Motor Vehicle Accident (MVA) claims can be confusing. We get it! With that in mind, we decided to outline the Ontario MVA basics in an easy-to-read way. In this article, you’ll find the essential information you and your team need to know about MVA claims in Ontario including: types of claims, claim coverage amounts, and a guide to common MVA forms.
Ontario SABS coverage
In Ontario, automobile accident injuries are covered under the Statutory Accident Benefits Schedule (SABS) that serve the guideline to the distribution of benefits under a no-fault insurance system. This means a claimant’s injuries are eligible for insurance coverage under the SABS regardless of who was responsible for the accident. If someone does not have their own auto insurance policy but were involved in a motor vehicle accident as a passenger, cyclist, or pedestrian, they are still eligible to make a claim through the insurance company of the vehicle’s driver.
SABS coverage is mandatory for every Ontario auto insurance policy. The 2010 SABS update retired the Pre-Authorized Framework (PAF) and introduced the Minor Injury Guidelines (MIG). That switch brought a number of changes to the motor vehicle claims process and monetary compensation limits. Within the SABS, injuries fall into one of three categories: minor injury guideline (MIG), non-minor injury, or catastrophic impairment. The type and amount of benefits an injured person is eligible for will depend on the level of injuries and which category they fall into.
Types of MVA Claims
Minor Injury Guideline (MIG)
- The MIG outlines a treatment course of 12 weeks and consists of 5 blocks:
- Initial visit: includes assessment, treatment and form completion fee
- Block 1: weeks 1 to 4 consist of treatment phase
- Block 2: weeks 5 to 8 consist of treatment phase
- Block 3: weeks 9 to 12 consist of treatment phase
- Supplementary goods and services block: from weeks 1-12, for additional products and services outside blocks 1-3
- OCF-24 block: week 12 consists of completion of OCF-24 and the discharge report
- Purpose:
- Speedy access to rehabilitation for those with minor injuries from auto accidents
- Improved utilization of healthcare resources
- Certainty around cost and payment for insurers and regulated health professionals
- MIG injuries include:
- Sprain
- Strain
- Whiplash associated disorder
- Contusion
- Abrasion
- Laceration
- Subluxation (when a joint begins to dislocate)
- Clinically associated sequelae (an injury or other health complaints that arises as a result of the initial concern)
- Since the MIG provides for goods and services with a functional restoration approach (getting the injured person to a state of health where they can function), there’s plenty of room for a subjective determination of what that might mean.
Non-Minor Injury
- If the patient’s injuries are outside of the MIG and are not “catastrophic”, then the injuries would be classified as “non-minor injury”.
- In order for a victim to claim higher benefits, they must prove that their injuries are outside of the minor injury classification, or that a pre-existing condition precludes them for the limits of the MIG.
- Compelling evidence is to be provided using the Treatment and Assessment Plan (OCF-18) with attached medical documentation, if any, prepared by a health practitioner. The existence of any pre-existing condition will not automatically exclude a person’s impairment from this guideline.
- If the auto insurer decides that the injuries sustained fall within the MIG, and you disagree, you need to:
- provide the auto insurer with medical documents supporting that the injuries do not fall within the “minor injury” definition, OR
- provide “compelling evidence” from a healthcare provider that the patient is excluded from the MIG because of a pre-existing injury or illness that prevents healing within a normal time frame.
- Not being a “minor injury” as defined by the SABS, or actions by the insurer that entitles the insured to NCAT entitlements, will include:
- Chronic pain
- Concussion
- Psychological impairment
- Pre-existing injury
- Technical breach of the SABS
Catastrophic Impairment (CAT)
- Under Ontario law, there are six injuries that constitute catastrophic injuries in the province:
- Paralysis
- Amputation resulting in loss of entire function of one arm or leg
- Blindness in both eyes
- Severe brain trauma
- A combination of injuries that results in 55% impairment of the victim’s entire person
- Any severe impairment, or three marked impairments, caused by a mental or behavioural disorder
Coverage Amounts
The amount of compensation available will largely depend on the degree of injury (minor, non-minor, catastrophic).
MIG
- MIG limits the amount that a victim can access to $2,200, or, with an extension, to an absolute maximum of $3,500.
