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Breaking Down the Changes in Statutory Accident Benefits

Written by: Candice Thornton

Statutory accident benefits are provided to individuals in Ontario who are injured as the result of a “no fault” motor vehicle accident. They are legislated by the Statutory Accident Benefits Schedule (SABS), which is a regulation under the Insurance Act of Ontario, governed by the Financial Services Commission of Ontario (FSCO).

The SABS largely dictate how we practice MVA services within Dalton Associates, and as with any legislation, we are required to comply with regular updates. Any auto insurance policies that are issued or renewed as of June 1, 2016, are subject to the revised SABS. The following is a summary of the changes (note that this is not a comprehensive list of the changes – only those that directly affect the way we practice at Dalton Associates):

1. Reduction to accident benefit limits and expiration of benefits

a. Prior to June 1, 2016, clients who were involved in an MVA were allotted $50,000 for rehabilitation benefits (which includes psychological services, chiropractic care, physiotherapy, massage, etc.), and $36,000 for attendant care benefits. However, the new legislation combines medical, rehabilitation and accident care benefits for a total of only $65,000, which expires after 5 years. This means that if a client requires attendant care, there are less funds available for rehabilitation services. Conversely, if the client does not require attendant care, there are potentially more funds available for rehabilitation services, including psychological treatment.

b. Consumers may choose to purchase “optional benefits” through their auto insurance broker, which would allow $130,000 combined medical, rehabilitation and accident care benefits, which expires after 10 years (versus the standard $65,000 expiring after 5 years). If you are interested in purchasing optional benefits, contact your auto insurer or auto insurance broker.

2. Redefining catastrophic impairment

a. Clients with a catastrophic impairment designation are allotted $1 million for combined medical, rehabilitation and accident care benefits as a standard. Consumers may purchase optional benefits for up to $2 million.

b. As of June 1, 2016, the definition of “catastrophic impairment” has been revised to reflect current medical studies. In addition to undergoing a neuropsychological assessment, the client must meet the following criteria to obtain “catastrophic status”: positive MRI findings, vegetative or disability rating on the Glasgow Outcome Scale, significant decreased activities of daily living via client interview, interview of treating practitioners and/or file review of collateral medical documents. As such, legal experts caution practitioners to be mindful of what is being documented in a client’s file, as it may be used to support (or deny) a client’s catastrophic impairment status.

3. Changes to the dispute resolution process

a. Should a client be denied funding for psychological (or any other rehabilitation service), they are given the option to appeal the denial. Previously, the appeals were processed through FSCO (who regulates the insurance sector). However, after June 1, 2016 the Licence Appeal Tribunal (a less-biased organization) has taken over the appeals process. The cost for a client to appeal any single denial is $100. “Expert” practitioners (i.e., a Psychologist) may be required to testify over the phone for appeal proceedings.

For more information about these changes, or for rehabilitation services inquiries, please contact Candice Thornton at Dalton Associates’ administrative office in Fergus.

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