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Accident Benefits Coverage in Ontario June 2016

Table of Contents If You Are In A Car Accident 2 Weekly Benefits 5 Income Replacement Benefit 7 Non Earner Benefit 9 Caregiver Benefit 10 Medical Rehabilitation and Attendant Care Benefits 12 Other Expenses 16 Lost Educational Expenses 16 Expenses of Visitors 17 Housekeeping and Home Maintenance Benefit 17 Damage to Clothing Glasses Hearing Aids Etc 18 Cost of Examinations 18 Catastrophic Impairments 19 Death Funeral Benefits 20 There is not enough space in this brochure to deal with every detail of the laws covering statutory accident benefits It does not contain all aspects of the auto insurance legislation For the precise wordings of the law you should consult the Ontario Insurance Act and the Statutory Accident Benefits Schedule made under that Act Contact your claims representative if you would like a copy of the Statutory Accident Benefits Schedule If you have any questions about the legislation or how to make a claim contact your claims representative or call the Insurance Bureau of Canada Consumer Information Centre at 1 800 387 2880 or 416 362 9528 in the Toronto area CO C 35 June 2016

If You Are In A Car Accident THERE ARE IMPORTANT FACTS YOU NEED TO KNOW ABOUT ONTARIO S LAWS THAT WILL AFFECT THE ACCIDENT BENEFITS YOU COULD RECEIVE Accident benefits are available to people who suffer disabling physical or psychological injuries as a direct result of a motor vehicle accident that occurs in Canada or in the United States of America If the accident occurs outside of Ontario you may have to elect whether to receive benefits in accordance with the laws of Ontario or in accordance with the province or state in which the accident occurred How Do I Apply For Benefits If you suffer a disabling injury in a motor vehicle accident you must tell your insurer within 7 days of the accident or as soon after that as possible that you wish to apply for benefit payments You must send your application for benefits within 30 days of receiving the application forms Your insurer will supply the forms Failing to notify your insurer within 7 days or failing to return the forms within 30 days could mean that you will lose your right to receive any benefits Where Does My Application Go If you have your own motor vehicle insurance have regular use of a company vehicle or are covered under someone else s policy such as your spouse or parent return the completed application to that insurance company If you don t have insurance return the completed application to the insurer of the vehicle in which you were an occupant or which hit you if you were a pedestrian If there is no insurance on that vehicle return the application to the insurer of any other vehicle involved in the accident If no automobile insurance exists to respond to your claim you may be entitled to receive benefits from the Motor Vehicle Accident Claims Fund MVACF Your claims representative or the MVACF can explain how the Fund works in these situations If you are insured under more than one policy there are special rules that determine from which policy you are eligible to receive benefits Your claims representative can explain these rules Who Is Eligible For Benefits Any person who is injured as a direct result of a motor vehicle accident and certain persons who suffer psychological or mental injuries because of an accident that injures certain relatives or dependants 2

You are not entitled to receive accident benefits if as a result of the accident you qualify to receive benefits under any worker s compensation law or plan There are certain exceptions Your claims representative can discuss these with you What Are The Benefits The following are brief descriptions of the types of benefits for which you may be eligible Some of these benefits will only be available if you have suffered a catastrophic impairment or if you have purchased them as optional benefits For more complete descriptions and to determine if you are in fact eligible for any of the following benefits you should refer to the specific sections of this booklet that deal with that benefit and to the Statutory Accident Benefits Schedule INCOME REPLACEMENT BENEFIT This weekly benefit will partially compensate you for the loss of your income if you are unable to return to work because of your injuries NON EARNER BENEFIT This weekly benefit is payable if you suffer a complete inability to carry on your normal activities because of your injuries CAREGIVER BENEFIT This weekly benefit will reimburse you for expenses you incur if you are unable to continue as the main caregiver for a member of your household who is under 16 or who is over 16 and suffers from a disability MEDICAL REHABILITATION AND ATTENDANT CARE BENEFITS This benefit will pay for reasonable and necessary medical and rehabilitation expenses not covered by a government health plan or by any supplementary health plan you may have This benefit will also pay reasonable and necessary expenses you incur to have an aide attendant or long term care facility help with your personal care Persons who sustain minor injuries are not eligible to receive attendant care benefits OTHER EXPENSES This benefit will pay for other expenses such as lost educational expenses expenses of visitors and the reasonable cost of housekeeping and home maintenance necessary due to injuries sustained in the accident Repairing or replacing certain items lost or damaged in the accident may also be covered DEATH AND FUNERAL BENEFITS There are lump sum payments available for certain survivors of a person killed in an accident and to help pay for the expense of a funeral Payment Restrictions For Certain Benefits You are not eligible to receive income replacement benefits non earner benefits lost educational expenses expenses of visitors and housekeeping 3

