OCF-19 Application for Determination of Catastrophic Impairment

People who have been very very very seriously hurt in a motor vehicle accident need to know the ins and outs of the OCF-19 Application for Determination of Catastrophic Impairment Form.

If your insurer deems your injuries to be “catastrophic” your benefits will skyrocket from $3,500 under the minor injury guideline, or $65,000 up to $1,000,000 or $2,000,000 (depending on when your accident took place). Not only does the dollar amount of your benefits skyrocket, but so does the duration, along with the types of benefits which are available to catastrophically injured accident victims, vs. non-catastrophically injured accident victims.

The first step to being deemed catastrophic is having your doctor or treating specialist complete the OCF-19 Application for Determination of Catastrophic Impairment Form.

Finding the form can be a bit tricky. It’s not a typical form that insurance companies include in the standard Accident Benefit Package which is sent to injured accident victims.

Your personal injury lawyer will know how to find the form. You can also find the form on the website of the Financial Services Commission of Ontario, link here. 

When printing off the OCF-19, make sure that you are printing off the right form.

There are currently two differing versions of the OCF-19 contained on the FSCO website. The first OCF-19 Form is only two pages. It applies for accidents which have occurred between November 1, 1996-May 31, 2016. If your motor vehicle accident took place between these dates, then this first OCF-19 is the right form for you.

The second OCF-19 is six pages long. This OCF-19 applies to motor vehicle accidents which took place on or after June 1, 2016.

Printing off and completing the right version of the OCF-19 is important because if you aren’t completing the right version of the form, your application for catastrophic benefits will be rejected rather quickly. That’s not to say that you won’t be able to re-apply. You just want to do it right the first time to avoid the headaches, time and expense with completing the form. Not to mention the additional time it will take to get another appointment with the doctor who completed the form.

The older OCF-19 for accidents between November 1, 1996-May 31, 2016 has no summary for what the catastrophic criteria for disability are. It only has a brief explanation of what is deemed a catastrophic injury.

The newer OCF-19 includes a two page appendix which summarizes what the criteria for catastrophic impairment are; and directs the physician completing the OCF-19 to section 3.1 of the Statutory Accident Benefits Schedule-Effective September 1, 2010 (SABS). So, at least in this newer version of the OCF-19, there is a bit more direction for the reader to summarize what it means to be catastrophically impaired and what it is the insurer is looking for.

In combination, the OCF-19 along with the criteria for catastrophic impairment in the SABS refers to a variety of medical texts and publications which are either out of circulation (because they’re so dated), and not in your average physician’s medical library. Here are a few of those medical publications:

• International Standards for Neurological Classification of Spinal Cord Injury, Journal of Spinal Cord Medicine, Volume 26, Supplement 1, Spring 2003
• A multicentre international study on the Spinal Cord Independence Measure, version III: Rasch psychometric validation, Spinal Cord (2007) 45, 275-291
•  Structured Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for Their Use, Journal of Neurotrauma, Volume 15, Number 8, 1998
• A practical outcome scale for paediatric head injury, Archives of Disease in Childhood, 2001: 84: 120-124
• American Medical Association’s Guides to the Evaluation of Permanent Impairment, 6th edition, 2008 (this is the most current edition)
• American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993 

Here are a few thoughts:

1. What average physician has these texts readily available at their disposal in their office?
2. Why are we relying on the AMA Guidelines 6th edition from 2008 PLUS the AMA Guidelines 4th edition from 1993?
3. There is a lot of reliance in the SABS based on the AMA Guidelines 4th edition from 1993. This text is luckily NOT out of circulation (it can be picked up brand new for $199.75USD off the AMA website; cheaper second hand). According to the AMA website, the 4th edition is currently used in just 7 states…..
4. Can we please develop a simplified, novel, easy to understand definition for what it means to be catastrophic without requiring physicians to head over to their local medical library and spend all day driving through the archives to find out what the criteria are? Not to mention the costs associated with accessing all of these texts likely approaches over $1,000+.

Once the form has been completed in the affirmative, it will set off a chain reaction of events. The insurance adjuster will either accept that your injuries are catastrophic, or won’t and refer it to series of IEs (insurance examinations). One insurer recently requested that our client see 8 different assessors for CAT IEs. This is not uncommon as the determination of catastrophic benefits often requires a multi disciplinary approach. The costs of these CAT IEs and rebuttal reports can cost in excess of $30,000. We have seen CAT reports go as high as around $47,000. That’s for one side’s reports. You have to assume that the other side will also pay that, or slightly more or less for catastrophic reports. Those medical costs alone for catastrophic reports when factoring in both sides can range around $60,000-$94,000!

People who have been seriously injured in a motor vehicle accident need to know about what benefit options are available to them so that they can make the best informed decision which is right for their needs. Better understanding the details behind the OCF-19 is a step in the right direction. But also better educating doctors and specialists about the OCF-19 is also important. Doctors and specialists are the gate keepers to getting the ball rolling for catastrophic benefits for a seriously injured accident victim. Being deemed catastrophic or not will have life changing consequences for the injured accident victims and his/her family. It can certainly go a long way towards making life just a bit easier.