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ACCIDENT BENEFITS AVAILABLE PURSUANT
TO THE STATUTORY ACCIDENT BENEFITS SCHEDULE (S.A.B.S.)
FOR ACCIDENTS AFTER NOVEMBER 1, 1996
Supplementary Medical Benefits & Rehabilitation Benefits
Attendant Care Benefits
Funeral and Death Benefits
Weekly Income Replacement Benefits
Care Giver Benefits
Stoppage in Weekly Benefits
Every automobile insurance policy contains mandatory accident benefits coverage, as set forth in the Statutory Accident Benefits Schedule (S.A.B.S.). If you have been injured in a car accident you may be entitled to payment pursuant to the S.A.B.S.
It is not only the injured person who is covered. Any member of the injured person's family may also be entitled to receive benefits if he or she suffers psychological or mental injury as a result of the accident and its aftermath. This provision also extends to include persons who are dependent on the injured person even though not related.
It is critical to remember that this coverage only pays for losses which are not covered by some other private policy of insurance or employment benefit plan. If these other benefit plans or policies cover only part of the expenses incurred, the statutory accident benefits may pay the balance, subject to certain limitations.
If an insured person suffers an impairment as a result of an accident, the insurer may be required to pay for all reasonable expenses incurred by or on behalf of the insured person, including medical, hospital and nursing care, chiropractic, psychological, occupational therapy and physiotherapy services, medication, prescription eye wear, dentures and dental devices, medical devices including aids, wheelchairs, prostheses and orthotics, and transportation to and from treatment sessions. However, the insurer does not have to pay for the first 50 kilometres of the trip in the injured person's automobile to and from a treatment session.
An insurer may also be required to pay for reasonable measures to lessen or eliminate the effects of any disability and to enable the insured person's reintegration into his or her family, the labour market and the rest of society, including social and vocational rehabilitation, home renovations and vehicle modifications.
The maximum amount of supplementary medical benefits and rehabilitation benefits payable is $100,000.00 for each person who qualifies for these or $1,000,000.00 if the person has experienced a "catastrophic impairment". We will contact necessary medical experts to obtain an opinion regarding whether a "catastrophic impairment" has occurred, if we think it is required.
A person claiming any medical or rehabilitation benefits must submit a Treatment Plan to the insurance company. This should be done before any treatment is commenced; however, the Treatment Plan can be submitted up to 30 days after the expense is incurred. The Treatment Plan must be prepared by a Health Professional (a doctor, massage therapist, occupational therapist, etc.), and it must be signed by one of the six Health Practitioners (physician, psychologist, physiotherapist, dentist, optometrist or chiropractor).
An insurer may be required to pay the cost of providing an aide or attendant for an injured person. These benefits include the services of a family member caring for an injured family member at home, the cost of an in-home care attendant, or for services provided by a long-term care facility including a nursing home, home for the aged or chronic care hospital.
The maximum payable each month, with respect to each injured person, is $3,000.00. However, if a person has suffered a "catastrophic impairment", a monthly maximum of $6,000.00 may be payable.
An insurer may require a certificate from a member of the health profession stating that the expense is reasonable and necessary for the person's care.
When an insured person dies as a result of a motor vehicle accident the insurer may be required to pay funeral expenses incurred to a maximum of $6,000.00.
The insurer may also pay death benefits. If the deceased was married, a sum of $25,000.00 would be payable to his or her spouse. If the deceased was not married but was survived by a dependant or dependants, the $25,000.00 payment that would be payable to a spouse would be split equally among the dependants.
In any case, the insurer would also be required to pay an additional $10,000.00 to every surviving dependant of the deceased and perhaps to each former spouse of the deceased.
If the deceased was himself or herself a dependant at the time of the accident, sum of the $10,000.00 would be payable to the person upon whom the deceased was dependent or, if that person is dead, to that person's surviving spouse or surviving dependant or dependants.
