Injuries are, unfortunately, a common occurrence in serious motor vehicle accidents. However, not all injuries are equally severe. Some injuries are minor and only require a little time to heal. Other injuries are more severe, requiring a lifetime of exceptional help or treatment. These devastating injuries are known as catastrophic injuries. If you or a family member suffers an injury in a motor vehicle accident, you are entitled to Accident Benefits through the Statutory Accident Benefits Schedule (also known as “SABS”). To qualify, you will need an OCF-19 Application for Designation of Catastrophic Impairment form. “OCF forms” are also known as the Auto Insurance Benefit. We outline what a catastrophic impairment is and advise on how to submit an OCF-19 form. Additionally, we provide a brief overview of the benefits for which you may be eligible.
What is a Catastrophic Injury or Impairment?
Catastrophic injury or catastrophic impairment refers to the most severe level of injury that you sustain in a car accident. This type of impairment is detailed in the SABS. To fall into this category, your injuries must meet one of several criteria that are set out in the legislation. If you fall into this category, your medical rehabilitation and attendant care needs are typically funded up to $1 million for your lifetime. However, you do have the option to increase this to $2 million in your auto policy as an add-on.
A catastrophic injury is a physical injury or illness that is extreme or particularly serious. Additionally, it has a considerable impact on the victim of the injury or illness and requires a substantial amount of medical treatment. These impairments have the most significant impact on your ability to function normally. They typically impact your performance of day-to-day activities and social interactions. Additionally, the physical and psychological effects usually result in a diminished quality of life. Catastrophic injuries may not always be permanent but can take months (or years) to heal.
What is an OCF-19 Form?
To be “catastrophically impaired”, your auto insurer requires the completion of an OCF-19 Application for Determination of Catastrophic Impairment. This form must be completed (in full) and sent to your auto insurer. Based on this application, your insurer may designate you as someone with a catastrophic impairment. This form is commonly known as a CAT application. To view the OCF-19 form, click here.
What Constitutes a “Catastrophic” Injury?
While there are eight categories of impairments in the FSCO guidelines, here is a simplified list:
Paralysis
Either paraplegia or quadriplegia that leaves you unable to use some (or all) limbs or torso. This condition can manifest as a result of a catastrophic spinal cord injury.
Amputation
The amputation must result in the complete loss of function of an arm or leg.
Vision Loss
Total loss of vision in both eyes.
Severe Brain Impairment
Must result in 55% impairment, which would be a catastrophic brain injury.
Mental or Behavioural Disability
Must result in 55% or more of impairment in three or more functional areas.
The complete criteria can be found in Section 3.1(1) of the SABS, which is also available here.
Who is Entitled to These Benefits?
If the injury occurs as a result of a motor vehicle accident, you are eligible to claim statutory Accident Benefits. These benefits can be against your insurance policy or the policy of a driver involved in the accident. Anyone who suffers injuries in a motor vehicle accident may claim AB, including pedestrians, cyclists, motorcyclists, snowmobilers, and/or vehicle passengers. You are eligible for these benefits, regardless of whether you were at fault in causing the accident.
Incidents That Most Often Result in Catastrophic Injury
- Motorcycle accidents
- Cycling-motorist accidents
- Pedestrian-motorist collisions
- Car accidents
- Boating accidents
- Slip, trip and fall accidents
- Medical malpractice
Catastrophic injuries can result from a variety of factors. If your limb is crushed or you are hit suddenly in the head, a devastating injury may result.
Benefits Available to Accident Victims with a Catastrophic Impairment
If you suffer from catastrophic injuries as a result of a collision, you may be entitlement to the following benefits:
- Medical and rehabilitative benefits of $1,000,000
- Attendant care benefits of $6,000 monthly, $72,000 annually (additional top-up possibilities available)
- Income replacement benefit (pays 70% of gross income, up to $400 weekly for the first 104 weeks, after 104 weeks, the greater of that IRB/ $185 weekly, adjusted for age 65+)
- Non-earner benefit (for persons who don’t qualify for income replacement, such as full-time students)
- Caregiver benefit: Up to $250 weekly per dependent, plus $50 weekly for individual dependent.
- Lost education expenses: Up to $15,000 for incurred costs that are suspended due to injury
- Housekeeping and home maintenance benefits: Up to $100 per week for catastrophic injuries
- Visitor’s expenses
- Death expenses for family members (including $25,000 for a spouse and $10,000 for each child)
- Funeral expenses for family members (up to $6,000)
Who Can Complete the OCF-19 Application?
A physician is to complete the majority of your OCF-19 form. Sometimes, it is beneficial if your family doctor fills out the form. However, you will eventually have to hire a paid medical expert to provide a comprehensive medical-legal report. Oftentimes, family doctors are trusted as impartial physicians and, therefore, make good candidates when filling out this form.
Medical personnel who can complete the form are:
- Physicians
- Neuropsychologist (in the case of traumatic brain injuries)
- Occupational therapist
- A Speech Language Pathologist, who may assist in assessing impairment of a traumatic brain injury
- Psychologist
FYI: An occupational therapist and psychologist may be particularly helpful where the injury that forms the basis of the application is a mental or psychological impairment.
Who Determines if I Have a “Catastrophic” Injury?
Ultimately, the designation of a catastrophic impairment in Ontario is made by your insurance company. That said, the documentation given by your medical care providers will have an enormous impact on your chances. Some injuries are automatically deemed catastrophic upon receiving the OCF-19, such as a paraplegic, amputee, or a child with a brain injury. Other injuries, such as a traumatic brain injury in an adult or a person claiming to have a 55% “whole person impairment”, may require that you wait two years or more before submitting an OCF-19.
Once the OCF-19 form is given to your auto insurer, they can accept the application and deem you catastrophically impaired. In most instances, the insurance company will require you to attend a series of medical assessments to determine whether the criteria for catastrophic impairment have been met. If the medical assessments, conducted under Section 44 of the SABS, determine that the requirements have been met. In that case, your insurer must designate you as catastrophically impaired and begin providing you with the benefits above.
What If My Insurer Does Not Find My Injuries Catastrophic?
If these assessments are found to be non-CAT, you can dispute them. You can do so by hiring your experts and obtaining your reports. You can proceed with an application to the License Appeal Tribunal for dispute resolution. An adjudicator at the License Appeal Tribunal will decide whether the criteria are met. That is unless the parties resolve it before a hearing.
OCF-19: Should I Pursue a Catastrophic Designation?
OHIP-funded health care for individuals who have been seriously injured in a car accident can be insufficient. As OHIP does not cover treatment by physiotherapists, massage therapists, speech-language pathologists, occupational therapists, or psychologists, your out-of-pocket expenses can be substantial. Additionally, OHIP does not cover the cost of medication, assistive devices, or home modifications, such as ramps and stair lifts.
OCF-19: Final Thoughts
The consequences of a serious injury can be life-long and potentially cause bankruptcy. Accident Benefits are meant to supplement OHIP and provide you with financial and emotional peace of mind. Maximizing the resources available to you will enable you to function as effectively as possible in your home and society.
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