- They can also recommend supplementary treatment or certain therapeutic goods that will aid in recovery, such as ice packs, back supports, lumbar rolls, etc. These are also potentially covered by the insurer, but this amount is included in the $3,500 cap.
- It’s also important to note that if a person has extended health benefits privately or through their employer, these are to be accessed first, thus depleting a person’s extended health benefits for the year. The good news is that the amount paid by such extended health benefits is not deducted from a person’s MIG allowable amount of $3,500.
Non-Minor
- Up to $50,000 in medical benefits.
- If the patient’s injuries are non-catastrophic, they are eligible for a combined total of $65,000 for medical and rehabilitation benefits and attendant care benefits. These benefits are available for five years, or until age 28 for minors.
Catastrophic
- If a patient has a catastrophic impairment, they are eligible for a combined total of $1,000,000 for medical catastrophic injury. To cover medical, rehabilitation and attendant care, catastrophic benefits are available for life.
Guide to Common MVA Forms
OCF-18 and OCF-23
- A Treatment Confirmation Form (OCF-23) is completed and submitted by the healthcare provider for patients whose injuries fall within the MIG; for information on how to create and submit an OCF-23 in Universal Office, click here.
- A Treatment and Assessment Plan (OCF-18) is completed and submitted by the healthcare provider for patients whose injuries fall outside the MIG; for information on how to create and submit an OCF-18 in Universal Office, click here.
OCF-1
- An OCF1 is used to open a claim and legally certify that the information provided on the form, about the accident and the injured, is accurate and complete. An injured party must complete and submit the Application for Accident Benefits (OCF-1) to their insurer within 30 days of the accident.
OCF-3
- An OCF-3 is used, in part, as proof that an injured party has suffered a disability resulting from their motor vehicle accident. It must be completed by a qualified healthcare provider.
How to Get Started
Are you new to Ontario MVA claims? Now that you are familiar with 2021 MVA Claim Guidelines, you may want to consider:
- Enrolling with HCAI. All healthcare facilities submitting claims on behalf of a client are required to use the Health Claims for Auto Insurance (HCAI) system for submitting claims to participating automobile insurance companies. The HCAI system is used by the insurance adjusters to adjudicate submitted claim forms and allows the processing of three types of claim forms: OCF-18, OCF-23, and FORM 1.
- Applying for FSCO license. In order to use the HCAI system, each facility is required to have a FSCO license and an active HCAI account.
Check out 10 HCAI & FSCO Links Every Rehab Should Know blog to learn more on this topic.
We hope this article has brought some clarity and will be your go-to guide for Ontario MVA claims. As always, we are here to help. Feel free to access our knowledge base or contact us. Also if you want more detailed assistance with MVA claims in Universal Office, you can book training with one of our instructors on how to create plans, invoices, and more for Ontario MVA patients.
References:
Financial Services Commission of Ontario, Superintendent’s Guideline No. 01/14. [https://www.fsco.gov.on.ca/en/auto/autobulletins/2014/Documents/a-01-14-1.pdf]. Accessed October 3, 2021.
Rooz Law Professional Corporation, Minor Injury Guideline and What It Means to You. [https://roozlaw.ca/minor-injury-guideline-and-what-it-means-to-you/]. Accessed October 3, 2021.
aha insurance, A closer look at accident benefits in Ontario and what they cover. [https://www.ahainsurance.ca/car-insurance/accident-benefits-ontario/]. Accessed October 3, 2021.
Rupa Karyampudi, Motor Vehicle Accidents 101: Overview of Ontario Law. [https://www.mkdisabilitylawyers.com/blog/motor-vehicle-accidents-101-overview-of-ontario-law/]. Accessed October 3, 2021.
Blaney McMurtry LLP, An Introduction to Handling MVA Claims in Ontario. [https://www.blaney.com/articles/an-introduction-to-handling-mva-claims-in-ontario]. Accessed October 3, 2021.
Financial Services Regulatory Authority of Ontario, After an Accident: Understanding the Claims Process. [https://www.fsrao.ca/consumers/auto-insurance/after-accident-understanding-claims-process]. Accessed October 3, 2021.
