By: Ronald Carranza
This article was originally published in Mosaic Newsletter for Fall 2018 / Winter 2019.
Since 1990, when Ontario’s no-fault automobile insurance system was introduced, Attendant Care Benefits have been available to injured claimants through the Statutory Accident Benefits Schedule (SABS). The SABS is a regulation under the Insurance Act that delineates entitlement for benefits and the process to obtain benefits for motor vehicle accident victims. The Attendant Care Benefit can be used to pay for “reasonable and necessary” expenses incurred when hiring someone to help care for an injured person after an accident. In order for attendant care benefits to be paid out, an Assessment of Attendant Care Needs Form 1 needs to be completed by an occupational therapist. The Form 1 will determine the amount of time required for attendant care and the monetary amount needed to pay for those expenses.
The laws surrounding attendant care benefits have changed significantly since they were conceived under the SABS and the Insurance Act of Ontario. For whatever reason, insurers and the government have been tinkering with the benefits and changing the laws more often than what would seem necessary. These changes have made it even more difficult for accident victims to navigate the already obscure paths of the Statutory Accident Benefits Schedule.
Although there have been several changes to the SABS regarding attendant care benefits and entitlement, the test to determine entitlement has remained the same: “whether the expense is reasonable and necessary”. Nonetheless, there have been changes in regards to monetary limits. The first change was a reduction, which went from $72,000.00 to $36,000.00 for non-catastrophic impairment. The latest change combines the attendant care benefit with the medical rehabilitation benefit to a maximum of $65,000.00 for non-catastrophic impairment.
If cutting monetary limits was not enough, there is now also the added difficulty that the expenses need to be incurred in accordance with the definition as outlined under paragraph 3(7)(e) of the SABS. Gone are the days when a family member could be entitled to attendant care payments for the help provided to a relative who had been injured in a motor vehicle accident. Although it was a more convenient approach, as it stands now, in order to be entitled to receive payment, the help and aid must be provided by a professional doing it under the course of his/her employment. Lastly, since June 1, 2016, payment for attendant care has been limited to actual expenses incurred. In other words, if the expense incurred for paid attendant care service providers is lower than the monthly amount assessed under a Form 1, then the insurer is liable to pay only for the incurred expense.
Due to of all of the barriers imposed by the insurer and the law, it’s very important to contact a lawyer to help you navigate through the complicated accident benefits system.