and home maintenance expenses if you were driving an automobile that you knew or should reasonably have known was not insured driving without a valid licence driving an automobile under which you were an excluded driver driving a vehicle you knew or should have known you were driving without the owner s consent an occupant who knew or should have known that the driver did not have the owner s consent to drive the vehicle Note Excluded drivers and occupants of vehicles driven by excluded drivers may be able to collect under a policy where they are a named insured convicted of impaired driving exceeding the blood alcohol limit or refusing to provide a breath sample an occupant of a vehicle and convicted of a criminal offence arising out of the use of an automobile in connection with criminal activity at the time of the accident engaged in an act for which you are convicted of a criminal offence or a person who knowingly misrepresented any important information when applying for auto insurance or who intentionally failed to notify the insurer of any change in the risk material to the contract of insurance Your insurance company can terminate the payment of any benefit if you wilfully misrepresent material facts regarding your application for the benefit Requests For Additional Information Your insurance company may need additional information in order to process your application for a benefit When this happens you will be given a written request and a deadline for giving the information to your insurer Penalties may apply if you do not meet the deadline What Are Incurred Expenses The following benefits require that an expense be incurred before any payment can be made Caregiver Medical Rehabilitation and Attendant Care Expenses of Visitors Housekeeping and Home Maintenance and Cost of Examinations An expense is incurred if you can prove all of the following You received a good or service You paid the expense promised to pay the expense or otherwise are legally obligated to pay the expense and The person who provided the goods or services did so in the course of the employment occupation or profession in which s he would ordinarily have been engaged but for the accident or 4

The person who provided the goods or services sustained an economic loss as a result of providing the goods or services It is your responsibility to prove that you have incurred an expense Ask your claims representative what type of documentation you need to submit What Is An Insurer Examination Your insurer has the right to arrange to have you assessed by a regulated health practitioner or vocational rehabilitation expert of its choice This examination is done to help determine whether your injuries entitle you to receive or continue to receive a benefit that you have applied for or to help your insurer determine whether you have sustained a catastrophic impairment Your insurer can reject or stop payment of a benefit if you refuse to attend the examination or refuse to provide relevant or necessary information and documents to the examiner upon request After the examination is completed your insurance company will give you a written notice letting you know whether they agree to pay you the benefit related to the examination or whether they agree that you have sustained a catastrophic impairment You will receive a copy of the insurer examination report What If I Have A Dispute With My Insurance Company If your insurance company believes that you do not qualify or no longer qualify to receive a benefit or if it reduces the amount of your benefit it will notify you in writing If you disagree with the decision you have the right to apply to the Licence Appeal Tribunal Automobile Accident Benefits Service LATAABS for dispute resolution services The first step in the process requires that you file an application within two years of your insurer s refusal or reduction of a benefit An Application by an Injured Person can be obtained from your insurance company or from the LAT AABS To find out more about the Licence Appeal Tribunal dispute resolution services call 1 800 255 2214 or 416 314 4260 from the Toronto area Additional Information And Help If you need help understanding the benefits or your eligibility to the benefits contact your claims representative or the Insurance Bureau of Canada Consumer Information Centre at 1 800 387 2880 or 416 362 9528 in the Toronto area Weekly Benefits If as a result of being injured in a motor vehicle accident you are not able to work or carry on your normal activities as before a weekly benefit may be available to you There are three types of weekly benefits the income replacement benefit the 5

