What are “motor vehicle accident benefits”?

These are benefits that are provided by law to victims of motor vehicle accidents in Ontario, regardless of who is at-fault for an accident. You could be the driver of a car, the passenger, a pedestrian or cyclist who was struck by a motor vehicle.  These benefits are called Statutory Accident Benefits, SABS, ABs or no-fault benefits. They are part of your automobile insurance policy that you have purchased.  

There are 3 injury categories for Medical/Rehabilitation benefits.

Minor Injury: $3500

Non Catastrophic:  $65,000 (medical/rehabilitation and attendant care combined)

Catastrophic:  1 million (medical/rehabilitation and attendant care combined)

In addition to the basic coverage in your policy, you may also purchase additional coverage for your benefits.

Do I automatically get my MVA benefits and how do I apply for them?

No. Your accident benefits are not automatic. You have to apply for your benefits through forms that you request from your insurer. Notify your insurance company/Broker no later than 7 days (or as soon as it is practical for you to do so after the accident) if you want to apply for benefits because there are strict time limits and deadlines that must be met in order to avoid delays or disqualification from obtaining compensation. These forms must be returned to your insurer within a 30-day time limit.  No benefit is payable until the insurance company has received the completed forms.

Fill this application out even if you have benefits available to you through other plans since there will be a limited amount of funding available to you through those other policies. Your automobile accident benefits may make up the difference. It is recommended that a Personal Injury Lawyer review these forms to help with the process.

Who pays for my treatment after a car accident?

In Ontario, your own insurance company is responsible for the cost of accident benefits including med/rehab services regardless if you are found to be at fault or not. If you have any extended health insurance, you must submit your claim to them first and the unpaid or uncovered portion will be picked up by your own auto insurance company. If you don’t have any insurance and are involved in a motor vehicle accident and if you live with your partner, parents or someone who has auto insurance then their insurance may be liable to pay for your cost of medical/rehab expenses and if you live alone then you may be covered by the insurance of the car you were in at the time of the accident or the other car that hit you.

If you have absolutely no insurance coverage, you can seek as a last resort, financial compensation from the province’s Motor Vehicle Accident Claims Fund (MVACF), but it only covers damage to vehicles up to $10,000 and the cap on personal injury claims is $200,000 – Motor Vehicle Accident Claims Act, RSO 1990, c M.41; s. 23(1)

Any accident with more than $1,000 in damages and/or involving injury must be reported to the police, while accidents with minor damage and no injury can be registered at collision reporting centres.

Your Situation / Circumstance Where to Send the Application
You were driving a company vehicle. The insurance company that insures the company vehicle.  
You were a passenger in someone else’s vehicle when injured The insurance company that insures the vehicle you were a passenger in.
You were a passenger in an uninsured vehicle and there was more than one vehicle involved in the accident. The insurance company of an insured vehicle involved in the accident.
You were a pedestrian or cyclist. The insurance company of the vehicle that hit you.
None of the above. The Motor Vehicle Accident Claims Fund (MVACF); see below for more details.

 

http://www.fsco.gov.on.ca/en/auto/mvacf/Pages/default.aspx

Source: http://www.fsco.gov.on.ca/en/auto/brochures/Pages/brochure_claims.aspx#auto

If I apply for “accident benefits” will my insurance premiums go up?

No, your premiums do not go up because you make an accident benefits claim. Ontario has a no-fault motor vehicle insurance system. This means that regardless if you are at fault for the accident or not you access accident benefits from your own insurance company.  Accessing your benefits does not affect your premiums.  

Your premiums may go up if your insurance company determines that you were more than 25% at fault for the accident. Premiums will increase if you are more than 25% at fault and your insurance policy does not provide you with accident forgiveness. This has no bearing on your accident benefits as they are two separate systems.

Source:  https://www.fsco.gov.on.ca/en/auto/brochures/Pages/brochure_claims.aspx

Can I go to any health professional/clinic for services following an MVA?

Yes, you can go to any Ontario health care facility (clinic/practice) and health care provider.  Health care providers assisting Ontarians after an MVA are registered on the HCAI data base. Those providers wishing to direct-bill the insurance company also have a FSCO service provider’s license.

*Service providers without a FSCO license will be billing you directly.

Effective February 1, 2011, every Ontario health care facility (business/clinic/practice) and associated health care provider that submits OCF-18s, -21s and -23s directly to insurers is required to use HCAI to transmit these OCFs. Any OCF-18, -21 or -23 that is mailed or otherwise delivered by health care facilities to insurers directly will be deemed “not received”.  s. 64(7)

What is a “Service Provider”?

A “service provider” is a business that provides specified goods or services (“listed expenses”) to statutory accident benefit claimants for which it submits an invoice through Health Claims for Auto Insurance (HCAI) for payment by automobile insurers. Typically, these businesses are health and rehabilitation clinics, as well as providers of examinations and assessments.

FSCO has regulated the business and billing practices of service providers (businesses that invoice auto insurers for Statutory Accident Benefits). FSCO’s service provider licence authorizes service providers to receive direct payments from auto insurers for specific listed expenses.

(Without FSCO’s service provider licence, service providers must seek direct payment from claimants (MVA victim) for goods and services provided in connection with statutory accident benefits. Claimants will then need to seek reimbursement directly from their automobile insurer.)

Source:  http://www.fsco.gov.on.ca/en/service-providers/faqs/Pages/definition.aspx

http://www.fsco.gov.on.ca/en/service-providers/faqs/pages/about-the-license.aspx

Do I pay for my therapies upfront?

Yes and No.  Under the law in Ontario, it is mandatory to exhaust all other insurance policies first.  This applies to all private and work insurance policies for dental and health benefits as well as short term and long term disability benefit policies.

Yes – If you are accessing your motor vehicle accident benefits and you do not go to a FSCO licensed service provider, “you” (the MVA client) will be personally responsible for paying your practitioner (service provider) for the goods and services (therapies) up front and then you will have to seek reimbursement from your insurance company.  

No – You do not pay for your therapies upfront if you go to a FSCO licensed service provider. Clinics and practitioners who help MVA clients are registered with HCAI, an electronic database that transmits auto insurance Ontario Claim Forms (OCF Forms) between health care businesses and insurers in Ontario.  If the service provider also has a FSCO license, their services are billed directly to the insurance companies.  

The monies available to you are dependent on your injury designation and the “medical rehabilitation” coverage you have chosen on your insurance policy.  

For out-of-pocket expenses, you must submit proof of payment (an original receipt) to your insurer for services rendered in order to be reimbursed. This is done on an “Application for Expenses Claim Form (OCF-6).

Source:  http://www.fsco.gov.on.ca/en/service-providers/Pages/2014-july2-newsletter7.aspx

Source: https://www.fsco.gov.on.ca/en/auto/forms/Documents/SABS-Claims-Forms/1227E.pdf