If you have been involved in a motor vehicle accident in Ontario, you are entitled to no-fault accident benefits, even if you caused the accident. However, the amount and duration of those benefits will depend on the severity of your injuries.
If your injuries are serious, you may be classified as having a Catastrophic Impairment, which will significantly increase the benefits available to you.
Unless you’ve purchased optional enhanced coverage, your access to medical, rehabilitation, and attendant care benefits will depend on how your injuries are classified:
- Minor Injuries: Up to $3,500 in medical and rehabilitation benefits, available for a maximum of five years;
- Non-Catastrophic Injuries: Up to $65,000 in medical, rehabilitation and attendant care benefits, available for a maximum of five years; and
- Catastrophic Injuries: Up to $1,000,000 in medical, rehabilitation and attendant care benefits, with no five-year limit on access.
In short, whether or not your injuries meet the criteria of a catastrophic impairment can drastically impact your ability to receive long-term care and support.
What Is a Catastrophic Impairment?
Whether or not your injuries will be considered catastrophic is set out in Section 3.1 of the Statutory Accident Benefits Schedule (SABS), which creates eight categories of catastrophic impairments:
Criteria 1–5:
Injuries such as:
- Paraplegia or quadriplegia;
- Amputations or total loss of use of limbs;
- Total loss of vision in both eyes; and
- Serious brain injuries.
Criterion 6:
You are considered catastrophically impaired if your physical injuries, when assessed under the American Medical Association’s Guides to the Evaluation of Permanent Impairment (4th edition, 1993), result in a Whole Person Impairment (WPI) of 55% or more.
Criterion 7:
If you have a combination of physical and psychological impairments, they may qualify as catastrophic if, together, they meet the 55% WPI threshold.
The Whole Person Impairment rating is a method of calculating how much your entire body is affected by your injuries. Each body system is rated using detailed medical criteria in the AMA Guides. These ratings are then combined using a specific formula to determine your overall impairment level. Someone who has a WPI of 55%, has lost 55% of their function.
The rating system is technical and nuanced and calculated by a medical expert, based on various assessments.
Criterion 8:
This category applies to serious mental or behavioral disorders. To qualify as catastrophic under this criterion, your impairments must:
- Significantly restrict functioning in three out of four life spheres; or
- Completely prevent useful functioning in one life sphere.
The four spheres of functioning are:
- Activities of daily living;
- Social functioning;
- Concentration, persistence, and pace; and
- Adaptation to work-like settings
Just like a WPI rating, assessing the four spheres of functioning is technical and nuanced and done by a medical expert.
What Does This Mean for You?
Establishing that your injuries qualify as a Catastrophic Impairment is not automatic, and the onus is on you to prove it on a balance of probabilities (ie: it is more probable than not) with medical evidence. Doing so, particularly when you may have suffered a Catastrophic Impairment under Criterion 6, 7 or 8 is very complicated. If you are working with a team of skilled and experienced personal injury lawyers, they will arrange for you to undergo the appropriate medical assessments to make this determination.
Even once your insurer has been provided with medical reports confirming your injuries meet the criteria of a Catastrophic Impairment, they may still dispute that your injuries indeed meet the criteria of a Catastrophic Impairment, and they may compel you to attend Insurer Examinations. Depending on the results of the Insurer Examinations, a Hearing before the Licence Appeal Tribunal, decided by a Hearing Adjudicator, may be necessary to secure a designation of Catastrophic Impairment.
The medical malpractice lawyers at Bogoroch & Associates LLP are skilled in handling catastrophic claims. If you or a loved one has suffered a potentially catastrophic impairment, do not hesitate to contact one of the lawyers at Bogoroch & Associates LLP for a prompt and thorough assessment of your case.