Articles Posted in Accident Benefits

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Personal Injury Lawyers are familiar with hospitals. Visiting the hospital in order to see an innocent accident victim to conduct a consultation and explain to them their rights is part of the job as a personal injury lawyer. As such, personal injury lawyers get to know the ins and outs and routines at many hospitals. We also see some pretty weird stuff at hospital as well. And these weird occurrences are through no fault of the people hospitalized. It just so happens that hospital can be very strange places. How so you might ask?

For starters, there are no barriers to entry at the hospital. Every Canadian has free healthcare. You don’t have to pay, or pass security in order to get inside of a hospital. As such, you might have people wandering the hallways looking for shelter, a warm bed, pills to steal, supplies like sheets or pillows, or people looking to scam patients who are not at their best. As a personal injury lawyer, I’ve had many clients tell me that while they are staying at hospital, they’ve had strangers approach their bed purporting to be a hospital worker asking for their banking information. I can assure you that hospital staff are not asking patients for their banking information. This doesn’t happen. It can however happen that people with ill intentions enter the hospital trying to defraud or steal patients. While all hospital do have some form of security, it’s never enough to monitor an entire hospital. And, by the time that people have found out that they’ve been stolen from, or defrauded, it’s too late. The focus while staying in hospital is rarely about money or security because hospitals should be (and often are) safe spaces. Rather, it’s about health, recovery, and getting home.

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Ontario has a no fault system of accident benefits if you’ve been involved in a car accident.

Understanding the concept of “no fault” is hard to grasp (even for lawyers!).

You would think that if you’re not at fault, then the at fault driver’s insurer should pay for everything.

But, that’s not how things work in Ontario’s no fault system. We have a first party pays system.

What this means is that regardless of fault, your own car insurer is responsible to pay for accident benefits in your car accident case.

This means that the other driver could have been drunk, high, on his/her cell phone, having run a red light; and still your own car insurer is the primary payor for accident benefits.

Even more strange is that if you had collateral benefits at the time of the accident, such as health, disability or anything else through work; those benefits kick in BEFORE the car insurance benefits kick in. Even though your collateral benefits have nothing to do with car insurance, those collateral benefits must be used up before the car insurer has to pay anything. How does that make sense? It’s like a disability insurer telling you that they will not pay any disability benefits until you’ve purchased 3 lottery tickets to see if you win. In the event you win, then they disability insurer does not pay because you’ve been paid lottery winnings. If you loose the lottery, and only once you’ve lost and submitted proof of losing that they will pay. All of these laws defy logic, but this is how Ontario’s archaic system of accident benefits has been designed.

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If you are injured in a motor vehicle accident, regardless of whose fault the accident is; you are entitled to claim an income replacement benefit of up to $400/week. That income replacement benefit can be increased to $800/week if you purchase an optional rider on your car insurance policy.

The income replacement benefit was automatic if you were an income earner, and if you met the disability test. This means that you needed to show that you made money (hard to show cash income) and that you were too disabled from returning to work.

You did not have to purchase any additional benefits, or pay extra on your policy to qualify for the income replacement benefit. It was part of the standard automobile policy in Ontario.

Even if you didn’t own a car, or have a driver’s license, you were still entitled to claim the income replacement benefit if you were hurt or injured in a motor vehicle accident. That meant that innocent pedestrians, cyclists, or simply those who didn’t drive had the same access to income replacement benefits as those who did drive.

Things are changing when it comes to the income replacement benefit.

Ontario Regulation 383/24 was announced in the Ontario Gazette on October 11, 2024. Beginning on July 1, 2026, the income replacement benefit will now be optional:

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It’s golf season.

People use golf carts on golf courses.

People get injured using golf carts.

Sounds really weird when you put that in writing, but they’re all true statements!

People get injured in very strange, and sometime very serious (often catastrophic) ways in the use or operating of golf carts.

Do I have an explanation as to why this happens? I can put out a few theories:

1. Alcohol. Drinking on the golf course is a thing. Alcohol impairs your judgment. This impaired judgment and liquid courage to do things you normally wouldn’t can lead to disaster.

2. Inexperienced golf cart drivers. There is no driving test to operate a golf cart. Anyone can operate one on the course. It’s not like there are police officers on the golf course pulling people over for their erratic driving

3. Driving on terrain not suitable for a golf cart. Golf carts don’t really operate as a traditional off road vehicle with the large grippy tires, roll bars, or reinforced panelling. They tend to be flimsy buggies, meant to transport people and their golf clubs on relatively even terrain.

4. Speed and erratic driving. The top speed of a golf cart isn’t very fast, but it’s just fast enough to cause serious injury.  They aren’t meant for rolling hills, steep drops, or sharp turns at their top speed. Their centre of gravity isn’t the best, and they’re prone to tip over, unlike other off road vehicles which have a wider base and lower centre of gravity. They aren’t bumper cars, or dune buggies, though people tend to operate them as such.

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For those unfamiliar with personal injury law, and more specifically, the law surrounding motor vehicle accidents (car crashes, motorcycle accidents, pedestrian-car accidents, bike-car accidents), the idea of what the law should be and how it works is perceived to be rather straight forward.

Car accident. Innocent accident victim not at fault. They were in the wrong place, and the wrong time and sustained injuries. Those injuries ought to be compensated by the car insurer for the at fault driver. Case closed.

