Articles Posted in Accident Benefits

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After a serious car or motorcycle accident, chances are you will need a wide variety of treatment. Some of that treatment will be covered by Ontario’s OHIP Healtcare System. That means if you have a valid Ontario Health Card, it will be FREE.  Seeing a medical doctor (not a chiropractor or a psychologist), a hospital visit, and even treatment through the Community Care Access System (CCAC) is all covered. This is fantastic news for accident victims, especially when you compare healthcare in Canada vs. health care costs for our neighbours south of the border.

Some treatment isn’t covered by OHIP. Things like physiotherapy, massage, chiropractic care, occupational therapy, speech language pathology outside of the hospital, psychology treatment, social work, rehab coach etc. All of these things are NOT covered by OHIP (with some exceptions). If you’ve been involved in a serious motor vehicle accident, chances are you will need at least one, if not a few of the aforementioned treatments. Without OHIP or collateral benefits, you will have to pay for these treatments out of your own pocket. If you aren’t working following a serious car accident, you likely won’t have the money to spend out of pocket on these treatments unless you’re incredible well off.

Here is the “good news”. When I put “good news” in quotes, it’s because I’m explaining a text book; best case scenario…And we all know at law; these text book best case scenarios rarely happen. That’s why there are so many personal injury lawyers around.

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It seems that every few months or so, the Toronto Injury Lawyer Blog is discussing the topics to changes in car insurance and accident benefit disputes in Ontario. Is it because we LOVE blogging about accident benefits? Not really. Accident benefits are quite frankly, an incredibly complicated and dense area of the law. The rules for accident benefits, in many respects, are made in favour of large insurance companies and designed to limit an injured claimant’s ability to recover an income. It’s not a committee of accident victims who sit around and make these laws, and tweek them ever so slightly. Rather, it’s deep pocketed insurers and so called “insurance experts” who do so at the behest of the large insurance lobby.

A few quick examples of some arbitrary decisions which accident benefit laws have imposed:

  • No monetary reimbursement for a trip to the doctor which is under 50km. Why 50km? Who picked the 50km distance? Your guess is as good as mine
  • A maximum recovery of just $3,500 for soft tissue injuries which are classified to fit under the Minor Injury Guideline. Why just $3,500? Because that’s what insurers and our government deems to be reasonable. Interesting enough, that $3,500 is less than you paying the full value of your car insurance premiums over a 3 year period in Toronto, London, Ottawa or another large city in Ontario.
  • A maximum recover of $50,000 for claims which aren’t catastrophic, but not Minor. Why a $50,000 limit? Beats me.
  • An income replacement benefit of a maximum of just $400/week under a standard Ontario Automobile Policy, which has NOT increased to reflect inflation over the past 15 years.
  • A deductible which will be increasing from $30,000 to $36,500 for pain and suffering claims. Why $36,500? Beats me.

As you can see, many of the monetary limits imposed in accident benefit law in Ontario are just numbers which seem to be picked out of a hat to favour insurers. Not once have I ever met an injured accident victim, or an ordinary person who believes that these limits are reasonable or helpful for claims.

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The OCF-6 Application for Expenses or Expenses Claim Form is the MOST IMPORTANT FORM to get paid back for your out of pocket expenses following a car or motor vehicle accident.

Immediately after a serious accident, the bills and expenses can quickly add up. Hospital parking is a fortune these days. Hospital meals, medication, the ambulance bill, damaged clothing, broken glasses, equipment rental for ramps, crutches, a wheelchair or simply purchasing a cheap cane from a drug store. All of these expenses quickly add up.

Some of the first questions from prospective clients isn’t how much their case is worth. It’s how can I get re-reimbursed for my out of pocket expenses?

I’ve always found this a bit odd; but I suppose it’s human nature. In the context of a multi million dollar claim, we are worried and insurers fight over the smaller $10 expenses; yet they are willing to pay out $1,500/month for attendant care benefits without issue; or pay out much larger amounts on a periodic basis.

In any event, the purpose of this Toronto Injury Lawyer Blog is to assist you in preparing your OCF-6 the right way, so that your out of pocket expense claims gets approved instead of denied.

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The most serious motor vehicle accidents in Ontario are classified as “Catastrophic” by our Ontario insurance law. The term “Catastrophic” is a term of art; meaning that it carries its own legal definition; separate and apart from the common definition you would find in an English dictionary.

