Injuries are unfortunately a common part of serious motor vehicle accidents. However, not all injuries are equal in severity. Some injuries are minor and only require little time to heal. Other injuries are more severe, requiring a lifetime of special help or treatment. These devastating injuries are known as catastrophic injuries. In the event that you or a family memeber 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 give a brief overview of benefits you may be eligible to receive.
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 do fall into this category, then your medical rehabilitation and attendant care needs are usually funded up to $1 million for your lifetime. However, you do have the option to increase this to $2 million in your auto policy.
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 needs a considerable amount of medical treatment. These impairments have the greatest 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 typically 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?
In order 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. On the basis of 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:
Either paraplegia or quadriplegia that leaves you unable to use some (or all) limbs or torso. This can result from a catastrophic spinal cord injury.
The amputation must result in complete loss of function of an arm or leg.
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 at Section 3.1(1) of the SABS, also found 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. This can be against your insurance policy or the policy of a driver involved in the accident. In fact, anyone who suffers injuries in the 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 be a result of a variety of factors. If your limb is crushed or you are hit suddenly in the head, a catastrophic 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 have entitlement to the following benefits:
- Medical and rehabilitative benefits of $1,000,000
- Attendant care benefits of $6,000 monthly
- Income replacement benefit
- Non-earner benefit (for persons who don’t qualify for income replacement, such as full-time students)
- Caregiver benefit: Up to $250 per week
- 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
- Visitor’s expenses
- Death and funeral expenses for family members (including $25,000 for a spouse and $10,000 for each child)
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 it out. However, you will eventually have to hire a paid medical expert to provide a comprehensive medical-legal report. Often times, family doctors are trusted as impartial physicians, and therefore, make good candidates when filling out this form.
Medical personnel that are able to complete the form are:
- Neuropsychologist (in the case of traumatic brain injuries)
- Occupational therapist
- Speech Language Pathologist, who may provide assistance in assessing impairment of a traumatic brain injury
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 must 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 for the purposes of determining whether the criteria for catastrophic impairment have been met. If the medical assessments – conducted under S.44 of the SABS – determine that the criteria have been met, then your insurer must designate you as catastrophically impaired and begin providing you the benefits above.
What if my insurer does not find my injuries catastrophic?
If these assessments come back as non-CAT, then you can dispute it. You can do so by hiring your own experts and obtaining your own 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.
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 devastating. In addition, OHIP also does not fund medication, assistive devices or home modifications, such as ramps and stair lifts.
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 resources available to you will allow you to be as functional as possible in your home and in society.