What Are Statutory Accident Benefits (SABS) in Ontario?

Any person who suffers injuries in a motor vehicle accident in Canada can be entitled to no-fault statutory accident benefits, commonly known as Statutory Accident Benefits (SABS), through their automobile insurance policy. Even people who cause car accidents can still be entitled to SABS.

If a person does not have a motor vehicle insurance policy, they are still entitled to claim benefits from an insurer for the vehicle in which they were a passenger or the insurer of any vehicle that struck them if they were a pedestrian or bicyclist.

According to our personal injury lawyer in Hamiton, When it comes to medical, rehabilitation, and attendant care benefits, a person will fall into one of three categories:

• minor-injury guidelines under which a person will have $3,500 of available coverage
• non-catastrophic injuries for which a person will have $65,000 of available coverage
• catastrophic injuries for which a person will have $1,000,000 of available coverage.

SABS guidelines

SABS is a mandatory kind of no-fault insurance that provides certain kinds of accident benefits to any person who suffers injuries in an automobile accident, regardless of which party was at fault. SABS will cover a driver, their passengers, motorcyclists, pedestrians and any other person who might suffer injuries because of an insured motor vehicle.

Because statutory accident benefits are mandatory even in basic motor vehicle liability policies, people injured in automobile accidents may file claims and often obtain necessary financial relief for various expenses and losses. Benefits often include all medical bills not covered by the Ontario Health Insurance Plan (OHIP), lost income, caregiver costs and many more.

Provisions of SABS are often amended, so all accident victims should be sure to consult an experienced car accident lawyer as soon as possible for help with a SABS claim. An experienced lawyer will know what steps need to be taken to help people recover all of the benefits they are entitled to.

Statutory Accident Benefits Schedule

After a person notifies their insurance company that they have been involved in a car accident, the insurer will open a SABS file for them and forward a package of documents that must be completed. It will be important for people to note their claim number and all contact information, including phone number and email, for the claims adjuster assigned to their file.

There are several documents that must be completed, which will include:

• Application For Accident Benefits (OCF-1) — People must complete this form themselves, and it needs to be completed as soon as possible. This document will provide an insurer with an overview of a person’s background and injuries to make determinations about the management and collection of accident benefits.

• Employers Confirmation Form (OCF-2) — An employer completes this form when a person is employed, but a person must complete this form themselves if they are self-employed. This form will relate to how a person’s injuries affect their ability to work.

• Disability Certificate (OCF-3) — A doctor or other treating medical practitioner will complete this form for a person. It will provide an insurance company with a summary of a person’s accident-related injuries and impairments, as well as pre-existing conditions that could complicate recovery.

• Permission To Disclose Health Information (OCF-5) — Packages sent by insurance companies often include OCF-5 forms, but people should not sign and return the form to the insurer. Instead, people should have their lawyers provide insurers with copies of all reasonable and relevant documentation.

• Expenses Claim Form (OCF-6) — When people are paying out-of-pocket expenses relating to their accidents and injuries, they should retain copies of all receipts relating to the expenses. Common expenses that could be covered often include various medications, assistive devices like braces or crutches, parking costs, transportation costs, goods damaged in accidents, and visitor expenses. Such expenses can be submitted to an auto insurer on an OCF-6. When people have extended health coverage (meaning health insurance privately, through an employer, or under a spouse’s policy), they will be required to first submit their expenses to the extended health coverage provider. Any expenses not covered by an extended health coverage provider are then submitted to the auto insurance company for consideration and reimbursement.

• Election Of Benefits (OCF-10) — A lawyer will complete this form for a person. If, at the time of an accident, a person was working, caregiving, attending school, retired, and/or unemployed, they must elect a weekly indemnity benefit most suitable to their circumstances.

• Treatment And Assessment Plan (OCF-18) — This is another form to be completed by a doctor or other treating medical practitioner. To obtain treatment, a treatment provider must submit to the insurance company an OCF-18 via a platform called the Department of Health Care Access and Information (HCAI). Doing this will allow a person’s provider to submit billing directly to an insurer. It also allows the insurer to submit reimbursements directly to a provider. If a provider does not submit the form to the insurer via HCAI, there will be no guarantee that any expenses incurred by a person with the provider will be reimbursed. People should ask their providers if they are equipped to submit their treatment via HCAI before commencing treatment with them.

• Assessment Of Attendant Care Benefits (Form 1) — A registered nurse or occupational therapist will complete this form. When injuries prevent people from independently carrying out their personal care needs, they may be eligible to receive attendant care benefits. People should consult with their treatment providers and lawyers to coordinate an Assessment of Attendant Care Needs, which can be submitted to an insurance company on the Form 1 document.

