Your Accident Benefits Under
No-Fault Legislation

Every automobile insurance policy contains mandatory accident benefits coverage. A list of available benefits is set out in the Statutory Accident Benefits Schedule. Please note that on September 1, 2010, mandatory Accident Benefits are changing in Ontario. The information below pertains to benefits up to September 1. We will be updating our site to reflect the new legislation shortly.
  1.   Do I have to be a passenger in an automobile to be eligible for accident benefits?
  2.   Are accident benefits paid automatically after I have an automobile accident?
  3.   If I miss the deadline of 30 days can I still apply for benefits?
  4.   Is the injured accident victim only one covered for Statutory Accident Benefits?
  5.   What if you have a private insurance policy?
Supplementary Medical Benefits & Rehabilitation Benefits
  6.   What is your auto insurer required to pay for medical and rehabilitation benefits?
  7.   How much are you entitled to receive for medical and rehabilitation benefits?
  8.   What do you need to submit to your insurer to obtain a medical and/or rehabilitation benefit?
Attendant Care Benefits
  9.   Is your insurer required to pay for an aide or attendant?
  10.   How much can you receive for attendant care?
Treatment
  11.   Can I arrange for my own medical or rehabilitation assessment to determine what treatment I need?
Funeral and Death Benefits
  12.   Is your insurer required to pay for funeral expenses?
  13.   Is your insurer required to pay death benefits?
  14.   How do you qualify for death benefits?
Weekly Income Replacement Benefits 
  15.   When are you entitled to receive weekly income replacement benefits?
  16.   When can you begin receiving income replacement benefits?
  17.   What is the maximum amount of income replacement benefits you can receive?
  18.   Can self-employed persons receive income replacement benefits?
  19.   How long can you receive income replacement benefits?
Non-Earner Benefits
  20.   When are you entitled to receive non-earner benefits?
  21.   What is the maximum amount of non-earner benefits you can receive?
Caregiver Benefits 
  22.   When are you entitled to receive caregiver benefits?
  23.   What is the maximum amount of caregiver benefits you can receive?
  24.   Can you receive income replacement benefits, non-earner benefits and caregiver benefits at the same time?
  25.   What if I am employed and also a caregiver? Which benefit do I choose?
Stoppage in Weekly Benefits 
  26.   When can the insurer stop payment of your weekly benefits?
  27.   How will attempting to return to work affect my weekly benefits?
Exclusions 
  28.   When is your insurer not obligated to pay benefits?
Expenses of Visitors 
  29.   Who is entitled to receive payment for visiting expenses that incur while you are injured?
Lost Education Expenses 
  30.   When are you entitled to receive payment for lost education expenses?
  31.   What is the maximum amount you can receive for lost education expenses?
Housekeeping and Maintenance 
  32.   What is the maximum amount you can receive for housekeeping and home maintenance expenses?
  33.   How long can you receive payment for these expenses?
Other Expenses 
  34.   What other expenses can you receive payment for from your insurer?
Catastrophic Impairment 
  35.   What constitutes a catastrophic impairment?
  36.   What if your injury is catastrophic, as defined by the Insurance Act?
Medical Examinations 
  37.   Can the insurer require me to go to its doctor or other health care worker for a physical or psychological examination?
Optional Benefits 
  38.   What if you have optional benefits?
Claiming Benefits 
  39.   What steps must you take when claiming benefits?
  40.   Do I need a lawyer for my accident benefits?

Answers

  1.   Do I have to be a passenger in an automobile to be eligible for accident benefits?
  A.   No. Pedestrians and cyclists are also entitled to accident benefits so long as an automobile was also involved in the accident.
Back to the question list 
  2.   Are accident benefits paid automatically after I have an automobile accident?
  A.   No. You must notify your insurer within 7 days after the accident, or as soon as practical after the accident, that you wish to apply for accident benefits. Your insurer must then promptly give you application forms. To avoid delays in processing your application, you must file the completed application forms with your insurer within 30 days after receiving them from your insurer.
Back to the question list 
  3.   If I miss the deadline of 30 days can I still apply for benefits?
  A.   Yes. Insurers must accept late applications if you have a reasonable explanation for the delay. However, if you do not have a reasonable explanation for the delay, the insurer is allowed to delay up to 45 days in processing your application. It is always best to meet the 30-day time limit. No benefit is payable until a complete application is sent and approved by the insurer.
Back to the question list 
  4.   Is the injured accident victim only one covered for Statutory Accident Benefits?
  A.   No. Any member of your immediate family may also be entitled to benefits if he or she suffers psychological or mental injury as a result of your accident.
Back to the question list 
  5.   What if you have a private insurance policy?
  A.   Accident benefits only pay for losses that are not covered by some other private policy or employment benefit plan. If these other benefit plans cover only part of the expenses, accident benefits may pay the balance.
Back to the question list 
  6.   What is your auto insurer required to pay for medical and rehabilitation benefits?
  A.   The insurer may be required to pay all of the reasonable expenses incurred as a result of your accident, including:
    