non earner benefit and the caregiver benefit There are important facts you need to know when applying for a weekly benefit This section will help explain the laws concerning the payment of these benefits to people injured in motor vehicle accidents Weekly benefits are available to the following persons People who have been employed Those who have no income non earners C aregivers who suffer a catastrophic impairment because of the accident or to whom the optional caregiver housekeeping and home maintenance benefit applies Disability Certificate Requirement In order to receive an income replacement non earner or caregiver benefit you will be required to provide a certificate from a qualified medical person stating the cause and nature of your injuries with an estimate of how long your disability will last Your insurer will provide you with the certificate and pay for it to be completed The certificate has to be sent with your application form If you send your application without a disability certificate your insurance company does not have to pay you a weekly benefit for any time before the completed certificate is received If your application for a weekly benefit is approved your insurance company has the right to ask that you provide updated disability certificates to determine if you are still entitled to the benefit Insurer Examinations Requests For Additional Information You should review the information on page 5 to help you understand these important requirements If You Refuse Treatment Or Rehabilitation Your weekly benefit payment can be reduced to 0 if you refuse to participate in rehabilitation or treatment that is reasonable available and necessary Which Weekly Benefit Is Right For Me If your application for benefits indicates that you may qualify for more than one of the weekly benefits your insurance company will notify you that you must choose one of the benefits You may only receive one of the weekly benefits during any given time You must advise your insurance company which weekly benefit you wish to receive by signing and returning an election form within 30 days of receiving it Your insurance company will give you this form If your insurance company notifies you that you must choose which weekly benefit to receive you should pay special attention to the fact that the weekly benefit that pays the most might not be the benefit that pays for the longest period of time 6

What follows is an overview of the three weekly benefits Contact your claims representative if you have questions after reading this information Income Replacement Benefit This benefit may be available to you if you were employed or self employed at the time of the accident or were employed just before the accident The benefit provides a payment to partially replace lost income if within two years of the accident you suffer a physical or psychological impairment that prevents you from working as a direct result of the motor vehicle accident You may qualify to receive an income replacement benefit if You were employed or self employed at the time of the accident and your injuries substantially prevent you from completing the essential tasks of your job or You were unemployed at the time of the accident and had been employed for at least 26 weeks during the 52 weeks before the accident or were receiving Employment Insurance benefits at the time of the accident and were 16 years of age or more or were excused from attending school under the Education Act and your injuries substantially prevent you from completing the essential tasks of the job you spent the most time in during the 52 weeks before the accident How Is The Benefit Calculated The policy allows for payment of 70 of your gross income from employment and self employment based on your income history before the accident Included in the gross income calculation are payments received from Employment Insurance before the accident Gross annual income is calculated as follows For persons employed at the time of the accident the gross annual income is based on earnings in the four or 52 weeks before the accident Self employed people have their gross annual income based on earnings during the 52 weeks before the accident or based on their last fiscal year completed before the accident For persons unemployed at the time of the accident and receiving Employment Insurance Benefits or for persons who were unemployed but employed for at least 26 weeks in the 52 weeks before the accident gross annual income is based on earnings during the 52 weeks before the accident Income that you were required to report and did not report for income tax purposes will not be included in the calculation of your gross income from employment 7

From 70 of your gross income will be deducted benefits you receive from other sources as a result of the accident such as employment or private income continuation benefit plans or payments from the Canada Pension Plan Also deductible are certain temporary disability benefits that are received because of a disability you had before the accident If you are able to start back to work after the accident on a part time basis your insurance company can deduct 70 of those gross earnings from the benefit payable How Much Is Payable The maximum payment is 400 00 per week unless you purchased higher benefits before the accident There is no minimum weekly benefit unless your disability lasts for more than 104 weeks If you qualify to continue receiving the benefit after 104 weeks because you suffer a complete inability to engage in any employment for which you are reasonably suited by education training or experience the minimum weekly benefit is 185 Benefits you receive from other sources or plans are deductible from the minimum amount If you are 65 years of age or older benefits are payable for a maximum of four years and the amount of your benefit will be reduced on an annual basis If you are less than 65 years of age and continue to qualify to receive the benefit when you reach age 65 your benefit will be converted to a lifetime pension at a reduced rate When Are Payments Made Benefit payments will begin within 10 business days of your insurance company approving your application If your application is questioned or refused your insurance company will send you a written explanation or a request for more information If your application is approved a payment will be sent to you at least once every two weeks as long as your disability continues to entitle you to receive the benefit Updated medical documentation is required to prove your ongoing entitlement to the benefit Are There Any Restrictions On When Or How Long The Benefit Is Payable An income replacement benefit is not payable For the first week of disability W hen your injuries no longer substantially prevent you from completing the essential tasks of your job This applies during the first 104 weeks of your disability F or longer than 104 weeks of disability unless because of the accident you suffer a complete inability to engage in any employment or self employment for which you are reasonably suited by education training or experience 8

