original practitioner was not, then you can have a rebuttal examination conducted by a member of any health profession that is appropriately qualified to do so. Who Pays for the Rebuttal Examination? Your insurer pays for the rebuttal examination subject to monetary limits contained within the Statutory Accident Benefits regulations. If After a Rebuttal Examination My Claim is Still Being Denied, Do I Have Any Recourse? Yes. FSCO oversees several services to help consumers and insurance companies settle accident benefit claims fairly and without delay. If you and your insurance company disagree about your entitlement to accident benefits, or the amount of benefits, FSCO's Dispute Resolution Services Branch offers a series of dispute resolution processes, that are fast and cost-effective alternatives to court. FSCO's Dispute Resolution Services Branch provides a comprehensive dispute resolution system, which includes mediation, neutral evaluation, and arbitration with an internal appeals mechanism. These services help resolve disputes about whether or not you qualify for accident benefits under the Statutory Accident Benefits Schedule and how much those benefits should be. Page 15

18 Paralegals (SABS Representatives) Ontario's Auto Insurance Laws Effective November 1, 2003, there are new requirements for individuals who are not lawyers and who provide representation to claimants under the Statutory Accident Benefits Schedule (SABS). No one may act as an adviser, consultant or representative on behalf of a person concerning a claim for statutory accident benefits, unless the representative meets the requirements set out in the regulations. This includes any person who: advises another person about his or her rights under the SABS; completes or assists in completing application forms; discusses and negotiates with an insurer or adjusters; attends dispute resolution proceeding at Financial Services Commission of Ontario (FSCO), in small claims court or private arbitration; or negotiates the settlement of SABS claims. The regulations require paralegals (SABS representatives) to file information required by the Superintendent with FSCO; carry Errors & Omissions (E&O) liability insurance coverage of $1,000,000 in respect of any one occurrence; and refrain from acting for any individual whom they know, or ought reasonably to know, has a catastrophic impairment as defined in the SABS. The E&O liability insurance must not have a deductible greater than $5,000 per occurrence. The regulations also amend the definition of unfair or deceptive acts or practices to prohibit the following activities by paralegals (SABS representatives): charging fees under a contingency fee arrangement; paying or accepting referral fees; committing an act or omission inconsistent with a Code of Conduct issued by the Superintendent; and failing to disclose any conflict of interest to the claimant and the insurer. The following are exempt from regulations applying to paralegals (SABS representatives): lawyers acting in the usual course or practice of the law; employees of lawyers under direct supervision, if the lawyer or law firm is retained by the client; unpaid representatives, such as family or friends of the claimant who assist in an informal manner. A person is considered to be providing representation for compensation if he or she receives, directly or indirectly, a financial benefit in connection with the claimant s representation. Individuals who are paid service providers and combine the provision of health care or other services with claimant representation must comply with these requirements. Additional information is available from FSCO s website at Filing & Other Regulatory Requirements for Paralegals (SABS Representatives) is FSCO Bulletin No. A-06/03 Property & Casualty Auto. Also available is Superintendent s Code of Conduct for SABS Representatives. Page 16

19 Payment of Other Expenses Ontario's Auto Insurance Laws You have been injured in a car crash and, as a result, you are not able to work or carry on your normal activities as before. There are important facts you need to know when applying, through your car insurance, for payment of other expenses including: lost educational expenses; expenses of visitors; housekeeping and home maintenance expenses; and cost of examinations. You must tell your insurance company within 7 days of the accident, or as soon as possible, that you wish to apply for benefits. Your insurance company will provide you with the appropriate application forms. You must send your application for benefits within 30 days of receiving the forms. If there is a disagreement about payments or what is considered a reasonable and necessary expense and it cannot be resolved, the Financial Services Commission of Ontario can be called in to help find a solution. To find out more about FSCO s dispute resolution services call: (or in the Toronto area). Lost Educational Expenses This benefit is for people who, at the time of the accident, were enrolled in an elementary, secondary, post-secondary or continuing education program and, as a result of the accident, are unable to continue the program. The benefit covers expenses incurred before the accident for tuition, books, equipment or room and board. The expenses must be related to the program that you can no longer continue and for the school term in which you were enrolled at the time of the accident, to a maximum of $15,000. Expenses of Visitors If you suffer impairment as a result of an accident, your insurance company will pay for reasonable and necessary expenses incurred by the following people when they visit you during your treatment or recovery: your spouse, children, grandchildren, parents, grandparents, brothers and sisters; an individual who was living with you at the time of the accident; an individual whom you are treating as a child of your family; in the case of an injured child, an individual who is clearly treating that child as part of the individual's family. There is a maximum of 104 weeks after the accident during which these expenses can be claimed, unless the impairment is catastrophic. Page 17

