How to Navigate Ontario's Accident Benefits System
The accident benefits system in Ontario is likely not something you've ever thought about, because why would you? But if you've been in an accident and now suddenly find yourself needing to navigate this process, we've got you covered. In this article, Joshua Goldberg, Toronto personal injury lawyer and Lawggle member, breaks down each of the forms you're going to come across so you know what to expect from the Accident Benefits System.
The Accident Benefits System in Ontario
When clients come to us, most already have an open accident benefits claim, and for the first year following their accident, they are heavily involved in the accident benefits process. As much as we try and manage the process for you, it can be challenging to learn how this strange system works when even lawyers like me take years to fully understand it. It’s a daunting task! This article is here to help demystify some of it, especially the many forms that most claimants will need to know - complete with links to each of the current forms.
The first form that you need to know about is the Application for Accident Benefits - aka the OCF-1. This form must be filled out for every accident benefits claim.
Even though your accident benefits insurer may open a claim for you immediately following the accident, you will still need to complete this application form. We try to make this process more manageable for our clients by working with you to fill it out on your behalf. Then after you sign it, we'll also send it right to the insurer for you.
This is a form that only needs to be filled out if you are claiming Income Replacement Benefits. If you are employed and have had to stop working due to injuries sustained from your accident, you are eligible to claim Income Replacement Benefits.
This form needs to be completed for the most part by your employer, but to assist you, we usually send the form to your employer for you, and we can provide them with any guidance needed in completing it.
Virtually all accident benefit cases require a Disability Certificate. This is a form that needs to be done by a treating physician or by one of your qualified treatment providers. The Disability Certificate sets out your injuries and indicates what activities you are disabled from doing.
Most clinics and physicians experienced with Accident Benefit claims will know what to do. Often they will even get the ball rolling themselves, but my job as an experienced personal injury lawyer is to work with them to make sure it’s being dealt with for you claim.
This is a form many clients will find useful. Any expense a claimant incurs due to the accident, whether the expense is for the benefit of their rehabilitation or was caused by the accident, either directly or indirectly, can be claimed back through these claim forms. That means any out of pocket expenses for treatment, but also things like transportation, caregivers, housekeepers, or even expenses paid to replace things that may have been damaged in the accident, like your glasses or clothing! You can also claim financial losses, like lost education expenses.
To make the process as simple as possible, we have all our clients send us their expense receipts, and we put the form together for you. We can submit it on your behalf so you can focus on your recovery.
These are the forms clinics or physicians use to outline treatments and assessments for your insurer in order to get them approved for you. The form lays out the treatment or assessment requested, the details of how much each service costs, and why the provider thinks it’s reasonable. In response to these treatment plans, insurers send OCF-9s to either approve or deny the coverage for the treatment requested.
OCF-18 forms are almost always prepared by the treatment provider and signed by the client. Your personal injury lawyer's job is to work with your treatment providers to make sure they are providing you with the best treatment options possible.
The Explanation of Benefits form is used by the insurance company. They send it to you to confirm approval (or denial) of any benefits you've claimed, most often in response to the treatment plans submitted by treatment providers, but OCF-9s are also used to explain the results Income Replacement Benefits or Attendant Care Benefits claims. These forms are only sent by the insurance company, so you'll need to understand what the form is telling you, but never need to fill it out.
The form also explains your right to dispute the insurer's assessment, and the steps to take when you wish to dispute. If you've been navigating your claim on your own, and this is the situation you are in, we definitely recommend reaching out to a legal professional for advice.
If you've been in an accident in Ontario, chances are you are going to need to know what all or most of these forms are about. Hopefully this breakdown has shed a little bit of light onto the Accident Benefits System for you. Yes, it's a little dry, but nonetheless important information. When you've been injured in an accident, it is so important to not only have any and all of your losses and expenses paid back to you, but also to be able to focus 100% on your recovery! This is where a good legal professional can make all the difference. Trust us, you don't want to end up losing out on what you deserve.