  1. medical, hospital and nursing care,
  2. chiropractic, psychological and occupational therapy,
  3. medication, prescription eyewear, dental and medical aids,
  4. transportation to and from treatment sessions,
  5. social and vocational rehabilitation,
  6. home renovations and vehicle modifications.
Back to the question list 
  7.   How much are you entitled to receive for medical and rehabilitation benefits?
  A.   You are entitled to receive up to $100,000 of medical and rehabilitation benefits for expenses incurred up to 10 years after the accident.
     If your injury is catastrophic as defined by the legislation, you are entitled to receive up to $1,000,000 for medical and rehabilitation expenses incurred over your lifetime.
Back to the question list 
  8.   What do you need to submit to your insurer to obtain a medical and/or rehabilitation benefit?
  A.   You must submit a treatment plan to the insurance company. This should be done before any treatment commences. The treatment plan must be prepared by a health professional and signed by one of the following health practitioners:
    
  1. physician,
  2. psychologist,
  3. physiotherapist,
  4. dentist,
  5. optometrist,
  6. chiropractor.
     Insurers are entitled to refuse to pay for treatment unless a treatment plan is completed. Pre-Approved Framework Guidelines apply to certain soft tissue claims that provide a fixed package of benefits to people without going through the treatment plan process. The guidelines mandate the provision of treatment, and goods and services for certain types of injuries, without the injured party having to obtain insurance company approval. Currently, Guidelines have been introduced to deal with Whiplash Associated Disorders (WAD) Grade I or II, with or without back symptoms. Treatment for injuries falling outside of these categories must be pursued through the ordinary treatment plan procedure.
Back to the question list 
  9.   Is your insurer required to pay for an aide or attendant?
  A.   If you have been injured in an accident your insurer may be required to pay the cost of providing for an aide or attendant. These benefits include the services of one of your family members caring for you at home. The insurance regulations have special forms, which can be completed by an occupational therapist or physician for this benefit.
Back to the question list 
  10.   How much can you receive for attendant care?
  A.   You can receive up to $3,000 per month in attendant care for two years after the accident. If your injury is catastrophic, you can receive up to $6,000 per month to a maximum of $1,000,000 and there is no time limit.
Back to the question list 
  11.   Can I arrange for my own medical or rehabilitation assessment to determine what treatment I need?
  A.   Yes. Your own treating health care specialists can perform an assessment under the regulation and in most cases the insurer is obligated to pay for the cost of that assessment.
Back to the question list 
  12.   Is your insurer required to pay for funeral expenses?
  A.   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.
Back to the question list 
  13.   Is your insurer required to pay death benefits?
  A.   If the deceased was married, a sum of $25,000 would be payable to his or her spouse. If the deceased was not married but was survived by a dependant(s), the $25,000 is divided equally among the dependants. If the deceased was a dependant at the time of the accident, $10,000 would be payable to the person upon whom the deceased was dependent.
Back to the question list 
  14.   How do you qualify for death benefits?
  A.   In order to qualify for death benefits, the deceased must have died within 180 days from the accident, or, if the deceased was continuously disabled as a result of the accident, within 156 weeks of the day of the accident.
Back to the question list 
  15.   When are you entitled to receive weekly income replacement benefits?
  A.   You are entitled to receive weekly income replacement benefits for up to the first 104 weeks (excluding the first week) after a collision in the following circumstances:
    
