Personal injuries following a motor vehicle accident can range from minor to catastrophic, the latter of which will undoubtedly have life-changing effects on a victim. Obtaining a “catastrophic impairment” designation in Ontario can also have critical implications for your personal injury claim.
Below, we’ll explain the significance of a catastrophic impairment designation in Ontario personal injury claims and the process for obtaining the designation.
Background: Personal Injury Claims and the Statutory Accident Benefits Schedule
Ontario’s Insurance Act, RSO 1990, c. I.8 provides that injured persons who require medical or rehabilitative treatment are entitled to benefits pending dispute resolution. As a result, you can receive your statutory accident benefits without waiting for your case to settle or to go to court.
A person claiming accident benefits must have sustained an “impairment” due to a motor vehicle accident to be eligible for the benefits.
What Medical Costs are Covered by Statutory Accident Benefits?
If you are eligible for statutory accident benefits (i.e., if you have sustained an impairment due to a motor vehicle accident), your “reasonable and necessary” medical expenses will be covered. These expenses might include treatment from chiropractors, psychologists, occupational therapists, and physiotherapists, along with transportation to and from treatment sessions. For a comprehensive list of the types of treatments covered, consult the Statutory Accident Benefits Schedule, O Reg 34/10.
“Catastrophic Impairment” and its Impact on Statutory Accident Benefits
As noted above, those claiming accident benefits are entitled to coverage if they sustain an impairment as a result of a motor vehicle accident. However, the types of statutory accident benefits they are entitled to can vary based on the classification of their injuries.
The Statutory Accident Benefits Schedule, O Reg 34/10, provides for three “tiers” of injuries, with maximum funding as follows:
- Minor injuries: up to $3,500 plus HST for medical expenses
- Non-minor/non-catastrophic injuries: up to $65,000 plus HST for medical expenses
- Catastrophic injuries: $1,000,000 plus HST for medical expenses
Individuals who have suffered catastrophic injuries may be entitled to additional or enhanced benefits, including housekeeping and attendant care.
What Qualifies as a “Catastrophic Impairment”?
“Catastrophic impairment” is defined in the Statutory Accident Benefits Schedule, O Reg 34/10, and can include paraplegia or tetraplegia; severe impairment of ambulatory mobility or use of an arm, or amputation; loss of vision of both eyes; or traumatic brain injury meeting certain requirements.
An injury (or combination of injuries), whether physical, mental, or behavioural, may be categorized as “catastrophic” if it results in 55 percent or more physical impairment of the whole person. Marked impairments in three or more areas of function that preclude useful functioning or extreme impairment in one or more areas of functioning may also qualify an individual for catastrophic impairment.
A more comprehensive outline of the classes of catastrophic impairment is found in the Statutory Accident Benefits Schedule, O Reg 34/10.
The Catastrophic Impairment Designation Process
If an individual believes they have sustained catastrophic impairment following an accident, they must apply to their insurer for the designation.
When Do I Submit an Application for Catastrophic Impairment?
The timing for submitting an Application for Determination of Catastrophic Impairment will depend on the type of injury sustained. For example, paraplegia or amputation will usually be deemed catastrophic automatically. More “subjective” types of injuries, such as those where an individual claims to have a 55% total impairment, require the injured person to wait two years before submitting their application.
How Do I Submit an Application for Catastrophic Impairment?
To be deemed catastrophically impaired, an injured person must provide a completed Application for Determination of Catastrophic Impairment for their insurer after filing their initial claim. This document is primarily completed by the injured person’s physician (or other medical specialist, depending on the type of injury) and outlines the physician’s report regarding the injured person’s treatment and assessment of their injuries and associated impairments.
What Happens After Submitting My Application?
One of a few things can happen after submitting an Application for Determination of Catastrophic Impairment.
In some cases, the insurer may accept the application and determine that the individual’s injuries amount to a catastrophic impairment, following which the individual is entitled to payment of any relevant expenses they have incurred relating to their catastrophic impairment between the date of the accident and the determination date.
In other cases, the insurer may require that the individual submit to further medical assessment by one or more medical specialists chosen by the insurer to confirm whether the individual is catastrophically impaired under s. 44 of the Statutory Accident Benefits Schedule, O Reg 34/10.
The insurer must notify the individual of their decision within 10 business days of receiving the medical specialist’s report (or reports, as the case may be). If, following the medical assessments, the insurer determines that the individual has not suffered catastrophic impairment,
Appealing the Insurer’s Determination that an Individual Has Not Suffered Catastrophic Impairment
If the insurer determines that an individual has not suffered catastrophic impairment, the individual may appeal to the Licence Appeal Tribunal for a determination of whether the individual suffered catastrophic impairment.
What is the Licence Appeal Tribunal?
The Licence Appeal Tribunal is an administrative tribunal that hears applications and resolves disputes relating to, among other things, compensation, benefits, and designations for auto insurance benefits in Ontario.
Appearing before the Licence Appeal Tribunal – or any tribunal, for that matter – is similar to a court. However, unlike appearing in court, administrative tribunals tend to be more flexible on matters relating to evidence and procedure. In the Licence Appeal Tribunal, cases are heard by an adjudicator instead of a judge.
Bringing an Appeal to the Licence Appeal Tribunal
To appeal an insurer’s determination that an individual has not suffered catastrophic impairment, the individual may file an appeal with the Licence Appeal Tribunal. Hearings will typically occur orally by video conference for determinations regarding catastrophic impairment designations.
Following the hearing, the adjudicator will decide whether the individual should be categorized as catastrophically impaired and render a decision.
Ottawa Accident Benefits Lawyers Serving Ontario Personal Injury Claimants
Tierney Stauffer LLP’s skilled personal injury lawyers can help if you have been denied benefits following an accident. We have many years of experience fighting for benefits-seekers’ rights, whether you’re just starting your application or seeking an appeal of a determination.
At Tierney Stauffer LLP, our personal injury lawyers believe in ensuring everyone’s equal rights are respected. If you believe you are entitled to benefits and are being turned down, please call us at 1-888-799-8057 or contact us online to set up a free consultation with a member of our team.