Other Restriction Your income replacement benefit payment can be reduced to 0 if you do not make a reasonable effort to return to work or to obtain other employment for which you are suited once you receive medical approval to do so What If My Injuries Stop Me From Working Again After I Go Back To Work Your insurer will stop paying you an income replacement benefit when you go back to work You can re apply for the benefit if You went back to your job or started another job within 104 weeks of when you first became disabled AND You have to stop working again because of the injuries you received in the accident You must tell your insurance company that you want to re apply for an income replacement benefit within 7 days of stopping work or as soon after that date as possible Failing to notify your insurer within 7 days could mean that you will lose your right to receive any further income replacement benefits Before the benefit can be resumed you will need to give your insurance company medical and other information to confirm that your injuries are the reason you can t work Non Earner Benefit To receive a non earner benefit the accident must cause you to suffer a complete inability to carry on a normal life This means that within two years of the accident you must be continuously prevented from engaging in substantially all of the activities in which you ordinarily engaged before the accident due to a physical or psychological impairment In addition to suffering a complete inability to carry on a normal life at least one of the following situations must apply to you You do not qualify for an income replacement benefit You are at least 18 years of age and a full time student at the time of the accident Y ou are a recent graduate meaning that you completed your education less than one year before the accident but haven t yet secured employment related to your education and training How Much Is Payable The non earner benefit pays a weekly benefit of 185 less the total of all other income replacement assistance if any for the same week 9

When Are Payments Made Your insurance company will let you know whether you qualify to receive this benefit within 10 business days of receiving your application If your application is questioned or refused your insurance company will send you a written explanation or a request for more information If your application is approved benefit payments will begin within 10 business days after expiry of the four 4 week waiting period or after you reach age 18 so long as you still qualify to receive the benefit at that time If your application is approved a payment will be sent to you at least once every two weeks as long as your disability continues to entitle you to receive the benefit Updated medical documentation is required to prove your ongoing entitlement to the benefit Are There Any Restrictions On When Or How Long The Benefit Is Payable A non earner benefit is not payable For the first 4 weeks after the onset of your complete inability to carry on a normal life Before you reach the age of 18 For more than 104 weeks after the accident or If you elected to receive either an income replacement benefit or a caregiver benefit Caregiver Benefit This benefit is only payable if you have suffered a catastrophic impairment or if the optional caregiver housekeeping and home maintenance benefit applies to you This benefit may apply to you if you were responsible for but were not paid for looking after others at the time of the accident The benefit provides reimbursement of your expenses to have someone else provide the care you can no longer provide if within two years of the accident you suffer a physical or psychological impairment as a direct result of a motor vehicle accident All of the following must apply in order for you to qualify to receive a caregiver benefit 10

You must reside with the person s you provided care to You must be the primary caregiver to the person s you provided care to You did not receive any compensation for providing the care The person s receiving the care must be under the age of 16 or must require your care due to their physical or mental incapacity You must suffer a substantial inability to engage in the caregiving activities you engaged in at the time of the accident How Much Is Payable The caregiver benefit will refund your incurred expenses to replace your preaccident caregiving services Payment is limited to up to 250 per week if you cared for one person at the time of the accident If you cared for more than one person expenses of up to 50 per week are payable for each additional person How do I Incur Expenses Please review the definition of incurred on page 4 to help you understand this important requirement When Are Payments Made Your insurance company must first receive all of the necessary completed application forms before a payment can be made If your application or expenses are questioned or refused your insurance company will send you a written explanation or a request for more information If your application is approved benefits are payable within 10 business days of you giving your insurance company written documentation of your incurred expenses Are There Any Restrictions On When Or How Long The Benefit Is Payable A caregiver benefit is not payable For expenses incurred for children after they reach the age of 16 or persons who previously received care due to a physical or mental incapacity F once they no longer require care W hen your injuries no longer substantially prevent you from engaging in the caregiving activities you engaged in at the time of the accident This applies to the first 104 weeks of your disability 11