In order to qualify for death benefits, the deceased must have died within 180 days from the day of the accident, or, if the deceased was continuously disabled as a result of the accident, within 156 weeks of the day of the accident.
No one is entitled to claim death benefits unless he or she survives the deceased by a minimum of 30 days.
An insured person who suffers an impairment as a result of an accident may be entitled to a weekly income replacement benefit if, at the time of the accident:
a. he or she was employed;
b. he or she was not employed but was employed for at least 26 weeks during the 52 weeks before the accident and was at least 16 years old;
c. he or she was at least 16 years old and receiving Employment Insurance benefits; or
d. he or she was entitled to start work within one year under a contract of employment;
e. and as a result of and within two years of the accident, he or she suffers a substantial inability to perform the essential tasks of the employment.
A weekly income replacement benefit may be payable during the period the insured person suffers a substantial inability to perform the necessary tasks of the employment. No benefit is payable during the first week of the disability.
The amount of the weekly income replacement benefit paid for the first 104 weeks of disability is 80% of the injured person's net weekly income from employment. (Your "net weekly income" is calculated in accordance with a prescribed formula.)
After the first 104 weeks of disability, the weekly income replacement benefit is only payable if the injured person suffers a complete inability to participate in any employment for which he or she is adequately suited by education, training or experience. The amount of the benefit is 80% of the injured person's net weekly income from employment or $185.00, whichever is greater. In any case, the amount payable to an injured person for weekly income replacement benefits shall not be greater than $400.00 per week (unless optional increased benefits were purchased from one's car insurer).
The insurer is entitled to deduct from the weekly income replacement benefits net payments for loss of income available to or received by the insured person. The insurer may not deduct Employment Insurance benefits.
If a person who is entitled to weekly income replacement benefits attained age 65 prior to the accident, an amount to be determined in accordance with the S.A.B.S. may be payable only up to 208 weeks after the onset of the disability.
If, at the time of the accident, the injured person was not working but was enrolled in school or had completed his or her education during the year prior to the accident and was not employed in a job that reflected his or her education, he or she may be entitled to a non-earner benefit. An injured person is only entitled to this benefit if he or she suffers a complete inability to carry on a normal life as a result of and within 104 weeks after the accident. The non-earner benefit is not payable for the first 26 weeks of the disability, and is not payable for any period before the injured person is 16 years old.
The amount of the non-earner benefit is $185.00 per week. However, an injured person who was enrolled in school or who had completed his or her education in the year prior to the accident, and whose disability has lasted for more than 104 weeks, is entitled to $320.00 per week for the non-earner benefit, after the first 104-week period.
An insured person who sustains an impairment as a result of an accident may be entitled to a care giver benefit if the insured person was residing with and was the primary care giver for a person in need of care, providing the insured person did not receive any remuneration for providing care giving activities.
The care giver benefit is meant to pay for reasonable and essential expenses incurred in caring for a person in need of care.
The amount of the care giver benefit shall not exceed $250.00 per week for the first person in need of care plus $50.00 per week for each additional person.
NOTE: The income replacement, non-earner and care giver benefits are payable so long as the insured person suffers from the disability. Only one of these three benefits is payable for any given period of time.
The insurer may require a certificate from a health practitioner confirming that the insured person continues to suffer from the disability. The insurer may also stop payment of weekly benefits after 21 days of its request of a certificate if the certificate is not provided.
The insurer may require that the insured person be evaluated by a health practitioner of the insurer's choice. The assessment report arising from the examination must be provided to the insurer, and the insurer must then provide a copy of the report to the insured person within seven days.
Every insurance company must provide accident benefits to each person injured in a motor vehicle accident. If any benefit is denied by the company, before one can sue in court or arbitrate the dispute, an application for mediation must be filed at the Financial Services Commission. We need to know if any benefit has been terminated so that we can promptly file for mediation on your behalf.
Please notify us immediately should benefits be discontinued or if any expense claimed is denied by the insurance company. We will immediately mediate this matter before the Financial Services Commission.