By Matt Lalande in Accident Benefits (SABS) on September 20, 2021
Accident Benefits, otherwise known as no-fault benefits or SABS (a shortform taken from the piece of law called the Statutory Accident Benefit Schedule), are “benefits” that you are entitled to receive from your OWN insurance company after an accident to pay for such things as:
Accident benefits are available to you after an accident from your own insurance company. If you are hurt in a crash, you need to turn to your own insurance company to make an Accident Benefits claim, even if you were a passenger in someone else’s car at the time. If you don’t have your own car insurance policy, you would claim no-fault accident benefits from the policy that covers the vehicle you were hurt in…or hurt by.
Accident benefits are terribly complex, highly regulated and subject to constant change to the benefit of insurance companies – and not to the accident victim. Although they are designed to assist an injured person reintegrate back in to society after an accident, insurance companies inevitably become adversarial, hostile, inhospitable and inevitably, do whatever they can to stop paying their policy holders.
To make matters worse – there is never enough money to assist the injured person who suffer the worst of injuries. For example, if an accident victim is left tetraplegic (left with the complete inability to voluntarily move the upper and lower parts of the body) after an accident, the Ontario Government, working in conjunction with the insurance industry, radically reduced the availability of benefits to only $1,000,000.00 (not subject to inflationary increase). For some paralysis victims, a lifecare plan would more likely than not state that $1M would not be enough money to fund the first 5 years of accomodation, care and rehabilitation…let alone a lifetime of care.
Another example of the inequality that exists between policy holders and tinsruance companies with what we call “income replacement benefits,” which are designed to assist an accident victim with wage replacement after an accident. Starting one week after the accident, IRBs can compensate an insured person for 70% of their gross income up to a weekly maximum of $400, only. Despite inflation constantly rearing it’s ugly head and the cost of living increasing, $400.00 a week will barely cover rent, let alone food and clothing. Despite the expensive premiums you pay for monthly to drive your car and the billions in profits enjoyed by insurance companies – your income replacement benefit will level you well below the poverty line.
Income Replacement Benefits
Many will have to look at a lawsuit against the at-fault driver to recover additional lost wages. Starting one week after the accident, IRBs compensate an insured person for 70% of gross income up to a weekly maximum of $400. The maximum amount can be higher if the claimant had purchased optional benefits prior to the accident.
Given its strict requirements, it is a difficult benefits to qualify for under the SABS. In particular, it is difficult to qualify for applicants with soft-tissue injuries or psychological impairment. Claimants must suffer from a complete inability to perform their daily activities in order to qualify. Non-earner benefits pay a base rate of $185 per week for the qualifying period. Prior to June 1, 2016, some claimants, such as students, could potentially qualify for higher amounts.
These higher amounts are not available for accidents after June 1, 2016.For accidents prior to June 1, 2016, non-earner benefits can potentially last the claimant’s entire life. F or accidents after June 1, 2016 these benefits have been severely curtailed, being terminated two years after the date of the accident. A claimant cannot receive non-earner benefits if he has elected to receive income replacement or caregiver benefits.
Caregiver benefits are only available to catastrophically impaired claimants who were also the primary caregiver of one or more dependents at the time of the accident. Non-catastrophically injured claimants who purchased optional benefits may also qualify.
Caregiver benefits pay eligible claimants $250 for the first person in need of care per week, and $50 per week for each additional person in need of care. They last up to 104 weeks after the accident unless claimants can show that they suffer from a complete inability to carry on a normal life.
Claimants cannot receive caregiver benefits if they elected to receive income replacement or non-earner benefits.
Medical and Rehabilitation Benefits
Medical and rehabilitation benefits, covered under sections 14 to 20 of the SABS, are the most common of all the benefits available to motor vehicle accident victims under Ontario’s no-fault accident benefits regime.
Medical and rehabilitation benefits provide your clients with the modalities needed to restore their health and return to work and society. Claimants are entitled to “reasonable and necessary” medical and rehabilitation treatment, and all modalities must be submitted to the insurer in advance by way of a treatment plan. The amounts available for medical and rehabilitation benefits change significantly depending on whether the accident took place on or after June 1, 2016. As of June 1, 2016, the amounts available for medical and rehabilitation benefits merge with attendant care benefits.
Attendant Care Benefits
Attendant care benefits allow claimants to be reimbursed for expenses related to hiring an aide or attendant to help them with their day-to-day functions. These functions include help with dressing and personal grooming, bathing, cooking and feeding, and getting around, ect.
