The Nitty-gritty on Medical & Rehabilitation Benefits Under the Statutory Accident Benefits Schedule

Medical Treatment – who pays?

If you require treatment for your accident related injuries, your own insurance company will be responsible to pay (for treatment which you qualify that is not covered by OHIP or from some other source, such as a private health plan that you may have through work or your spouse). Medical and rehabilitation benefits are part of the accident benefits (no fault) coverage which is governed by the Ontario Insurance Act.

What type of medical benefits are available to me?

The “medical” coverage from your own insurance company includes reasonable and necessary expenses for:

• Medical, surgical, dental, optometric, hospital, nursing, ambulance, audiometric and speech-language pathology services
• Chiropractic, psychological, occupational therapy and physiotherapy services
• Medication
• Prescription eyewear
• Dentures and other dental devices
• Hearing aids, wheelchairs or other mobility devices, prostheses, orthotics and other assistive devices
• Transportation to and from treatment including transportation for an aide or attendant
• Other required goods and services of a medical nature that are not covered elsewhere

What type of rehabilitation benefits are available?

The “rehabilitation” coverage from your own insurance company is designed to reimburse you for payments you have made for reasonable and necessary measures to reduce and eliminate the effects of the disability resulting from the injury or assist you in reintegrating into a family role or the labour market (if you had a labour force attachment) and also your community.

The rehabilitation coverage includes reasonable and necessary expenses for:

• Life skills training
• Family, social rehabilitation, financial and employment counselling
• Vocational assessments
• Workplace, home and vehicle modifications
• Transportation to and from counselling and training sessions including transportation for an aide or attendant
• Other goods and services required that are rehabilitative in nature

Amount of benefits available?

The amount of medical and rehabilitation benefits that are available to you will depend on the “class” of injury that you sustained in the motor vehicle accident. There are three classes of injuries: minor, non-minor, and catastrophic.

If you suffer a “minor injury”, then your benefits may be limited to $3,500 in treatment. Generally speaking, minor injuries are defined to include sprains and strains, cuts and bruises.

If you have a “non-minor” injury, the benefits will pay for up to $50,000 in treatment over the course of 10 years. Non-minor/non-catastrophic injuries would include broken bones or some kinds of internal organ damage, such as a ruptured spleen.

If you suffer a “catastrophic impairment”, the maximum amount of medical and rehabiltation benefits available increases to $1,000,000 over the course of your lifetime. Catastrophic injuries are defined by the legislation and can include amputation of a limb, spinal cord injuries and severe brain damage.

These amounts may be affected by any optional benefits that you may have purchased from your insurance company, which increase the various limits.

How do I get the treatment paid for?

In order to receive the medical and rehabilitation benefits, you will have to obtain pre-approval by your insurance company before you receive the treatment. Your family doctor or other treatment provider will be required to complete forms which will need to be sent to your insurance company for pre-approval.

Attendant Care Benefits

If your injuries are severe enough, you may require an attendant or long-term care facility to help you with your daily care, including personal hygiene, feeding yourself and dressing. You are not eligible for attendant care benefits if your injury is minor. Either a registered nurse or an occupational therapist may assess how much assistance you need, and they must complete a form for your insurance company, which will verify your needs.

For non-minor injuries, attendant care benefits will pay up to $3,000 per month, for up to 2 years after the accident, but only to a maximum of $36,000.

For catastrophic injuries, the benefit may be increased up to $6,000 per month, and to a maximum of $1,000,000 over the course of your lifetime.

Again, these amounts may change depending on the optional benefits you may have purchased with higher limits.

Your Bridge over Troubled Waters – We Can Help!

Accident benefits are a complicated area of personal injury law. You need to know what you are entitled to, whether you qualify and what to do if your insurance company denies your benefits, or cuts you off your benefits prematurely.

If you get into trouble with your own insurance company after being injured in a motor vehicle accident, call Santucci Law to help you. We will be your bridge over troubled waters. To obtain a free consultation, please contact our office by e-mail or call (905) 667-1987.