Unfortunately, that’s not the way things work in Ontario.

We have take an easy to understand event (a car accident) and complicated that event tremendously.  The complexities have been created by the government at the behest of the insurance industry in order to keep the number of car accident claims down; and to limit the compensation available to innocent accident victims.

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I’ve had a few interesting conversations over the past few days with some very thoughtful, rational, insightful and logical people. These people are not lawyers. They have no skin in the game when it comes to the field of personal injury law. That means that they are neither lawyers, insurance adjusters, service providers, doctors, or lobbyists. It’s always nice to get someone’s perspective on the law, and how they perceive it works (or doesn’t) from an “outsider“.

For whatever reason, they were thinking about how the law worked in Ontario. And, in particular, how auto insurance claims worked. They were thinking along these lines because recently, a friend or family member had either been involved in a serious car accident, or something bad happened to their car which required that they get the auto insurer involved.

All of their experiences shared some common threads.

For starters, the people didn’t understand why the insurance claims system was so complicated. Why did the system need to be so complex, with so many hard to understand forms? It was like you had to have a law degree or some expertise in personal injury just to get the insurer to approve a benefit. And just because a benefit was deemed approved, does not necessarily mean that the money would be flowing in a timely manner.

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It may be your first time being involved in a serious car accident where you have sustained serious injuries. These are not common events. And because these are not common events, few people know exactly what to after the accident, or how to deal with their car insurer.

The purpose of this edition of the Toronto Injury Lawyer Blog is to provide you with quick tips dealing with your Car Insurance Company after a serious collision.

1.You deal with your own car insurer first. Ontario  has a no fault system of accident benefits for car accident cases. That means that regardless of fault, the first insurer you will deal with is your own insurer. This seems counter intuitive, but this is how the law works. So, the at fault driver could have been drunk driving, high on drugs, texting on his phone, and ran multiple red lights. It does not matter. The first insurer you will deal with is your own insurer regardless of fault. Weird huh!

2. Watch what you say to the insurance adjuster. When you call most insurers, there is a recorded message saying that the call will be recorded for training and customer service. The call is being recorded so that if you put your foot in your mouth, and say something which is helpful to the insurer, but hurtful to your case; it can and will be used against you moving forward. Many claimants put their feet in their mouths and cause more harm than good in these recorded phone calls with their insurance adjusters. It’s much wiser to let an experienced personal injury lawyer handle it.

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Some fact patterns regarding car accident cases can’t be made up. I suppose that you could try; but the reality of what actually happened often exceeds the bounds of your imagination. They are often unthinkable scenarios fit for a law school exam.

To be eligible for accident benefits in Ontario, an injured accident victim must prove the incident meets the definition of an accident under subsection 3(1) of the the Statutory Accident Benefits Schedule. An accident is defined as:

“an incident in which the use or operation of an automobile directly causes an impairment …”

The key words here are “the use or operation of an automobile”. Those words have been defined rather broadly. They are largely fact specific.

If the Plaintiff can establish that the incident arose out of the use or operation of an automobile; then the Plaintiff will be eligible to claim accident benefits. Things like an income replacement benefit; an attendant care benefit; and medical/rehabilitation benefits which are not covered by OHIP. These benefits can really help make ends meet; and can go a long way on the road to recovery following a serious accident. If the accident is deemed as “catastrophic”, these accident benefits will exceed $1,000,000 in value. Being eligible for accident benefits is also important because they will be paid out irrespective of fault. That means where the accident is an “act of G-d”, or some strange fluke; or a single vehicle accident with nobody to sue; then the Plaintiff regardless of fault will be eligible for benefits which is very important.

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Everyday, our personal injury law firm receives calls from people who have been involved in car accidents in Ontario.

Some people reside in Ontario.

Other people reside outside of Ontario.

Some accident victims have their own car insurance.

Others have no form of car insurance whatsoever.

Their common connection is that they’ve been involved in a car accident in Ontario; and now; don’t know what to do; or where to turn.

They don’t know the right things to do. They don’t want to do the wrong things either. It’s their first time being involved in a serious car accident and they are looking for answers.

People tell me that they weren’t taught in school how to handle a car accident case with an insurance company. Nor is there any quick and easy book on what to do after they’ve been involved in a car accident. They are right in stating that what to do after a car accident isn’t on the standard school curriculum. But, there is a fast and quick guide on what to do after they’ve been involved in a car accident in Ontario. The Goldfinger Guide to Fair Compensation is a great starting point and it can be found in the link above. Reading the Toronto Injury Lawyer Blog (as you are right now!) is another great resource.

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After a car accident, an innocent accident victim needs care and treatment to recover from their accident related injuries.

Treatment like physiotherapy, massage, chiropractic care and seeing a psychologist are not free. These items are not covered by OHIP for accident victims. If you want any of this sort of treatment, you will either need to pay out for it out of your own pocket, have an insurer agree to pay for it; or work out some deal with the provider that they provide care now; and that someone (you or an insurer) pays for it later. If the insurer doesn’t agree to pay under this last model, you are the one who will end up paying for it personally.

This is when the OCF-18 Treatment Plan comes in to play. This is essentially a permission slip; whereby the service provider puts forth a plan to provide treatment to an injured accident victim at a set rate. The insurer will either approve (or partially approve) for the treatment. Or they will deny it.

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