Being designated “Catastrophic” or “CAT” as its known in the medico-legal community is significant, as it provides accident victims and their families to a wider array of accident benefits, over a longer period of time. The advantages are significant such that insurers will fight very hard to find serious injured accident victims as not meeting the catastrophic definition.

Just because you’ve been involved in a serious car accident doesn’t mean that you will automatically be found to be catastrophic. There are a number of medico-legal tests which need to be met. In addition, there is one VERY important form that needs to be completed. This form is called the OCF-19 Application for Determination of Catastrophic Impairment form.  You can find a link to the OCF-19 CAT form, along with other OCF claim forms on the Goldfinger Injury Lawyers website here.

The OCF-19 is only two pages in length. Which, by comparison to some other forms (like the OCF-1 or the OCF-3) makes it a short form. But just because the OCF-19 CAT Claim Form is short, by no means is it not important or can it be completed carelessly.

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Almost every client who enters my law firm has the same idea after they’ve been injured in an accident:

“I ‘ve been paying my car insurance premiums for years and years; now that I’ve been hurt; it’s now the insurance company’s turn to play their part and start paying me benefits“.

In a perfect world, this is exactly how insurance would work. You pay premiums; and when you need it most, the insurance company pays you benefits. But the world is far from perfect. That’s why we have lawyers…

What exactly are those so called “benefits” and how do they work?

The term “benefits” is so loose and broad. What people have in mind for benefits is greatly different than what those benefits are.

The first benefit which may come to mind is a benefit which replaces your income if you can’t return to work on account of a serious injury.

Under the SABS/Insurance Act, this is called an income replacement benefit or IRB.

It’s a common misconception that the IRB covers 100% of your wages. It doesn’t. It also doesn’t kick in until 7 days after the accident. And just because you’ve been involved in a car accident, doesn’t automatically entitle you to an income replacement benefit. There are a variety of medico-legal tests which need to be met. In addition, you need to prove with real concrete evidence that you were gainfully employed in the 52 weeks prior to the accident and earning an income (not unreported cash income).

Helping accident victims understand exactly how the income replacement benefit works is not an easy task for a variety of reasons. But, this Toronto Injury Lawyer Blog post will do its best to de-mystify the IRB.

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One of the hardest things for people to understand in Ontario is how our No Fault system of car insurance works.

Ask 10 drivers how their no fault accident benefits work, or how no fault car insurance works, you’ll get 10 different answers. All of them will likely be wrong. Ask 10 lawyers who don’t practice in the field of persona injury law, you’ll probably get the same wrong answers! Even funnier is if you ask 10 different politicians, the ones who actually passed the laws to create no fault accident benefit insurance in Ontario, and they won’t know either.

The only people who truly know how no fault insurance and accident benefits work are personal injury lawyers, insurance defence lawyers, people who work for insurance companies and those service providers who routinely bill insurers through IEs or through OCF claim forms.

What people have a hard time understanding, is that after an accident involving the “use or operation of a motor vehicle” , they will have TWO SEPARATE CLAIMS. The first claim is the claim for no fault accident benefits. These claims are guaranteed provided there are no policy breach issues. This first accident benefit claim is against your OWN INSURER, regardless of fault. If you didn’t have car insurance at the time of the accident, then there are loss transfer provisions under the Insurance Act which create a duty to defend or respond to the claim from another insurer, or, in the last case scenario, from the Ontario Motor Vehicle Accident Claims Fund. These accident benefits will cover such things as medical/rehab benefits, attendant care benefits, non earner benefits, income replacement benefits and out of pocket expenses related to the car accident. Accident Benefits do NOT cover pain and suffering.

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Uber is a really cool service. Using an App, you can get essentially get a taxi fare for a fraction of the price, with less wait time as well. The App tells you exactly what distance you’ve traveled, and how much the fare cost. The fare cost is then debited directly from your credit card to pay the driver. You can chose to tip the driver if you wish. You can also leave comments or ratings about that Uber experience and that particular driver. If one driver or vehicle has too many negative comments, then the driver won’t be allowed to use to service to provide others with rides. I must admit that all of the lawyers and staff here at Goldfinger Law love Uber and the service which it provides.

For your ordinary person looking to make a few extra dollars on the side driving people around; Uber is a blessing. Especially for those people who don’t have enough money to afford an expensive taxi license.