After 104 weeks of disability unless because of the accident you suffer a complete inability to carry on a normal life Medical Rehabilitation And Attendant Care Benefits There is information you should know about the medical rehabilitation and attendant care benefits if you are injured in a motor vehicle accident and require treatment for your injuries or help with your personal care This section will help to explain the benefits that you may be eligible to receive What Are Medical Benefits Medical benefits are payments for reasonable and necessary expenses not covered by another health plan or other extended health policy incurred as a result of the motor vehicle accident in which you were injured The coverage includes reasonable and necessary expenses incurred for medical surgical dental optometric hospital nursing ambulance hearing and speech therapy services chiropractic psychological occupational therapy and physiotherapy services medication prescription eyewear dentures and other dental devices hearing aids wheelchairs or other mobility devices prostheses orthotics and other assistive devices transportation to and from treatment sessions including transportation for an attendant other required goods and services of a medical nature which your insurer agrees are essential for your treatment NOTE Your insurance company is not obligated to pay for any goods or services that are considered experimental What Are Rehabilitation Benefits Rehabilitation benefits pay for expenses incurred by you or on your behalf provided you have been injured in a motor vehicle accident for costs incurred for reasonable and necessary measures to 12

reduce or eliminate the effects of the disability resulting from your impairment or help you in reintegrating into a family role the labour market if you had a labour force attachment and into your community The coverage includes reasonable and necessary expenses incurred for life skills vocational and academic training family social rehabilitation financial and employment counselling vocational assessments workplace home and vehicle modifications transportation for you and if necessary an attendant to and from counselling and training sessions other goods and services that the insurer agrees are essential for your rehabilitation NOTE The expenses of a case manager are also payable if you sustain an impairment that is defined by the Regulation to be a catastrophic impairment or if you purchased either the optional medical rehabilitation and attendant care benefit for all injuries or the catastrophic impairment option before the accident A case manager is a person who is qualified to co ordinate medical rehabilitation and attendant care goods and services What Are Attendant Care Benefits Attendant care benefits pay for reasonable and necessary expenses you incur because your injuries require you to have someone help you with your personal care activities This benefit pays for the following services provided by an aide or attendant or services provided by a long term care facility including a long term care home or a chronic care hospital How Do I Incur an Expense Please review the definition of incurred on page 4 to help you understand this important requirement How Much Is Payable In Medical Rehabilitation And Attendant Care Benefits The amount payable for medical rehabilitation and attendant care benefits depends on the severity of the injury injuries If your injury is predominantly a minor injury the maximum amount payable for medical and rehabilitation benefits is 3 500 No attendant care benefits are payable for a minor injury If your injury does not result in a catastrophic impairment as defined by the 13

Regulation combined medical rehabilitation and attendant care benefit payments will be up to a maximum of 65 000 with a limit of 3 000 per month payable for incurred expenses for attendant care services If your injury is catastrophic combined benefit payments will be up to a maximum of 1 000 000 with a limit of 6 000 per month payable for incurred expenses for attendant care services If you purchased one of the optional medical rehabilitation and attendant care benefits or the catastrophic impairment benefit option before the accident the maximum amounts payable may be greater Your claims representative can provide you with more information about the optional benefits if one applies to you It is important to know that whichever maximum amount applies it includes amounts paid for assessments examinations and report preparation fees How Long Are Medical Rehabilitation And Attendant Care Benefits Payable If your injury is not catastrophic as defined by the Regulation medical rehabilitation and attendant care benefits are payable for up to 5 years after the accident If you are less than 18 years old at the time of the accident benefits may be paid until you reach age 28 There is no time limit for payment of these benefits if your injury is catastrophic or if you purchased the optional medical rehabilitation and attendant care benefit for all injuries Do I Qualify For Medical Rehabilitation And Attendant Care Benefits It is important to understand that expenses you incur must be as a result of injuries you sustained in the motor vehicle accident as well as being reasonable and necessary With the exception of ambulance fees emergency goods or services provided within 5 business days after the accident drugs prescribed by a regulated health professional goods with a cost of 250 or less per item and initial treatment under the Minor Injury Guideline medical and rehabilitation expenses must be preapproved by your insurance company Your insurance company has the right to refuse payment of all other medical or rehabilitation expenses you incur without its approval You must apply for a medical or rehabilitation expense by submitting a treatment and assessment plan form prepared by a regulated health professional A treatment and assessment plan includes a description of your impairment and of the goods and services recommended It must also indicate whether your impairment is predominantly a minor injury Minor injury is a category of injury described 14