Attendant care also includes paying for a stay in a long-term health facility or home, if not covered by the Ontario Health Insurance Plan (OHIP). Attendant care benefits pay up to $3,000 per month ($6,000 if catastrophic) for incurred expenses of professional attendants.
Non-professional attendants can only be compensated for the amount of income they have given up in order to care for the claimant, if any.T he total amounts available for attendant care vary depending on if the accident is on or after June 1, 2016. On June 1, 2016 the total amounts available for caregiver benefits were merged with medical and rehabilitation benefits. Effective October 1, 2018, all facilities must submit the Assessment of Attendant Care Needs Form (Form 1) through the Health Claims for Auto Insurance (HCAI) system. All insurers must communicate the approval or rejection of the Form 1 through HCAI.
Other Miscellaneous Benefits
Other benefits include:
Death and Funeral Expenses
These expenses provide death and funeral benefits to eligible beneficiaries. Death benefits provide $25,000 paid to a spouse and $10,000 to each qualifying dependant. Funeral benefits pay up to $6,000 for funeral expenses.
Many injured persons will be covered under other benefits plans that provide similar benefits to the SABS, such as group benefits plans through their place of employment.
No-fault benefits are defined as excess insurance, as per section 268(6) of the Insurance Act. This means that claimants who have other benefits plans must first apply to their other insurance providers, such as:
This chart describes the most commonly used no-fault benefits forms with and when to use them.
|OCF-1: Application for Accident Benefits|
This is the initial general application for benefits at the start of a claim. It also serves as the particular request for income replacement, non-earner and care-giving benefits.
|OCF-2: Employer’s Confirmation |
This form must be filled out by any employee seeking income replacement benefits after an accident.
|OCF-3: Disability Certificate|
This form describes your impairments and must be filled out by a health practitioner. It must be included when applying for IRB, non-earner, caregiver, housekeeping and home maintenance benefits.
|OCF-4: Death and |
This form is for your spouse and other dependants to apply for death and funeral benefits if you pass away due to the accident. It is recommended to use it, but not necessary.
|OCF-5: Permission to |
Insurers typically ask claimants to sign this form to give them permission to collect medical information from the claimant’s health practitioners. Most of the timewe will collect this information for you. We would recommend you not sign it.
|OCF-6: Expenses Claim Form|
Although no longer in effect, this form can still be used to submit incurred expenses that have not been directly submitted to the insurer by a treatment provider.
|OCF-9: Explanation of Benefits |
Payable by Insurance Company (discontinued).
Although officially discontinued as of September 1, 2010. many insurers still choose to use this form to provide notice of approvals and denials.
|OCF-10: Election of |
You can only receive one of income replacement, non-earner or caregiver benefits. Upon receiving an OCF-1 form, if the insurer determines that you may be eligible for at least two of these benefits, it will send you this form. You must then choose one of them to pursue.
OCF-13: Declaration of
Post-Accident Income and Benefits
|This form is no longer official, but can still be used submit information about your post-accident income and benefits.|
|OCF-18: Treatment and Assessment Plan.|
This form is used by treatment providers to submit proposed medical and rehabilitation treatment and assessments.
OCF-19: Application for
Determination of Catastrophic
|You would use this form to request that the insurer designates your client as catastrophically impaired.|
|OCF-21: Auto Insurance Standard Invoice.|
This form submitted to the insurer by treatment providers in order to get paid directly by the insurer.
|OCF-23: Treatment Confirmation |
This form to be submitted by treatment practitioners providing services to claimants under the MIG.
OCF-24: Minor Injury Treatment
This form used to potentially transfer a claimant out of the minor injury designation and into the standard stream.
If we settle your accident benefit claim, this is the form that is used as written notice to be provided to you by the insurer upon settlement of a claim.
Form 1: Assessment of Attendant
|This form must Must be submitted in order to apply for attendant care benefits.|
If you or a love one has suffered a serious injury in a car accident, trucking accident, bicycle accident, pedestrian accident or motorcycle accident and have questions regarding your acident benefits we can help. We have been representing accident victims in Hamilton and throughout Southern Ontario since 2003.
Our Hamilton Personal Injury Lawyres are proud to provide dedicated and personalized representation to each and every one of our clients. We want the best for you and will fight for the best possible results. Call us not matter where you are in Ontario at 1-844-LALANDE or local in the Hamilton/Burlington/Niagara areas at 905-333-8888. Alternatively, you can fill our a contact form on our website and we will be happy to get right back to you.