Statutory Accident Benefits Schedule of the Insurance Act

Ontario established strict regulations for SABS under the Ontario Insurance Act. Keeping in mind that injuries are classified as either minor injuries, non-catastrophic injuries, or catastrophic injuries, it is important for people to understand what constitutes a catastrophic injury.

Under Section 3.1 of the Ontario Insurance Act, an impairment is a catastrophic impairment if an insured person sustains an impairment in an accident that occurs on or after June 1, 2016, and the impairment results in any of the following:

1. Paraplegia or tetraplegia satisfying the following criteria:
   • An insured person’s neurological recovery is such that the person’s permanent grade on the ASIA Impairment Scale can be determined.
   • An insured person’s permanent grade on the ASIA Impairment Scale is or will be A, B or C, or D and their score the Spinal Cord Independence Measure, Version III, item 12 (Mobility Indoors), and applied over a distance of up to 10 meters on an even indoor surface is 0 to 5.
   • An insured person requires urological surgical diversion, an implanted device, or intermittent or constant catheterization in order to manage a residual neuro-urological impairment, or an insured person has impaired voluntary control over anorectal function that requires a bowel routine, a surgical diversion or an implanted device.
2. Severe impairment of ambulatory mobility or use of an arm, or amputation that meets one of the following criteria:
   • Trans-tibial or higher amputation of a leg.
   • Amputation of an arm or another impairment causing the total and permanent loss of use of an arm.
   • Severe and permanent alteration of prior structure and function involving one or both legs as a result of which the insured person’s score on the Spinal Cord Independence Measure, Version III, item 12 (Mobility Indoors), and applied over a distance of up to 10 meters on an even indoor surface is 0 to 5.
3. Loss of vision in both eyes that meets the following criteria:
   • Even with the use of corrective lenses or medication, visual acuity in both eyes is 20/200 (6/60) or less as measured by the Snellen Chart or an equivalent chart, or the greatest diameter of the field of vision in both eyes is 20 degrees or less.
   • The loss of vision is not attributable to non-organic causes.
4. If an insured person was 18 years of age or older at the time of the accident, a traumatic brain injury (TBI) that meets the following criteria:
   • An injury showing positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or hemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.
   • When assessed in accordance with Wilson, J., Pettigrew, L. and Teasdale, G., Structured Interviews for the Glasgow Outcome Scale and the Extended Glasgow Outcome Scale: Guidelines for Their Use, Journal of Neurotrauma, Volume 15, Number 8, 1998, the injury results in a rating of Vegetative State (VS or VS*), one month or more after the accident, Upper Severe Disability (Upper SD or Upper SD*) or Lower Severe Disability (Lower SD or Lower SD*), six months or more after the accident, or Lower Moderate Disability (Lower MD or Lower MD*), one year or more after the accident.
5. If an insured person was under 18 years of age at the time of the accident, a TBI that meets one of the following criteria:
   • An insured person is accepted for admission, on an in-patient basis, to a public hospital named in a Guideline with positive findings on a computerized axial tomography scan, a magnetic resonance imaging or any other medically recognized brain diagnostic technology indicating intracranial pathology that is a result of the accident, including, but not limited to, intracranial contusions or hemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.
   • An insured person is accepted for admission, on an in-patient basis, to a program of neurological rehabilitation in a pediatric rehabilitation facility that is a member of the Ontario Association of Children’s Rehabilitation Services.
   • One month or more after the accident, an insured person’s level of neurological function does not exceed category 2 (Vegetative) on the King’s Outcome Scale for Childhood Head Injury as published in Crouchman, M. et al., A practical outcome scale for a paediatric head injury, Archives of Disease in Childhood, 2001: 84: 120-124.
   • Six months or more after the accident, an insured person’s level of neurological function does not exceed category 3 (Severe disability) on the King’s Outcome Scale for Childhood Head Injury as published in Crouchman, M. et al., A practical outcome scale for paediatric head injury, Archives of Disease in Childhood, 2001: 84: 120-124.
   • Nine months or more after the accident, an insured person’s level of function remains seriously impaired such that the insured person is not age-appropriately independent and requires in-person supervision or assistance for physical, cognitive or behavioural impairments for the majority of the insured person’s waking day.
6. Under subsections (2) and (5), a physical impairment or combination of physical impairments that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 percent or more physical impairment of the whole person.
7. Under subsections (2) and (5), a mental or behavioural impairment, excluding TBI, determined in accordance with the rating methodology in Chapter 14, Section 14.6 of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, that, when the impairment score is combined with a physical impairment described in paragraph 6 in accordance with the combining requirements set out in the Combined Values Table of the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, 1993, results in 55 percent or more impairment of the whole person.
8. Under subsections (3) and (5), an impairment that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4th edition, results in 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 function that precludes useful functioning, due to mental or behavioural disorder.