in more detail below Your insurer will respond to the treatment and assessment plan within 10 business days of receiving it If the plan is acceptable your insurer will pay for expenses within 30 days of receiving invoices If any part of the plan is questioned your insurer will advise which goods services assessments or examinations it takes issue with and why and may notify you that they require your attendance at an insurer examination Any medical or rehabilitation coverage or coverage for the services of an aide attendant available to you through other sources such as provincial employment or private health plans must be accessed first before your insurance company is required to pay Any attendant care expenses you incur must be required as a result of the injuries you sustained in the motor vehicle accident as well as being reasonable and necessary To apply for this benefit you must give your insurance company an Assessment of Attendant Care Needs Form 1 completed by an occupational therapist or a registered nurse Information in the form will calculate the amount of the benefit Your insurance company can provide you with the form and will pay for it to be completed It is important for you to know that your insurance company has the right to refuse to pay for any attendant care expenses you incur before you send in a completed Assessment of Attendant Care Needs Form 1 Once it receives your completed form your insurer will let you know if it accepts your application or if it needs you to attend an insurer examination It will begin paying the benefit within 10 business days even if it questions your application If your application for attendant care benefits is accepted your insurer may ask you to submit a new Assessment of Attendant Care Needs Form 1 from time to time You can also submit a new form if your monthly needs change Your insurer can ask you to attend an insurer examination if they question your need for the benefit the amount of the benefit or if you apply to increase the benefit Insurer Examinations And Requests For Additional Information You should review the information on page 5 to help you understand these important requirements Minor Injuries and the Minor Injury Guideline A minor injury is defined as one or more of a sprain strain whiplash associated disorder contusion abrasion laceration or subluxation and includes any clinically associated sequelae to such an injury If your health practitioner determines that your injury is predominantly a minor injury treatment to facilitate recovery and restore function can begin immediately in accordance with the Minor Injury 15

Guideline which sets out the goods and services that will be paid for by your insurer without prior approval However a treatment confirmation form must first be submitted to the insurer unless your insurer has waived the requirement to do so The insurance company will be billed according to a pre determined fee schedule Ask your claims representative if you would like to receive a copy of the Minor Injury Guideline Maximum Fees For Professional Services Expenses for health care services are subject to maximum fees Motor vehicle insurers do not have to pay more than these fees Contact your claims representative if you would like a copy of the Professional Services Guideline or for information regarding maximum rates payable according to the Ontario Medical Association Transportation Expenses Medical and rehabilitation transportation expenses are payable according to a Guideline issued by the Superintendent of Insurance There is a set compensation rate for travel in a vehicle you own lease or have access to There is also a 50 km round trip deductible i e no compensation for the first 50 km of any trip unless the impairment you receive in the accident is a catastrophic impairment as defined in the Regulation Contact your claims representative if you would like a copy of the Transportation Expense Guideline Other Expenses Certain other expenses may be payable to you or on your behalf as a result of a motor vehicle accident What follows is an outline of the process for claiming these expenses and a description of the expenses Lost Educational Expenses This benefit is for people who at the time of the accident were enrolled in an elementary secondary post secondary or continuing education program and as a result of an impairment sustained in an accident are unable to continue the program The benefit covers expenses incurred before the accident for tuition books equipment or room and board to a maximum of 15 000 The expenses must be related to the program that you can no longer continue and for the school term in which you were enrolled at the time of the accident In order to receive a lost educational expense you will be required to supply proof of 16

