1. Do I have to be a passenger in an automobile to be eligible for accident benefits?
No. Pedestrians and cyclists are also entitled to accident benefits so long as an automobile was also involved in the accident.
2. Are accident benefits paid automatically after I have an automobile accident?
If your injury meets the threshold, you are entitled to an award of general damages subject to a $44,367.24 deductible. In cases where the general damages amount to $147,889.59 or more, there is no deductible.
3. If I miss the deadline of 30 days can I still apply for benefits?
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.
4. Is the injured accident victim only one covered for Statutory Accident Benefits?
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.
5. What if you have a private insurance policy?
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.
Supplementary Medical Benefits & Rehabilitation Benefits
6. What is your auto insurer required to pay for medical and rehabilitation benefits?
The insurer may be required to pay all of the reasonable expenses incurred as a result of your accident, including:
7. How much are you entitled to receive for medical and rehabilitation benefits?
You are entitled to receive up to $65,000 in (combined) medical, rehabilitation and attendant care benefits for expenses incurred up to 5 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 (combined) medical, rehabilitation and attendant care expenses incurred over your lifetime.
As well, anyone can purchase additional (optional) coverage for combined medical, rehabilitation and attendant care expenses, to provide a maximum of $130,000 in benefits for non-catastrophic injuries and/or $2 Million in the event of catastrophic injury.
8. What do you need to submit to your insurer to obtain a medical and/or rehabilitation benefit?
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.
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.
Attendant Care Benefits
9. Is your insurer required to pay for an aide or attendant?
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.
10. How much can you receive for attendant care?
You can receive up to $3000 per month in attendant care for two years after the accident. If your injury is catastrophic, you can receive up to $6000 monthly to a maximum of $1,000,000 for (combined) attendant care, medical and rehabilitation expenses, and there is no time limit.
11. Can I arrange for my own medical or rehabilitation assessment to determine what treatment I need?
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.
Funeral and Death Benefits
12. Is your insurer required to pay for funeral expenses?
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.
13. Is your insurer required to pay death benefits?
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.
14. How do you qualify for death benefits?
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.
Weekly Income Replacement Benefits
15. When are you entitled to receive weekly income replacement benefits?
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:
16. When can you begin receiving income replacement benefits?
You will not receive income replacement benefits for the first 7 days after a collision. Then, as long as you qualify, you can receive 70% of your gross weekly income (less any benefits you may be entitled to from other insurance policies or employment plans).
17. What is the maximum amount of income replacement benefits you can receive?
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.
18. Can self-employed persons receive income replacement benefits?
Yes. Self-employed persons are entitled depending on their income and expense situation. Usually an accountant will be necessary to determine eligibility and quantum.
19. How long can you receive income replacement benefits?
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.
20. When are you entitled to receive non-earner benefits?
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.
21. What is the maximum amount of non-earner benefits you can receive?
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.
22. When are you entitled to receive caregiver benefits?
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.
23. What is the maximum amount of caregiver benefits you can receive?
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.
24. Can you receive income replacement benefits, non-earner benefits and caregiver benefits at the same time?
No. Only one of the income replacement, non-earner and caregiver benefits is payable for any given period of time.
25. What if I am employed and also a caregiver? Which benefit do I choose?
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.
Stoppage in Weekly Benefits
26. When can the insurer stop payment of your weekly benefits?
Your insurer may stop payment of weekly benefits in the following cases:
27. How will attempting to return to work affect my weekly benefits?
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.
28. When is your insurer not obligated to pay benefits?
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;
Expenses of Visitors
29. Who is entitled to receive payment for visiting expenses that incur while you are injured?
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.
Lost Education Expenses
30. When are you entitled to receive payment for lost education expenses?
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.
31. What is the maximum amount you can receive for lost education expenses?
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.
Housekeeping and Maintenance
32. What is the maximum amount you can receive for housekeeping and home maintenance expenses?
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.
33. How long can you receive payment for these expenses?
Your housekeeping and home maintenance expenses are paid for 104 weeks unless the injury is catastrophic.
34. What other expenses can you receive payment for from your insurer?
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.
35. What constitutes a catastrophic impairment?
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.
36. What if your injury is catastrophic, as defined by the Insurance Act?
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, rehabilitation and attendant care benefits combined). These benefits are payable over your entire lifetime.
37. Can the insurer require me to go to its doctor or other health care worker for a physical or psychological examination?
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.
38. What if you have optional benefits?
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.
39. What steps must you take when claiming benefits?
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.
40. Do I need a lawyer for my accident benefits?
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.
For further information, contact Dietrich Law Office at 519-749-0770.