INTRODUCTION to ACCIDENT BENEFITS
People injured in motor vehicle accidents in Ontario generally qualify for statutory accident benefits (sometimes called accident benefits, ABs or SABS).
Injured people, especially those who suffer mobility impairments, often face the challenge of being discharged from a rehabilitation centre, (The Ottawa Rehabilitation Centre, The Ottawa Hospital-Civic Campus or Elizabeth Bruyere, in Eastern Ontario) only to return to their house, vehicle or job that cannot accommodate them.
This problem is addressed, in part, by the Accident Benefits which include home, work and vehicle modifications/renovations as some of the benefits available to injured people in Ontario.
THE STATUTORY ACCIDENT BENEFIT SCHEME
Generally, people injured in Ontario car accidents can receive accident benefits. The benefits are usually paid by their own car insurance company. However, the scheme also provides coverage for people who do not have their own insurance.
In most situations, accident benefits are available to replace lost salary, attendant care expenses, medical and rehabilitation expenses and death and funeral expenses.
There is a section in the Accident Benefits regime (section 15) that says that “all reasonable and necessary” rehabilitation expenses are to be paid. The purpose of the rehabilitation expenses are to reduce or eliminate the impact of a disability caused by the accident. Home renovations, assistive devices, workplace adaptations and vehicle modifications are all items which may be covered under section 15 of the Accident Benefit regime for “rehabilitation” benefits.
WHAT EXPENSES ARE COVERED BY ONTARIO ACCIDENT BENEFITS?
The insurance company is required to fund all reasonably and necessary workplace modifications and workplace assistive devices, including communication aids, to accommodate the needs of the injured person.
The insurance company also states that an insurance company must pay the injured person for all reasonable and necessary home modifications and home devices, including communication aids.
The Accident Benefits regime specifically allows for the purchase of a new home for the injured person where purchasing a new home to accommodate the injured person’s needs makes more sense than to renovate his or her existing home. However, the amount allocated for the purchase of a new home must not exceed the value of the renovations to the injured person’s existing home that would be required to accommodate the injured person’s needs.
If the existing home is incapable of being modified to accommodate the injured person, the only limit on the amount available to purchase a new home is the policy limits for this category of benefits.
For the injured person’s transportation needs, the Accident Benefit Regime provides that the insurance company has to pay for all reasonable and necessary vehicle modifications to accommodate the needs of the injured person, or the purchase of a new vehicle if it is more reasonable to purchase a new vehicle to accommodate the needs of the injured person.
WHAT ARE THE POLICY LIMITS? HOW MUCH DO YOU HAVE TO SPEND?
The medical and rehabilitation benefits are supposed to pay for all reasonable and necessary expenses that arise because of the accident.
Home, workplace and vehicle modification come under the medical / rehabilitation category. Medical expenses are more straightforward to understand. They include medical expenses that are not covered by OHIP or a personal insurance plan such as physiotherapy, prescriptions, chiropractor, occupational therapy, psychology and other similar expenses.
For the purpose of calculating how much money is available, the medical benefits and the rehabilitation benefits are combined.
If the injured person did not suffer a “catastrophic impairment” as that is described in the Accident Benefit regime, the total amount of the medical / rehabilitation benefit is $100,000 and the benefits expire after 10 years from the date of the accident
If the injured person did suffer a “catastrophic impairment” the medical / rehabilitation benefit increases to $1 Million and last for the person’s entire life.
HOW DO YOU GET THE BENEFITS?
You must notify your insurance company that you have had a car accident within 7 days of the accident, or as soon as possible, and you must complete your application for Accident Benefits within 30 days. While it is not fatal to your application if you miss these deadlines by a small margin, you should submit your applications as soon as possible.
Once you have successfully applied to the insurance company for Accident Benefits, the first step to get modifications is to obtain a home-site and, if appropriate, a work-site assessment.
These assessments will provide realistic, practical suggestions to help the injured person to live and work safely and reasonably their houses and at their jobs. The focus of the assessments is to return the injured person, to the extent it is possible, to a pre-accident level of function as quickly, safely and economically as possible.
Injured people with catastrophic or near catastrophic injuries may require other assessments as well, including a housing accessibility report, an alternative housing report.
The insurance company normally pays for the home-site and work-site assessments if they approve the assessment in advance. To get approval of this type of assessment, the injured party or his or her lawyer has to arrange for the completion of a form called an “OCF-22: Application for Approval of an Assessment or Examination”. Keep in mind that the person conducting the assessment is often not a regulated health professional and therefore will not be permitted to complete the OCF 22. An occupational therapist, a case manager or even a family doctor or physiotherapist can complete the form.
The insurance company will review the OCF 22. If it is approved, the assessment can take place. The assessment will result in a report. Once the report is generated, and if the insurance adjuster requires it, another form called a “OCF 18: Treatment Plan” will be submitted to the insurance company, outlining the proposed cost of the recommendations in the report. If the OCF 18 is approved, the work can begin.
ARE HOME MODIFICATIONS PERMITTED FOR NON-CATASTROPHIC INJURIES?
In some situations, the answer is yes. Where the injured person has suffered injuries that cause impairment but are on the less serious end of the spectrum, and if the renovations are not going to be extensive, an occupational therapist will perform a home and, if required, a work-site assessment.
A home assessment is an assessment of the injured person’s activities of daily living including from before the accident. This assessment looks at personal care, housekeeping, home maintenance and care giving tasks. The Occupational Therapist also provides a breakdown of any recommended assistive devices, home modifications and simple home renovations in the report. Examples of recommendations in this type of assessment include adding a stair railing, raising or lowering a bed or counter or adding hip-level storage in a kitchen.
A work place assessment examines the physical and mental demands of the injured person’s job and provides recommendations including workplace modifications where required. The assessment should also include an estimated cost of the proposed modifications.
If the recommended renovations included in the occupational therapist’s report are complete, it can be submitted to the insurance company together with a Treatment Plan costing the recommendations to the insurance company for approval.
HOW TO ACCESS THESE BENEFITS FOR CATASTROPHICALLY INJURED PEOPLE
If a person is seriously injured and needs significant home modifications like ramps, additions, elevators, walls moved, a home accessibility report is required.
A home accessibility report is centered around the injured person’s housing requirements. The report identifies the client’s housing requirements, a description and pictures or drawings of the current home. It also outlines the home modifications and renovations that would be needed to meet the client’s housing needs at the current house.
The home accessibility report includes costs as well as plans for the proposed renovations. The report addresses municipal by-laws and construction issues that are generally outside the scope of practice of an occupational therapist.
When the report is finalized, and the injured person decides to implement the renovations, a treatment plan is submitted to the insurance company for approval.
Sometimes the injured person will decide that the proposed renovations do not make sense and are not in their best interest. In that circumstance, it can be better to simply purchase a new home for rather than try to renovate the current one.
Factors that may impact the decision to purchase a new home rather than renovating an existing home are the following:
*Is the current home a rental or social housing?
* Are the renovations required so extensive that they will exhaust or exceed the policy limits or just not make financial sense?
* Are the renovation not allowed due to municipal restrictions?
* Was the injured person still living with parents at the time of the accident?
* Is the current home to far from required services for the person’s disabilities?
The housing benefit under s. 15 of the Statutory Accident Benefit Regulation is one of the largest components of most injured people’s AB claim. If you would like to speak to an experienced lawyer about this aspect of your claim, contact the personal injury lawyers at Auger Hollingsworth.