OCF-19 Catastrophic Claims
There are special legal connotations when injuries from a car accident are deemed to be “catastrophic“. This is a term of art; meaning the term “catastrophic” has a special legal meaning.
Catastrophic is defined under the insurance act as an injury which meets one of the following criteria:
- Paraplegia or Tetraplegia;
- Severe impairment of ambulatory mobility or use of an arm, or amputation;
- Loss of Vision of Both Eyes;
- Traumatic Brain Injury (applicant 18 years of age or older at the time of the accident);
- Traumatic Brain Injury (applicant under 18 years of age at the time of the accident);
- Physical Impairment or Combination of Physical Impairment which results in 55% or more of whole person (there are additional criteria which aren’t included in this instalment of the Toronto Injury Lawyer Blog);
- Mental or Behavioural Impairment, Excluding Traumatic Brain Injury, Combined with a Physical Impairment which results in 55 percent or more impairment of the whole person. (there are additional criteria which aren’t included in this instalment of the Toronto Injury Lawyer Blog); and/or
- A Class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning or a Class 5 impairment (extreme impairment) in one or more areas of functioning, due to mental or behavioural disorder (there are additional criteria which aren’t included in this instalment of the Toronto Injury Lawyer Blog).
If your injuries meet these catastrophic criteria; AND your insurance company accepts that your injuries meet these criteria; then the injured accident victim will be entitled to receive catastrophic levels of accident benefits. These levels are not discussed in this edition of the Toronto Injury Lawyer Blog, but let’s just say that those limits when put together exceed a million dollars; wheres non catatrophic med/rehab benefits under the minor injury guideline are only $3,500 which isn’t very much.
But how does an accident victim become catastrophic? Does the insurance company simply declare it so? Does a Judge magically appear and announce to the world that the injuries you’ve sustained are catastrophic? Does your doctor need to call the insurance company to set it up?
There is a not so simple application form called the OCF-19 Determination of Catastrophic Impairment Form which can be found on the FSCO website. This starts the process. Without a completed OCF-19 Determination of Catastrophic Impairment Form, the applicant will NOT be found catastrophic. These forms don’t magically fall from the sky. The majority of doctors have never seen the OCF-19 before. Most trauma doctors and orthopaedic surgeons are familiar with the OCF-19. Most social workers at trauma hospitals like Sunnybrook, St. Mike’s, London Health Sciences Centre-Victoria, Parkwood are familiar with the OCF-19. Some hospital social workers have them on site, but it’s not guaranteed they do. We have also seen occasions where the social workers at hospital have the wrong version of the OCF-19 completed.It’s an honest mistake, but it happens. But the reality is that most people at hospitals and doctors are not familiar with the OCF-19. These forms are generally completed by specialized doctors who deal with catastrophic car accident claims on a daily routine. There are assessment centres which are set up specifically do run catastrophic assessments for car insurance claims.
Given that there is limited knowledge outside of personal injury lawyers and the medico-legal community; it can sometimes be difficult to get the OCF-19 completed to get the catastrophic portion of the case started.
On the topic of assessment centres which focus on catastrophic accident claims, no doubt they will be very familiar at completing the OCF-19; completing it the right way; and having the right version and supporting documentation to get the form completed the right way. The problem is that most, of not all of these assessment centres will charge thousands and thousands of dollars for the completion of the OCF-19; which is only 6 pages in length and is standard form. In addition, most of these assessment centres will not agree to simply complete the OCF-19. Rather they will want to do an entire catastrophic assessment work up which will entail the applicant seeing a variety of doctors and other health related professionals. The report will be very comprehensive, but will cost even more money to the injured accident victim (who is likely so injured they cannot work and require extensive care so their income is tied up in other places). It hardly seems fair that the people who need the help the most are charged the most to get the help they need.
To get around these prohibitive costs, what an injured accident victim can do is ask that the insurer fund the cost of the catastrophic assessments by way of OCF-18 Treatment Plan. This is a great way of having a set of knowledgable professionals complete the OCF-19 and complete catastrophic testing, which will be funded in part by the insurance company. The hard part is that not all of the testing will likely be funded. It may very well be that only a portion of the testing will be funded leaving the applicant to pay the remaining charges. That remaining account can be significant so be careful.
Another way of getting around these prohibitive costs for catastrophic assessments is seeing if your family doctor, treating specialist or psychologist is prepared to put in the time to read and complete the OCF-19. The disadvantage to this is that these doctors/specialists likely won’t be familiar with the OCF-19; but if they are able to complete it the applicant won’t have to pay thousands and thousands of dollars to determine whether or not their injuries meet the definition of catastrophic. The doctor may charge for their time in completing the form, but those charges may be a few hundred dollars which pales in comparison to what other people bill for performing an entire catastrophic assessment.
The insurer will likely respond to the OCF-19 by assembling their own CAT team to prepare a some CAT assessments by way of IEs (Insurance Examinations). If the IE reports come back in the affirmative that the applicant is deemed catastrophic, then the battle has been won. In the event that the CAT IEs come back negative, then the battle continues and it will be but to the plaintiff and his/her lawyer to assemble a group of experts to refute these reports. The case would then march on to the License Appeals Tribunal for a catastrophic determination hearing before an adjudicator (not a Judge).