Frequently Asked Questions About Accident Benefits

The system is governed by the Statutory Accident Benefits Schedule (SABS), which sets out what benefits are available and how they are assessed. After an accident, you must apply through your insurer and provide medical documentation to support your claim. From there, the insurer will review treatment plans, income loss, and care needs to determine what accident benefits coverage applies.

While the framework is structured, the process itself is rarely straightforward. Many individuals encounter delays, denied treatment plans, or disputes over how injuries are classified. Understanding how the system works early on can make a significant difference in accessing the benefits you need.

SABS outlines eligibility criteria, coverage limits, timelines, and the process insurers must follow when assessing claims. It also sets out how disputes are handled. While most people are not familiar with SABS when they begin a claim, it plays a central role in determining what benefits are approved and how challenges are resolved.

Depending on your injuries and eligibility, accident benefits coverage may include medical and rehabilitation benefits, income replacement benefits, non-earner benefits, attendant care benefits, caregiver benefits, housekeeping and home maintenance benefits, and other expenses related to your recovery. The benefits available to you will depend on your policy, your medical evidence, and whether your injuries are classified as minor, non-minor, or catastrophic.

The classification of your injuries is important because it affects the amount of coverage available. Minor injuries are subject to lower treatment limits, while non-minor and catastrophic injuries may provide access to more substantial medical, rehabilitation, and attendant care benefits. Because insurers may dispute injury classifications or treatment needs, understanding your options under accident benefits insurance is an important step in protecting the support you are entitled to.

• Minor injuries are generally limited to $3,500 for medical and rehabilitation
• Non-minor injuries provide up to $65,000 combined for medical, rehabilitation, and attendant care
• Catastrophic injuries provide up to $1,000,000 combined for these same benefits

These limits can have a direct impact on your access to treatment and long-term care. For example, individuals with injuries categorized as “minor” may find that funding is quickly exhausted, even if symptoms persist beyond initial treatment. On the other hand, access to higher limits for non-minor or catastrophic injuries often depends on strong medical evidence and proper documentation.

It is also important to understand that insurers may challenge how your injuries are classified, particularly when a claim may move beyond the Minor Injury Guideline or toward a catastrophic impairment designation. These disputes can affect your access to ongoing care, rehabilitation, and long-term support.

In some cases, optional benefits purchased under your policy may increase these limits, but many individuals are unaware of their coverage until after an accident occurs. Understanding how these limits apply (and how they may be disputed) is an important part of protecting your entitlement to accident benefits.

A key point for income replacement benefits is the 104-week mark, which is approximately two years after the accident. Before 104 weeks, the focus is usually on whether you are substantially unable to perform the essential tasks of your pre-accident job. After 104 weeks, the test becomes stricter and considers whether you are unable to perform any work you are reasonably suited for by education, training, or experience.

Insurers may review your claim over time and may reduce, suspend, or terminate benefits if they believe you no longer meet the required test. This is often where disputes arise, especially for people dealing with chronic pain, psychological injuries, cognitive symptoms, or other long-term impairments. For more details, read our blog on post-104 income replacement benefit disputes.

Timelines are critical. Once you receive the application package, you have 30 days to complete and return the forms. Missing this deadline can delay your claim or give the insurer grounds to deny benefits, although extensions may be granted with a reasonable explanation. It is also important to submit medical forms as early as possible, since insurers rely on this information to determine eligibility.

There are also strict deadlines for treatment plans and disputes. For example, insurers must respond to most treatment plans within a set timeframe, but delays often occur if additional information or insurer examinations are requested. If a benefit is denied, you typically have 2 years from the date of the denial to dispute the decision through the Licence Appeal Tribunal (LAT).

Because accident benefits insurance claims depend heavily on documentation, incomplete forms, inconsistent medical reporting, or missed deadlines can significantly affect your access to benefits. Ensuring that your application is accurate, supported by medical evidence, and submitted on time can help avoid unnecessary delays and challenges early in the process.

Key documents often include a Disability Certificate (OCF-3) completed by a healthcare provider, Treatment and Assessment Plans (OCF-18) outlining recommended care, and proof of income through an Employer’s Confirmation Form (OCF-2) if you are applying for income replacement benefits. If you require attendant care assistance from a Personal Support Care Worker (PSW) or a Nurse, you will also require the completion of an Assessment of Attendant Care Needs (Form 1).

The strength of your claim depends heavily on the quality and consistency of your documentation. Insurers rely on medical evidence to determine whether your injuries meet certain thresholds, whether treatment is necessary, and whether you qualify for ongoing benefits. Gaps in medical records, incomplete forms, or inconsistencies between reports can lead to delays, requests for additional assessments, or outright denials.

Because accident benefits insurance claims are document-driven, even small errors or omissions can have a significant impact. Taking a careful, structured approach from the outset can make the process more efficient and reduce the likelihood of disputes later in your claim.

Some benefits, such as initial approvals for basic treatment or income replacement, may be addressed relatively quickly if the documentation is clear and complete. However, more complex claims – especially those involving ongoing treatment, attendant care, or disputed injuries – often take longer. Insurers may request additional medical records, require insurer examinations (IEs), or question whether certain treatments are reasonable and necessary before making a decision.

There are also legislated response timelines. For example, insurers are typically required to respond to treatment plans within a set number of days, but delays can occur if they argue that more information is needed. These delays are one of the most common issues claimants face.

If a benefit is denied, reduced, or not responded to within the required timeframe, you have the right to challenge that decision. All disputes regarding accident benefit disputes proceed to the Licence Appeal Tribunal (LAT), where an independent adjudicator reviews the evidence and makes a binding decision. The LAT process will involve medical evidence and will proceed by way of written submissions and an in-person or virtual hearing.

It is important to distinguish between accident benefits and other types of claims. Accident benefits are due and paid as stipulated by the SABS. For entitlement to income benefits, those are calculated weekly but paid bi-weekly. For medical and rehabilitation treatment, those benefits determined to be reasonable and necessary are paid at the completion of treatment and are usually paid directly to the provider of the treatment. Lump sums, on the other hand, are negotiated between the insurance company and your legal representative.

More often than not, denials of a particular accident benefit results in a dispute which can lead to an arbitration before the LAT which if resolved in your favour will allow for the continued benefit or a payback of a benefit already incurred. However, disputes over benefits can lead to negotiated resolutions before those denials proceed before the Licence Appeal Tribunal.

If you are considering settlement options, it is important to understand the risks involved. You can learn more about this in our blog on the risks of settling your accident benefits claim.

When choosing a lawyer, it is important to consider their experience with accident benefits Ontario claims, their ability to handle insurer disputes, and the level of attention they provide.

Has your lawyer had experience with virtual or in-person LAT hearings?

If your injuries are of the most serious kind, has your lawyer proceeded before the LAT and been successful, especially when handling potential catastrophic impairment claims (CAT)?

Having the right legal support can make a difference in how your claim is managed and resolved.