For those taxi drivers who have toiled with the long hard house and the red tape with respect to taxi licensing, Uber is undercutting their business. They aren’t following the same rules which apply to your ordinary taxi driver.

City Hall in Toronto has yet to sort out the details of how Uber will work on a go forward basis. Some cities have essentially regulated Uber and other ride sharing services. In Vancouver, you can’t use a ride sharing service like Uber for a fare which costs under $75. This has essentially killed Uber’s business out there where the fares tend to be short and fast ones.

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After you’ve been involved in a car accident, there are A LOT of forms to complete for the insurance company in order for you to start recovering benefits.

It’s not simple. You have to jump through a lot of hoops. The process can be long, tedious and very frustrating.

Why don’t they just make the process simple? I have no idea. The forms are created by the government, but are heavily influenced by the lobbying efforts of large insurance companies. So, the forms, along with the questions in the forms are skewed from the outset to create a bias against innocent accident victims and in favour of large, deep pocked insurance companies.

If English isn’t your first language, or you have problems completing paper work; or you have sustained a brain injury in the accident, then completing these forms will be particularly difficult. Get a lawyer to help you out.

The purpose of this Toronto Injury Lawyer Blog Post is to assist you in completing the somewhat tricky OCF-3 Disability Certificate follow a car accident.

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When injured accident victims think about damages, they often think of those valuations in very linear terms; as if they’re on a straight line.

Broken knee? $100,000 plus $150,000 loss of income = $250,000

Fractured wrist? $50,000 plus $25,000 loss of income = $75,000

These are very simple mathematical equations. The problem is these equations are too simple and don’t take in to consideration the whole story.

What accident victims don’t know is that often insurer are entitled to credits or set offs when calculating damages to make sure that the Plaintiff is not over paid for their injuries.

There are many examples when an insurance company is entitled to a set off. What is a set off?

Essentially, it’s a credit in favour of the insurance company. Take the example of a person who was involved in a catastrophic car accident. Prior to the car accident, they were earning $40,000/year. They will never be able to work again on account of a traumatic brain injury.

They are receiving an income replacement benefit in the amount of $400/week from their accident benefit insurer. The total amount of income replacement benefits equal $20,800/year.

If the tort insurer pays 100% of the $40,000 income loss; then the accident victim ends up with $60,800/year ($40,000 + $20,800). That would mean that the accident victim is in a better income position post accident than pre-accident. While this is great to see; unfortunately, this is NOT how the law or the Insurance Act works. In this example, the tort insurer is entitled to a credit; commonly known as a “set off” to make sure this type of over payment doesn’t happen. That set off would be for $20,800 for the income replacement benefits already paid out. Therefore, in order to make the accident victim whole, the tort insurer will pay the difference, that being $40,000-$20,800 = $19,200.

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If insurers paid out maximum compensation on each and every claim, there wouldn’t be any need for personal injury lawyers or paralegals who focus on benefit accident claims.

Why does an injured accident victim or disability claimant need a lawyer, if the insurer is paying them out the full value of their claim up front; without any hassle?

But, if an insurer paid out the maximum value of each and every claim which came across their table, chances are they wouldn’t be as profitable as they are; or profitable at all.

As much as we are made to believe that insurers are there to look out for our best interests and pay out when they are supposed to; at the end of the day; insurance companies exist to MAKE MONEY.

Many Canadian insurance companies trade on the Toronto Stock Exchange (TSX). Here are a few examples along with their stock symbols, along with current share values as of the time of preparing this Toronto Injury Lawyer Blog Post on July 7, 2015:

Intact Financial Corp: IFC $90.57

Sun Life Financial: SLF $41.80

Manulife Financial: MLF $23.03

Co-Operators General Insurance: CCS-PS $23.79

Those are just a few of the examples of insurance companies which do business in Canada, who trade of the Toronto Stock Exchange.

Those stock symbols and share prices are VERY important. If those share prices drop significantly, millions, if not billions of dollars will be lost value and options for shareholders around the world.

If one of these insurers paid out ALL claims, regardless of merit of an entire year, chances are those stock values would dip dramatically.

So, when accident victims or disability claimants wonder why so many claims are denied at first instance, or why insurers refused to believe what their doctors have to say about their injuries, there is a financial reason for this.

The more money an insurer pays out to your for your claim, the less money they get to report in profits for their share holders.There are certainly a variety of their factors involved in insurer profits, but this is one of the most tangible concepts for accident victims and disability claimants to understand.

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