Paragraphs 6 and 7 of subsection (1) do not apply in respect of an insured person who suffers an impairment as the result of an accident unless two years have elapsed since the accident or an assessment conducted by a physician three months or more after the accident determines that the insured person has a physical impairment or combination of physical impairments determined in accordance with paragraph 6 of subsection (1), or a combination of a mental or behavioural impairment and a physical impairment determined in accordance with paragraph 7 of subsection (1) that results in 55 percent or more impairment of the whole person, and the insured person’s condition is unlikely to improve to less than 55 percent impairment of the whole person.

Paragraph 8 of subsection (1) does not apply in respect of an insured person who sustains an impairment as a result of the accident unless two years have elapsed since the accident or a physician states in writing that the insured person’s impairment is unlikely to improve to less than a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning, due to mental or behavioural disorder. Subsection (5) applies to an insured person who was under the age of 18 at the time of the accident and whose impairment is not a catastrophic impairment within the meaning of subsection (1).

If an insured person’s impairment can reasonably be believed to be a catastrophic impairment for the purposes of paragraph 6, 7 or 8 of subsection (1), the impairment shall be deemed to be the impairment referred to in paragraph 6, 7 or 8 of subsection (1) that is most analogous to the impairment, after taking into consideration the developmental implications of the impairment.

What are the Limits for SABS in Ontario?

If a person cannot work because of an automobile accident, they may be eligible for weekly income replacement benefits of 70 percent of their gross income up to $400 per week. People have the option to increase the benefit to $1,000 per week for an additional premium.

If a person’s injuries prevent them from carrying on a normal life, and they do not qualify for income replacement benefits or were a full-time student at the time of the accident, they could be eligible for non-earner benefits of $185 per week. The combined mandatory minimum coverage for Medical, Rehabilitation and Attendant Care Benefits is $65,000 for non-catastrophic injuries and $1 million for catastrophic injuries.

If a person dies because of an automobile accident, benefits will include payments of $25,000 to a spouse, $10,000 to all dependents, and up to $6,000 for funeral expenses. Benefits could be increased to $50,000 for a spouse, $20,000 for dependents, and $8,000 for funeral expenses.

Lost educational expenses offer a maximum benefit of $15,000. There can also be up to $100 a week for housekeeping expenses when a person needs to hire another party to perform in-home maintenance.

Are Accident Benefits Mandatory in Ontario?

Yes, accident benefits will be mandatory in Ontario because all policies include them. There will be standard and optional additions people can add to their plans.

Benefits covered across the province include income replacement benefits for people unable to work who could qualify for benefits of 70 percent of their gross income, capped at $400 per week, although there may be an option to increase the amount to $1,000 per week. Caregiver benefits for people who cannot provide care to a dependent provides compensation to hire people to help care for them relating to specific injuries.

When a person does not qualify for income replacement, they are a student, or cannot continue on in daily life as they did prior to the incident, they could qualify to obtain $185 per week. Mandatory coverage typically includes up to $65,000 for non-catastrophic injuries or up to $1 million for catastrophic injuries, although this amount can be increased for non-catastrophic injuries to $130,000 and catastrophic injuries to $2 million.

Caregiver benefits for people who are unable to continue as a primary caregiver will offer assistance for home or healthcare facilities to help people recover from serious injuries. It can include up to $250 per week and an additional $50 per week for each subsequent dependent living in the house.

Additional expenses may also be covered, such as lost educational expenses, expenses of visitors, housekeeping and home maintenance, damage to personal property, and costs of examinations. Dependent care benefits can cover up to $75 per week for a person’s first dependent and $25 for each additional dependent but can only be claimed if a person was employed at the time of the accident and has to pay for additional childcare expenses due to injuries sustained.

Speak with an Experienced Hamilton Personal Injury Lawyer

If you have been involved in a car accident in the greater Ontario area, you will want to be sure to contact Derek Wilson Personal Injury Law Firm as soon as possible. Our firm is based in Hamilton, Ontario and has been dedicated to personal injury law since 1995. We will not require any payment from you until we successfully recover money for you first. Call (905) 769-0418 or contact us online to set up a free consultation.