  1. you were employed on the date of the accident and thereafter suffered a substantial inability to perform the essential tasks of your employment;
  2. you were not employed at the time of the accident but worked at least 26 of the 52 weeks before the accident (or were receiving Employment Insurance benefits at the time of the accident) and thereafter suffered a substantial inability to perform the essential tasks of the employment in which you spent most of your time during the 52 weeks before the accident; or
  3. you were entitled to start work within one year under a legitimate written contract that was made before the accident and, as a result of the accident, you suffer a substantial inability to perform the essential tasks of that employment. Note that this latter scenario is only applicable with respect to accidents that occurred before April 15, 2004.
Back to the question list 
  16.   When can you begin receiving income replacement benefits?
  A.   You will not receive income replacement benefits for the first 7 days after a collision. Then, as long as you qualify, you can receive 80% of your net weekly income (less any benefits you may be entitled to from other insurance policies or employment plans).
Back to the question list 
  17.   What is the maximum amount of income replacement benefits you can receive?
  A.   You can receive a maximum of $400 per week. If optional coverage was purchased, you can receive a maximum of $1,000 per week. If you are entitled to group benefits or private benefits you may still be entitled to up to an additional $400.
Back to the question list 
  18.   Can self-employed persons receive income replacement benefits?
  A.   Yes. Self-employed persons are entitled depending on their income and expense situation. Usually an accountant will be necessary to determine eligibility and quantum.
Back to the question list 
  19.   How long can you receive income replacement benefits?
  A.   Income replacement benefits are payable for 2 years following the accident so long as you suffer a substantial inability to engage in the essential tasks of your pre-accident employment. To continue to receive benefits beyond the 2-year mark, you must be suffering from a complete inability to engage in any employment for which you are suited by education, training, and experience.
     So long as you continue to satisfy the eligibility criteria, income replacement benefits are available to you up until age 65, at which point they are reduced on a gradual basis.
Back to the question list 
  20.   When are you entitled to receive non-earner benefits?
  A.   If, at the time of the accident, you were not working but were enrolled in school or had completed your education during the year prior to the accident and were not employed in a job that reflected your education, you may be entitled to a non-earner benefit. You are only entitled to this benefit if you suffer a complete inability to carry on a normal life and are over 16 years of age.
Back to the question list 
  21.   What is the maximum amount of non-earner benefits you can receive?
  A.   The amount of the non-earner benefit is $185.00 per week. However, nothing is payable for the first 26 weeks after the accident. If you were enrolled in school or had completed your education in the year prior to the accident, you are entitled to a non-earner benefit in the amount of $320 per week after the first 104-week period has expired.
Back to the question list 
  22.   When are you entitled to receive caregiver benefits?
  A.   You may be entitled to a caregiver benefit if you were living with and were primary caregiver for a person in need of care and were not being paid for these activities.
Back to the question list 
  23.   What is the maximum amount of caregiver benefits you can receive?
  A.   The maximum amount of the caregiver benefit is $250 per week for the first person in need of care plus $50 per week for each additional person.
Back to the question list 
  24.   Can you receive income replacement benefits, non-earner benefits and caregiver benefits at the same time?
  A.   No. Only one of the income replacement, non-earner and caregiver benefits is payable for any given period of time.
Back to the question list 
  25.   What if I am employed and also a caregiver? Which benefit do I choose?
  A.   You must elect one or the other. Advice from a personal injury lawyer may be of assistance in making the decision that is best for you.
Back to the question list 
  26.   When can the insurer stop payment of your weekly benefits?
  A.   Your insurer may stop payment of weekly benefits in the following cases:
    
  1. If, despite your insurer's request, you fail to provide a certificate from a health practitioner stating that you continue to suffer from the disability, the insurer may stop payment of weekly benefits after 21 days of its request;
  2. If your insurer arranges an assessment by a health practitioner and it is determined that you are no longer disabled, your insurer may stop payment of the weekly benefits. However, you are entitled, within specified time frames, to have a health practitioner of your choice rebut the insurer's decision to stop payment of your disability benefits.
Back to the question list 
  27.   How will attempting to return to work affect my weekly benefits?
  A.   You may attempt to return to work at any time during the first 104 weeks of your disability without affecting your entitlement to receive income replacement benefits so long as you cannot continue with the employment because of the accident.
Back to the question list 
  28.   When is your insurer not obligated to pay benefits?
  A.   Your insurer is not obligated to pay income replacement benefits, non-earner benefits, lost education expenses, expenses of visitors or home maintenance expenses if you were the driver of an automobile at the time of the accident and you;
    