your incurred expenses and provide a disability certificate from a qualified medical person stating the cause and nature of your injuries with an estimate of how long your disability will last Your insurer will provide you with the certificate and pay for it to be completed Expenses of Visitors If you sustain an impairment as a result of an accident your insurance company will pay for reasonable and necessary expenses incurred by the following people when they visit you during your treatment or recovery your spouse children grandchildren parents grandparents brothers and sisters an individual who was living with you at the time of the accident an individual who you were clearly treating as a child of your family in the case of an injured child an individual who is clearly treating that child as part of the individual s family There is a maximum of 104 weeks after the accident during which these expenses can be claimed unless your impairment is catastrophic as defined by the Regulation Housekeeping and Home Maintenance Expenses This benefit is only payable if you have suffered a catastrophic impairment or if the optional caregiver housekeeping and home maintenance benefit applies to you If your injuries result in a substantial inability to take care of your home as you did before the accident your insurance company will pay for reasonable and necessary additional expenses actually incurred by you to replace your housekeeping and home maintenance services The maximum payable is up to 100 per week Incurred expenses can be claimed for a maximum of 104 weeks after the start of your disability unless your impairment is catastrophic as defined by the Regulation You will have to supply documentation to confirm that you have incurred expenses Your claims representative will explain what is needed Disability Certificate Requirement In order to receive payment of housekeeping and home maintenance expenses you will be required to provide a certificate from a qualified medical person stating the cause and nature of your injuries with an estimate of how long your disability 17

will last Your insurer will provide you with the certificate and pay for it to be completed The certificate has to be sent with your application for expenses If you send your application without a disability certificate your insurance company does not have to pay your housekeeping and home maintenance expenses for any time before the completed certificate is received If your application for housekeeping and home maintenance expenses is approved your insurance company has the right to ask that you provide updated disability certificates to determine if you are still entitled Damage to Clothing Glasses Hearing Aids Etc Your insurance company will pay for reasonable expenses incurred by you to repair or replace clothing you were wearing at the time of the accident and prescription eyewear dentures hearing aids prostheses and other medical or dental devices that were lost or damaged as a result of the accident Cost of Examinations Your insurer will pay for reasonable expenses incurred by you to have an authorized person complete an examination assessment or report or to complete certain claim forms Your insurer will also pay for transportation expenses incurred by you and an aide or attendant in travelling to and from an examination or assessment There is a 2 000 maximum limit per assessment or examination All assessment examination and report expenses are deductible from the maximum amount payable to you for medical rehabilitation and attendant care benefits If your injury is classified as a minor injury no assessments or examinations can be conducted in your home Any coverage available to you through other sources such as provincial employment or private health plans must be accessed first before your insurance company is required to pay How Do I Incur an Expense Please review the definition of incurred on page 4 to help you understand this important requirement 18

Catastrophic Impairments A catastrophic impairment is a serious injury that meets certain criteria outlined in the accident benefit Regulation When it is determined that a person has a catastrophic impairment due to the injuries they received in a motor vehicle accident they are entitled to receive extended medical rehabilitation attendant care visitor and or housekeeping and home maintenance benefits What Is A Catastrophic Impairment According to the accident benefit Regulation you will have sustained a catastrophic impairment if any of the following criteria apply to you because of the accident 1 2 3 4 5 Paraplegia or tetraplegia Severe impairment of ambulatory mobility or use of an arm or amputation Loss of vision of both eyes Traumatic brain injuries meeting certain conditions Mental and or physical impairments alone or combined meeting certain criteria NOTE There are special rules for determining how and when each of these impairments is to be assessed to determine whether there has been a catastrophic impairment How Do I Apply If I Think I Have A Catastrophic Impairment If after reading this information you think that you may have sustained a catastrophic impairment you should discuss this with your health practitioner You can apply to your insurance company for a determination of whether or not the injuries you received in the accident meet the definition of a catastrophic impairment under the accident benefit Regulation Ask your claims representative for an application form Your insurance company will pay for it to be completed Your insurance company will respond to your application for designation of a catastrophic impairment within 10 business days It will advise you in writing if it agrees that your impairment is catastrophic If it disagrees or questions whether your impairment is catastrophic it will give you an explanation in writing and may require you attend for an insurer examination Insurer Examinations And Requests For Additional Information You should review the information on page 4 5 to help you understand these important requirements 19

