Understanding the Basics of Ontario’s No-Fault Accident Benefit System

Author(s): Darcy R. Merkur

October 24, 2019

Are you one of the many people that have no idea what benefits would be available to you if you were injured in a car accident? If you are confused by Ontario no-fault accident benefits, this article should help.

Anyone injured in an incident involving the use of a car or motorcycle in Ontario is automatically eligible for no-fault accident benefits. There are really no exceptions to this rule.

You qualify for no-fault accident benefits even if you are a cyclist or a pedestrian impacted in any way by a vehicle.

There are some less common situations that may also qualify someone for accident benefits, like some ATV accidents for example. In addition, those with access to their own car insurance can qualify for accident benefits if they are injured in an accident outside Ontario in many circumstances.

The no-fault accident benefit system is designed so that every person injured by a motor vehicle qualifies for some basic benefits. The extent of benefits varies depending on the severity of the injuries.

Categories of Injuries

There are three categories of injuries that govern the extent of benefits available to you, namely: Minor Injuries; Non-Catastrophic Injuries; and a “Catastrophic Impairment”.

The concept is simple in that you will be eligible for benefits to cover all reasonable and necessary treatment along with the care that you may require following an accident, subject to certain maximums. Those maximums change depending on the categorization of your injury. The categorization of your injury could evolve over time so that you graduate from one category to the next. In other words, many people with Non-Catastrophic injuries later are reclassified as having suffered a “Catastrophic Impairment” as their accident-related injuries continue to cause ongoing difficulties and challenges.

The system is not designed to pay for all needed care and treatment, rather it is designed to limit the exposure of the insurance company to certain often inadequate benefit limits. As well, by law, access to these no-fault benefits is secondary to any group health benefits available. This means you must first seek reimbursement from your group health insurer before the motor vehicle insurer is required to cover expenses.

  • For Minor Injuries (like whiplash injuries) a $3,500 maximum applies to cover specific care needs.
  • Those in the Non-Catastrophic category (like concussions and fractures) are eligible for up to $65,000 in treatment benefits.
  • Those who are seriously injured and end up in the Catastrophic Impairment category qualify for up to $1,000,000 in coverage for necessary treatment.

If you were smart enough to purchase optional benefits from your car insurance provider, you may qualify for increased maximums.

The Benefits Are Available No Matter What

It does not matter if you are at-fault or charged with a driving offence, there is always an insurance company that will respond to your accident benefit claim (even if you have to resort to the Motor Vehicle Accident Claims Fund – this fund is available to pay benefits in situations where you do not have access to your own car insurance and you were hit by an uninsured driver or in a hit and run, etc.).

In addition to medical, rehabilitation and attendant care benefits you are eligible for up to $400 per week in income replacement benefits if you were working at the time of the accident and are unable to return to work because of your injuries. If you were not working you may be eligible for a non-earner benefit which is payable at a rate of $185 per week for a short period of time following the accident to people who have suffered a “complete inability to carry on a normal life”.

Other benefits are potentially available in cases of fatality (where funeral benefits of up $6,000 are available as well as death benefits to spouses, children and dependents) and lost educational expenses for people who are unable to return to school because of their injuries from an accident, etc.

Those with Catastrophic Impairments are eligible for housekeeping and home maintenance benefits of up to $100 per week as well as the services of a rehabilitation coordinator called a case manager.

Anyone injured in any way by a motor vehicle should apply for accident benefits by completing various mandatory forms including an Application for Accident Benefit (OCF-1).

You do not need to wait until your insurance company sends you these forms. They are readily available online.

You will be required to submit a Disability Certificate (OCF-3) completed by a treatment provider (usually a family doctor) confirming the extent of your injuries.

If you are unable to work then your employer will complete an Employer’s Confirmation Form (OCF-2) quantifying your income from before the accident so that you can qualify for the up to $400 per week that is available (based on 70% of your gross income from before the accident). Again, you need not wait for these forms to be sent to you as they are all available online.

Accident victims have the ability to sue for their pain and suffering, long-term care costs over and above the amounts available from their accident benefit insurers and any other financial impacts such as lost income, assuming that someone else is at-fault or partially at-fault for the accident.

Victims of serious accidents should speak with a lawyer in relation to a potential lawsuit against the at-fault parties and for assistance with their accident benefit claim.

Darcy Merkur is a highly regarded Ontario trauma lawyer helping accident victims such as pedestrians, cyclists and motorists, who have sustained catastrophic injuries. 

Darcy is one of just four plaintiff’s personal injury lawyers in Ontario recognized as a Certified Specialist in Civil Litigation by the Law Society of Ontario, listed in peer-reviewed publications – Lexpert®, The Best Lawyers™ in Canada and AV pre-eminent Martindale-Hubbell ®. He is also a partner at Thomson Rogers, one of Canada’s Top 10 Personal Injury Law Firms as selected by Canadian Lawyer Magazine. 

Darcy can be reached at 416-868-3176 or by EMAIL.

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