  1. knew or ought to have known that the automobile was not insured;
  2. were not licensed to drive;
  3. were an excluded driver under the contract of insurance for the vehicle which you were driving at the time of the accident;
  4. were driving a vehicle, or were an occupant of a vehicle, when you ought to have known that the vehicle was being driven without the owner's consent;
  5. were convicted of impaired driving;
  6. were convicted of driving with a blood alcohol level exceeding legal limits,
  7. were convicted of failing to provide a breath sample;
  8. were engaged in a criminal offence, or were an occupant of an automobile that was being used in connection with a criminal offence;
  9. misstated facts to the insurer in order to obtain motor vehicle insurance;
Back to the question list 
  29.   Who is entitled to receive payment for visiting expenses that incur while you are injured?
  A.   If your family members and other individuals who were living with you at the time of your accident visit you, they are entitled to payment of all reasonable and necessary expenses incurred as a result of the accident during your treatment or recovery. There is no payment after 104 weeks unless the injury is catastrophic.
Back to the question list 
  30.   When are you entitled to receive payment for lost education expenses?
  A.   If you are unable to continue in a program that you were enrolled in at the time of the accident, the insurer will pay for lost education expenses.
Back to the question list 
  31.   What is the maximum amount you can receive for lost education expenses?
  A.   The maximum amount you can receive is $15,000. This amount is meant to compensate for expenses incurred before the accident, such as tuition, books, equipment, and room and board.
Back to the question list 
  32.   What is the maximum amount you can receive for housekeeping and home maintenance expenses?
  A.   You can receive a maximum of $100 per week for all reasonable expenses for housekeeping and home maintenance, if you suffer substantial inability to perform these services and you performed these services before the accident.
Back to the question list 
  33.   How long can you receive payment for these expenses?
  A.   Your housekeeping and home maintenance expenses are paid for 104 weeks unless the injury is catastrophic.
Back to the question list 
  34.   What other expenses can you receive payment for from your insurer?
  A.   Your insurer may by be obligated to replace or repair clothing damaged in the accident, prescription eyewear, dentures, hearing aids, prostheses, and other medical or dental devices lost or damaged in the accident.
Back to the question list 
  35.   What constitutes a catastrophic impairment?
  A.   Some examples of catastrophic impairments are paraplegia or quadriplegia, permanent loss of use of both arms, loss of vision in both eyes, and severe brain injuries. In other cases, once your condition has stabilized or three years has elapsed since the accident, you may make an application to your insurer for a determination that the impairment is catastrophic.
Back to the question list 
  36.   What if your injury is catastrophic, as defined by the Insurance Act?
  A.   If your injury is defined as a catastrophic impairment by the Insurance Act you are entitled to a much higher level of medical and rehabilitation benefits and attendant care benefits (a maximum of $1,000,000 for medical and rehabilitation benefits and $1,000,000 for attendant care benefit). These benefits are payable over your entire lifetime.
Back to the question list 
  37.   Can the insurer require me to go to its doctor or other health care worker for a physical or psychological examination?
  A.   An insurance company may not require an injured person to attend an insurance examination (IE) with respect to an application for a benefit that is provided under the pre-approved framework guidelines.
Back to the question list 
  38.   What if you have optional benefits?
  A.   If you have purchased optional benefits from your insurance company, the amount of benefits available to you may be increased. For this reason you must always review your insurance policy and provide a copy to your lawyer to determine if these optional benefits have been purchased.
Back to the question list 
  39.   What steps must you take when claiming benefits?
  A.   You must notify your insurer within 7 days from the date of the accident that you wish to apply for benefits and your insurer must then promptly give you application forms. To avoid delays in processing your application, you must file the completed application forms with your insurer within 30 days after receiving them from the insurer. If you cannot do so within 30 days because of the severity of your injuries, the application must be made as soon as reasonably possible.
     If you are having difficulties recovering the benefits to which you are entitled you should consult with a lawyer. Any lawsuit or arbitration proceeding to enforce the payment of these benefits must be commenced within two years from the time the benefit was terminated or denied.
Back to the question list 
  40.   Do I need a lawyer for my accident benefits?
  A.   The system that has been established to govern accident benefits is technical and complex. It is advisable that you speak with a lawyer with experience in dealing with personal injury matters to assist you in navigating any issues that may arise.
Back to the question list