Death And Funeral Benefits If as the result of a motor vehicle accident you have lost your spouse dependant or someone on whom you have been dependent there are important facts you need to know when applying for survivor benefits through an automobile insurance policy You must notify the insurance company of the deceased person within 7 days of the person s death or as soon after that as possible that you wish to apply for payments The insurer will supply you with the necessary forms and any other information you need You must file your application for payment of death and funeral benefits within 30 days of receiving the application forms Failing to notify the insurer within 7 days or failing to return the forms within 30 days could mean that you will lose your right to receive any payments The insurance company that you apply to may ask you to provide a copy of the autopsy report Where Does the Application Go If the deceased had his or her own motor vehicle insurance or was covered under someone else s policy return the completed application to that insurance company If they did not have insurance return the completed application to the insurer of the vehicle in which the person was an occupant or which hit the person if s he was a pedestrian If there is no insurance on that vehicle return the application to the insurer of any other vehicle involved in the accident If no automobile insurance exists to respond to the claim there may be entitlement to benefits from the Motor Vehicle Accident Claims Fund MVACF Your claims representative or the MVACF can explain how the Fund works in these situations What Are Death Benefits and Funeral Benefits Death Benefits are lump sum payments to you if you have lost a spouse dependant or someone on whom you were dependent Funeral benefits provide reimbursement of funeral expenses up to a maximum amount Do I Qualify For Payments Before you can receive death benefits or reimbursement of funeral expenses under an automobile insurance policy your situation must qualify under the accident benefit Regulation You may qualify for payment of a death benefit if as a result of the accident 20

your spouse or former spouse from whom you were receiving support under a domestic contract or court order or the person on whom you were dependent or a person from whom you were receiving support under a domestic contract or court order or a person dependent on you dies within 180 days of the accident or within 156 weeks of the accident if the injury sustained was continuously disabling during that period The accident benefit Regulation defines spouse and dependant Your claims representative can give you more information about the definitions Death benefits are not payable to a person who dies before the person that is killed in the motor vehicle accident or who dies within 30 days of the person that is killed in the motor vehicle accident A funeral benefit is payable when an insured person dies as a result of a motor vehicle accident This benefit pays the person who incurs these expenses up to the policy maximum How Much Is Payable The amount of the death benefit payable depends on your particular situation 1 If you are the spouse of a person killed in the accident you may be entitled to a payment of 25 000 or 50 000 if the optional death and funeral benefit had been purchased If the deceased person had more than one spouse at the time of the accident this payment will be divided equally among them If the deceased person had no spouse the dependants of the deceased person will be entitled to share the death benefit payment equally 2 In addition if you were a dependant of the person who died or if the person who died was obligated under a domestic contract or court order to provide support to you you will be entitled to a payment of 10 000 or 20 000 if the additional death and funeral benefit was purchased 3 If a dependant died as a result of a motor vehicle accident the 10 000 payment will be made to the dependant s financial support or care provider or in the case that this individual has died to the spouse of the financial support or care provider if the spouse was the primary caregiver of the dependant If the financial support or care provider and spouse do not survive for 30 days after the collision the 10 000 payment is shared by all dependants who survive for these 30 days 21

Funeral expenses are reimbursed up to a maximum of 6 000 or 8 000 if the optional death and funeral benefit was purchased If after reading this you still have questions please contact your claims representative 22

More Information If you would like more information we encourage you to call the following organizations or visit their websites Insurance Bureau of Canada 416 362 9528 Toll free 1 800 387 2880 www ibc ca Financial Services Regulatory Authority of Ontario 416 250 7250 Toll free 1 800 668 0128 www fsrao ca Motor Vehicle Accident Claims Fund 416 250 1422 Toll free 1 800 268 7188 For more information on making a claim through MVACF visit FSCO s Automobile Insurance website at www autoinsurance gov on ca 23

Some information provided courtesy of the Insurance Bureau of Canada If you have any questions about the legislation or how to make a claim contact your claims representative or call the Insurance Bureau of Canada Consumer Information Centre at 1 800 387 2880 or 416 362 9528 in the Toronto area June 2016 24

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