Application for Accident Benefits – What You Need to Know

If you are injured in a motor vehicle accident you may be eligible for assistance in the form of Accident Benefits (“AB”) under an automobile insurance policy. In Ontario, AB’s are governed by regulation under the provincial Insurance Act, R.S.O. 1990, c.I.8, known as the Statutory Accident Benefits Schedule (“SABS”). Under Ontario legislation there is a standard auto insurance policy which is required to be purchased by every vehicle owner. This standard auto insurance policy includes a minimum set of AB coverage, designed to provide injured parties with basic necessities, regardless of who caused the accident (i.e. no-fault benefits).

Drivers of an automobile (i.e. “occupants”) are not the only persons who are entitled to AB’s under an insurance policy. Passengers and pedestrians (including cyclists) are entitled to AB’s (“non-occupants”) as long as there is a nexus between the injuries sustained and the use and operation of the automobile. Family members of a motor vehicle accident victim may also be entitled to AB’s if it can be shown that there is impairment as a direct result of an accident (for instance, psychological trauma). To understand your rights, speak to a lawyer.

Accident Benefits Available

Available AB’s under an insurance policy include:

• Income Replacement Benefits (“IRB”) – Compensates you for loss of your income if you cannot work because of the injuries caused by a motor vehicle accident;
• Medical/Rehabilitation Benefits – i.e. physiotherapy, massage therapy, chiropractic care and renovations made to home;
• Housekeeping Benefits (if it is reasonable and necessary);
• Death Benefits – Payable to a family member who has lost a family member in a motor vehicle accident (includes funeral payments);
• Non-earner / Caregiver benefits – If you do not qualify for IRB’s. (i.e. a student is a non-earner); and
• Attendant Care Benefits – i.e. if seriously impaired and you are required to have a health professional come into your home to attend to your care.

Each of the above benefits are subject to their own rules, requirements and limits. The amount of benefits available to you is also dependent on the classification of your injuries as either “catastrophic” or “minor injuries”.

You must contact and give notice to your insurance company within 7 days after the accident, or as soon as possible, that you intend on making an application for AB’s. The insurance company will then send you the Application for Accident Benefits, which must be returned within 30 days after receipt. Due to the strict timelines for applying for AB’s, it is a good idea to consult with an AB lawyer at your earliest who can assist you through the application process and submit the Application on your behalf.

If you qualify for AB’s, the insurer who first receives a completed application is responsible for paying the benefits.

Covered Under Someone Else’s Policy?

If you have your own automobile insurance or believe that you are covered under someone else’s policy, the completed application will be submitted to that insurance company. If you do not have your own insurance policy, the application will be submitted to your spouse’s insurance company or to the insurance company of the person you are dependent on. If you do not have access to insurance, the application can be submitted 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 you were an occupant of an uninsured vehicle or if you were a pedestrian struck by an uninsured vehicle, the application will be returned to the insurer of any other vehicle involved in the collision. If you believe that there is no insurance company responsible for processing the claim, then you may be able to claim benefits through the Motor Vehicle Accident Claims Fund.

Overall, the application requires you to complete detailed information regarding the accident details, your health information, details of your auto insurance, your employment status and other insurance or collateral payments which may be applicable. After the insurance company reviews your complete application package, you or your AB lawyer will be contacted about the benefits you are entitled to receive and to request any further information which the insurance company requires to assess your benefits. The insurance company may require you to submit further forms and documentation. Some of the forms will require you to visit your family doctor or other health care practitioner, such as a chiropractor, physical therapist or occupational therapist.

Get Help

If a dispute arises with your insurer with respect to entitlement or the amount of AB’s there is a dispute resolution process available through the Financial Services Commission of Ontario (FSCO). The parties can apply for mediation to attempt to settle the matter, or also have the dispute heard at an arbitration. An experienced AB lawyer who is involved with your case from the start can best assure you receive the benefits you are entitled to and guide you through the process.

For more information, visit our section on accident benefits.