The most serious types of motor vehicle accidents in Ontario are referred to as “catastrophic“, or “CAT” cases.
Just because the accident is bad, doesn’t necessarily make that the accident is “catastrophic“.
Just because the injuries are serious, also doesn’t make the accident “catastrophic“.
The term “catastrophic” carries a very specific medico-legal definition. It’s a term of art. This definition has been tinkered with throughout the years, over and over again. That’s how important it is for any car accident case.
Currently, in Ontario, in order for your car accident case to be defined as “catastrophic“, your doctor or specialist must find on an OCF-19 Application for Determination of Catastrophic Benefits Form which certifies that your injuries meet one of the following criteria:
1. Paraplegia or Tetraplegia;
2. Severe impairment of ambulatory mobility or use of an arm, or amputation;
3. Loss of Vision of Both Eyes;
4. Traumatic Brain Injury (applicant 18 years of age or older at the time of the accident);
5. Traumatic Brain Injury (applicant under 18 years of age at the time of the accident);
6. Physical Impairment or Combination of Physical Impairment which results in 55% or more of whole person (see “Additional Criteria” below);
7. Mental or Behavioural Impairment, Excluding Traumatic Brain Injury, Combined with a Physical Impairment which results in 55 percent or more impairment of the whole person. (see “Additional Criteria” below); and/or
8. A Class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning or a Class 5 impairment (extreme impairment) in one or more areas of functioning, due to mental or behavioural disorder (see “Additional Criteria” below).
Analogous Test – If the insured person is under the age of 18 at the time of the accident and the insured person’s impairment can reasonably be believed to be a catastrophic impairment for the purposes of item 6, 7 or 8 of the above criteria, the impairment shall be deemed to be the impairment referred to in item 6, 7 or 8 of the above criteria that is most analogous to the impairment, after taking into consideration the developmental implications of the impairment (see “Additional Criteria” below).
Additional Criteria Item 6, 7 or the Analogous Test of the above criteria apply to the applicant because: two years have elapsed since the accident; or an assessment conducted by a physician three months or more after the accident determines that, 1. the insured person has a physical impairment or combination of physical impairments determined in accordance with item 6, or a combination of a mental or behavioural impairment and a physical impairment determined in accordance with item 7 that results in 55 per cent or more impairment of the whole person, and 2. the insured person’s condition is unlikely to improve to less than 55 per cent impairment of the whole person.
Item 8 or the Analogous Test of the above criteria apply to the applicant because: two years have elapsed since the accident; or a physician states in writing that the insured person’s impairment is unlikely to improve to less than a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning, due to mental or behavioural disorder.
As you can see, not every car accident or injury will meet the definition of “catastrophic“. This definition is also very complicated. Why did they make it so complicated? Our take is whenever insurers lobby government hard enough to make something difficult to attain, the more complicated it becomes.
But once an accident has found to be “catastrophic“, things will change when it comes to your entitlement to accident benefits:
Regular Claim = $65,000 combined total for med/rehab & attendant care benefits ($3,500 med/rehab limit if the claim falls in the Minor Injury Guideline)
Catastrophic Claim = $1,000,000 combined total for med/rehab and attendant care benefits
Regular Claim = No Case Management Services except under special circumstances
Catastrophic Claim = Case Management Services
When there’s a catastrophic claim, there will often be a number of service providers required to assist the injured party on their road to recovery. This can include, but is not limited to a physiotherapist, occupational therapist, social worker, rehab coach, speech language pathologist, psychologist, personal support worker, case manager etc. Often, these services are NOT covered by OHIP. This means that the accident victim will need to pay for them out of their own pocket, or seek to have car insurer, or a collateral benefits insurer pay for these services.
The rehab team can be large for a catastrophic claim. It’s important that all of these treatment providers co-ordinate their services, and share information so that everyone is on the same page with respect to treatment, needs, progress and rehabilitation goals. You don’t want a duplicity of services. Nor, do you want one service provider’s treatment hurting another provider’s services.
When you have a big team, you need a team meeting! This brings everyone to the table, including the accident victim and their lawyer so that everyone can meet face to face and discuss an action plan along with progress on the case thus far. Team meetings are important not only to co-ordinate services, but also to game plan what future services ought to be so that treatment is getting steered in the right direction. Our personal injury lawyers also like putting a face to the name of the services provider working a file, in case we haven’t met them previously. This builds trust and a greater sense of team work so that the client’s rehabilitation needs and goals are met.
The team meeting can take place anywhere. In a hospital boardroom, at a lawyer’s office, at a client’s home. So long as there’s a quiet place to meet, the team can get together. Coffee and donuts never hurt either!
Will the insurance company attend at a team meeting? Our law firm has had a few catastrophic files where the accident benefit insurance adjuster is very hands on and insists on attending these meetings. This is rare, but it can happen. The adjuster just wanted to know exactly what sort of treatment was being proposed, and wanted to be at the ground level when it came to getting new with respect to the client’s wellness and rehabilitation. On that file, nearly everything got approved for the client with limited hassle from the insurance adjuster. This could have been because the insurance adjuster knew the file very well because she attended at these team meetings.