20 Housekeeping and Home Maintenance If your injuries result in a substantial inability to take care of your home as you did before the accident, your insurance company will pay for reasonable and necessary additional expenses actually incurred by you for housekeeping and home maintenance services. The maximum payable for housekeeping and home maintenance is $100 per week. Incurred expenses can be claimed for up to 104 weeks after the onset of the disability unless the impairment is catastrophic. Damage to Clothing, Glasses, Hearing Aids, Etc. Your insurance company will pay for reasonable expenses incurred by you to repair or replace clothing you were wearing at the time of the accident, and prescription eyewear, dentures, hearing aids, prostheses and other medical or dental devices that were lost or damaged as a result of the accident. Cost of Examinations Subject to any relevant Superintendent s guidelines and/or regulations governing insurance approval of assessments, your insurer will pay for reasonable expenses incurred for an examination or assessment or to obtain a certificate, report or treatment plan. This includes: fees charged by a person conducting an examination or assessment or providing a certificate, report or treatment plan; and transportation expenses incurred by you and an aide or attendant in travelling to and from an examination or assessment. If your automobile is used to get there, your insurer will not pay the expenses for the first 50 kilometres of any transportation. Where Does the Application Go? If you have your own automobile insurance or are covered under someone else's policy, return the completed application to that insurance company. If you don't have insurance, return the completed application to your spouse s insurance company or the insurance company of someone you are dependent on. If you do not have access to insurance that way, send the application to the insurer of the car in which you were an occupant or, if you were a pedestrian, the car that hit you. If there is no insurance on that vehicle, return the application to the insurer of any other vehicle involved in the accident and failing that, call the Motor Vehicle Accident Claims Fund at (or in the Toronto area). Page 18

21 Right to Sue If, as a result of a car crash, you suffer a disabling injury, you may, within limits, be able to sue an atfault party to recover some losses. There may be many benefits available to you without the need to sue. If you suffer a disabling injury in a car crash, you must tell your insurer within 7 days of the accident, or as soon after that as possible, that you wish to apply for benefit payments. You must send your application for benefits within 30 days of receiving the application forms supplied by your insurer. What Can I Sue For? ECONOMIC LOSSES Recovery of lost income and loss of earning ability is limited to 80% of your net income lost, beginning seven days after the accident until trial. After the trial date, recovery will be based on 100% of your gross income loss and loss of earning capacity. Accident benefits and benefits from other sources such as workplace disability plans will be subtracted from court awards. These also include: payments of disability pension benefits under the Canada Pension Plan; periodic payments of insurance for income replacement, if the insurance is offered by the insurer, only to persons who are employed at the time the contract of insurance is entered into; and only on the basis that the maximum benefits payable is limited to an amount calculated by reference to the insured person s income from employment. HEALTH-CARE EXPENSES Recovery for health-care expenses is available only to people who suffer serious and permanent injuries as defined by the regulations. Accident benefits and benefits from other sources will be subtracted from court awards. PAIN AND SUFFERING Seriously injured accident victims whose injuries meet a legislated "verbal threshold" test may sue for pain and suffering (non-economic loss). A $30,000 deductible applies. Where the injuries of accident victims meet the "verbal threshold," family members may sue for loss of guidance, care and companionship under the Family Law Act. A $15,000 deductible applies. What is the Verbal Threshold? To be able to sue for pain and suffering and health costs that exceed the accident benefits limits, the injury must result in death or permanent serious impairment of an important physical, mental or psychological function. This is referred to as the "verbal threshold." Page 19

22 How Do I Begin? The person you are suing must be to some degree at fault for the accident. If this is the case, you (the plaintiff) must notify your own insurer of the accident and apply for accident benefits. You must also notify the person being sued (the defendant) within 120 days of the accident that you intend to commence a lawsuit against him or her. That person has the right to information about the victim's insurer and claim for statutory accident benefits, and the victim's medical treatment as a result of the accident. The victim may also be required to undergo an examination by the defendant's health professional. A failure to comply with these procedural and disclosure steps may result in a cost penalty against the plaintiff. You must begin your lawsuit against the defendant within two years of the accident. At any time, either party can request mediation to try to help settle the claim. Victims who hire lawyers to represent them in the lawsuits will be responsible for their lawyers' fees. Often, if the victim is successful in the lawsuit, the court will require the defendant to pay part of the plaintiff's legal costs. Page 20

23 Additional Information and Help Whether or not you have the right to sue, you may be eligible for accident benefits. If you need help understanding accident benefit payments, call Insurance Bureau of Canada at (or in the Toronto area). Application for Mediation Application for Arbitration Financial Services Commission of Ontario Consumer Information Financial Services Commission of Ontario Bulletins Note: Bulletins listed by year. Section Property & Casualty Auto Bulletins BULLETINS 2006 BULLETINS A-06/05 Revised Professional Services Guideline A-01/06 Revised Pre-approved Framework Guidelines for Whiplash Associated Disorder Grade I and II Injuries With or Without Complaint of Back Symptoms and Revised Transportation Expense Guideline A-08/05 Elimination of Designated Assessment A-03/06 New and Revised Accident Benefit Claims Forms Centre System, Cost Sanctions at Arbitration for Non-attendance at Insurer Examinations, and Amendment of Unfair or Deceptive Acts and Practices Regulation A-09/ Indexation Percentage Under Bill 59/198, 2006 Indexation Percentage and Revised Deductibles/Monetary Amounts Under Bill 164 A-05/06 Insurance Bureau of Canada Consumer Information E-laws Changes Respecting Vicarious Liability, and Elimination of Designated Assessment Centres under Bill 164 Statutory Accident Benefits Schedule Page 21