Taking the Confusion Out of Accident Benefits Claims
Accidents happen. More than a familiar expression, it’s a fact of life that no matter the care taken, unforeseen events that lead to injury, disability or death occur. A reliance on automobiles—whose use has seen a resurgence as COVID-19 reduces transit ridership—place motor vehicle collisions among the top-three causes of personal injury in Ontario. Accident benefits provide no-fault compensation to those harmed in an automobile accident, including pedestrians and passengers.
What does “no-fault” mean?
Ontario’s Statutory Accident Benefits Schedule (SABS) is a mandatory, no-fault form of insurance coverage, included in all standard Ontario auto insurance policies. No-fault means that accident benefits may be claimed by anyone involved—the driver, a passenger, pedestrian or cyclist—regardless of fault. Any injured party makes claims to their own insurer—not that of the other party. It is important to note that accident benefits differ from tort claims, which are damages for pain and suffering.
The Financial Services Commission of Ontario (FSCO) defines the range of benefits to which an injured party may be entitled. Resolution of SABs claims is performed by the Automobile Accident Benefits Service (AABS) of Ontario.
Why should my insurer pay if the accident wasn’t my fault?
Ontario’s no-fault insurance system is advantageous to drivers. An injured party’s insurance provider pays their claim directly. Time not spent on determining fault or burdening an individual with seeking damages from the other party’s insurer allows claims to be processed and benefits received more quickly.
When an involved party lacks insurance or has inadequate coverage, insurers engage in what is often referred to as a coverage dispute. Such disputes take place without the involvement of the claimant.
What can be claimed?
Though pain and suffering are not covered by accident benefits coverage, a number of other predetermined damages can be claimed, including:
- Up to 2 years of non-earner benefits for non-catastrophic injuries
- Up to $400 per week of income replacement benefits
- Up to $3,000 per month to a maximum of $65,000 for attendant care benefits such as in-home care or convalescent care in a long-term care facility
- Case management services for catastrophic injury
- Coverage for visitation and out-of-pocket expenses, prescription medication and travel over 50 kilometres for appointments deemed reasonable and necessary
- Treatment not covered by OHIP, such as physiotherapy, chiropractic care, counselling and massage therapy, if deemed reasonable and necessary
How do I qualify and apply for accident benefits?
Despite a no-fault system, an injured claimant must still meet certain criteria, such as medical tests that justify benefits payments. Insurers may also request employment files, pay stubs, hospital records, medical files and other documentation to substantiate a claim. Additionally, accident benefits claims must be filed within thirty days of the accident—sooner if possible. Late claims may result in investigations, and delayed or denied benefits.
Do I need a personal injury lawyer?
Though unfortunate that accident victims seeking fair compensation may find themselves in dispute with their own insurer, it is a not uncommon occurrence. An Ontario personal injury lawyer—whose representation alone may encourage cooperation from a reluctant or combative insurance provider—can expedite and offer professional assistance throughout the oftentimes complex claims application process.