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What does it mean to have a Catastrophic Impairment?

Wednesday, January 22, 2020

According to the Statutory Accident Benefits Schedule (“SABS”) – the no-fault auto accident insurance benefits are available to anyone injured in a car accident in Ontario, subject to certain limitations.

 

The “SABS” determines how much funding that is available to you for any medical rehabilitation treatment, based on the severity of your injuries using a three-tier guideline, that is as follows:

 

Minor Injury Guideline - individuals with “minor injuries” (defined as whiplash-related injuries, muscular strains/sprains, contusions and lacerations), this tier entitles an injured person to $3,500 for any medical rehabilitation treatment they require;

 

Non-Catastrophic Impairmentindividuals that have injuries and impairments, which neither fits the defined criteria for a minor injury or that of a catastrophic impairment. This tier provides up to $65,000 of medical-rehabilitation and attendant care funding, lasting up to five years;

 

Catastrophic Impairmentindividuals with an impairment that is a catastrophic impairment covers their medical-rehabilitation and attendant care needs, this tier funds up to $1 Million for their lifetime. Certain other benefits are also increased, extended or made available.

 

Catastrophic Impairment is determined if an insured person sustains the impairment in an accident that occurs on or after June 1, 2016 and the impairment results in any of the following:

 

  1. Paraplegia or tetraplegia that meets criteria;

 

  1. Severe impairment of ambulatory mobility or use of an arm, or amputation that meets includes specific criteria;

 

  1. Loss of vision of both eyes that meets specific criteria;

 

  1. Traumatic brain impairment is defined using specific criteria including the GOS-E for adults:
    1. Vegetative State one month after accident;
    2. Upper Severe Disability or Lower Severe Disability six months after accident;
    3. Lower Moderate Disability one year or more after accident and brain imaging.

 

  1. Traumatic brain impairment If the person is under 18 years of age: a traumatic brain injury, confirmed by medical imaging, and the person has been admitted into hospital or the person has severely impaired neurological functioning;

 

  1. A physical impairment or combination of physical impairments that result in a 55% or more physical impairment of the whole person using the AMA Guides, 4th edition;

 

  1. A mental or behavioural impairment, that meets criteria of the AMA Guides, 6th edition, when combined with a physical impairment, results in a 55% or more impairment of the whole person;

 

  1. An extreme impairment, in accordance with the AMA Guides, 4th edition that results in a class 4 (marked impairment) in three or more areas of function or a class 5 (extreme impairment) in one or more areas of function that precludes useful functioning, due to a mental or behavioural disorder.

 

The complete criteria can be found at section 3.1(1) of the SABS, legislation.

The above is a summary of the more in-depth explanation within in the SABS. Your health care provider will need to review the complete criteria before coming to a final opinion on whether you are deemed Catastrophically Impaired. Health care providers will often require specialized knowledge and familiarity with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, and an understanding of the Glascow Outcome Scale and the ASIA Impairment Scale.

 

To determine whether you have a catastrophic impairment, a form called an “Application for Determination of Catastrophic Impairment (OCF-19)” will need to be completed by a doctor and/or Neurologist (in case of brain injury) and submitted to your auto insurance adjuster.

 

In some cases, where your injuries are severe, such as paraplegic, amputee, or a child with a brain injury who has been admitted to hospital are automatically deemed Catastrophic once the OCF-19 is received. Other impairments may require a wait time of two (2) or more years before submitting an OCF-19. In most cases, insurance companies will require you to attend a series of medical assessment to assist in determining the criteria for catastrophic impairment is met according to the SABS.

 

However, if the medical assessments have denied that you are catastrophically impaired then you may dispute the decision with your own set of assessments and appeal the decision with an application through the Licence Appeal Tribunal (LAT) that will result in a hearing before an adjudicator. Your lawyer will present supporting evidence at the hearing and you will likely be examined by the insurance company’s lawyer, but the decision will be made by the adjudicator based on the criteria of “Catastrophic Impairment” as set out in s.3.1 of the SABS.

 

The process of determining whether you are catastrophically impaired may sound discouraging but It is important to note that the consequences of these impairments can be a life long battle, burdened by potentially financial and emotional stress. OHIP funded health care for people seriously injured in a car accident are minimal considering the amount of treatment you will likely need ranging from physiotherapy, psychology, occupational therapy, assistive devices, speech language pathology, and/or modifications to your home such as ramps and stair lifts. If you fit the criteria of one of the above-summarized categories for catastrophic impairment it will be a life long journey that could be a financial burden on you without the funding you could be entitled to receive.

 

If you have been seriously injured in a motor vehicle accident, we strongly recommend that you contact our highly experienced personal injury lawyers immediately to ensure your future is protected. At TS Law, there are no legal fees unless you win, and our experienced team of litigators will come to you, if necessary, for a free no obligation consultation, regardless if your injuries have you in the hospital or at home.

Call us today and get your life back on track! Call 905-777-0070 and speak to one of our qualified legal support team members to book your free initial consultation.                  

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