Statutory Accident Benefits and Home Renovations
Posted: Saturday, February 14, 2009
by Brenda Hollingsworth
Auger Hollingsworth
If you have been injured in an Ontario car accident or other motor vehicle accident, you probably qualify for accident benefits. These are the no fault benefits that provide basic insurance coverage after an accident.
Injured people, especially those who suffer mobility impairments, often face the challenge of being discharged from a rehabilitation centre, (The Ottawa Rehabilitation Centre, The Ottawa Hospital-Civic Campus or Elizabeth Bruyere, in Eastern Ontario) only to return to their house that cannot accommodate them.
THE STATUTORY ACCIDENT BENEFIT SCHEME
Generally, people injured in Ontario car accidents can receive accident benefits. The benefits are usually paid by their own car insurance company. However, the scheme also provides coverage for people who do not have their own insurance.
Usually, statutory accident benefits are there to replace missed salary, attendant care, rehabilitation and medical needs as well as death benefits.
There is a section in the Accident Benefits regime (section 15) that says that "all reasonable and necessary" rehabilitation expenses are to be paid. The rehabilitation expense is designed to lower or eliminate the effect of the injuries caused by the accident. Workplace adaptations, required changes to any motor vehicle, devices and home modifications are all expenses that could come under s. 15 of the Statutory Accident Benefits which deals with "rehabilitation" benefits.
Housing
The insurance company also states that an insurance company must pay the injured person for all reasonable and necessary home modifications and home devices, including communication aids.
The Accident Benefits regime specifically allows for the purchase of a new home for the injured person where purchasing a new home to accommodate the injured person's needs makes more sense than to renovate his or her existing home. Having said that, the money alloted for the purchase of a home cannot be greater than the estimated cost of any renos that would theoretically be needed to meet the injured person's requirements.
If the existing home is incapable of being modified to accommodate the injured person, the only limit on the amount available to purchase a new home is the policy limits for this category of benefits.
WHAT ARE THE POLICY LIMITS? HOW MUCH DO YOU HAVE TO SPEND?
The medical and rehabilitation benefits are supposed to pay for all reasonable and necessary expenses that arise because of the accident.
Home modification comes under the medical / rehabilitation category.
For the purpose of calculating how much money is available, the medical benefits and the rehabilitation benefits are combined.
If the injured person did not suffer a "catastrophic impairment" as that is described in the Accident Benefit regime, the total amount of the medical / rehabilitation benefit is $100,000 and the benefits expire after 10 years from the date of the accident
If the injured person did suffer a "catastrophic impairment" the medical / rehabilitation benefit increases to $1 Million and last for the person's entire life.
HOW DO YOU GET THE BENEFITS?
You must notify your insurance company that you have had a car accident within 7 days of the accident, or as soon as possible, and you must complete your application for Accident Benefits within 30 days. While it is not fatal to your application if you miss these deadlines by a small margin, you should submit your applications as soon as possible.
Once you have successfully applied to the insurance company for Accident Benefits, the first step to get modifications is to obtain a home-site assessment.
The assessments give down to earth suggestions to assist an person who is injured to lives safely and comfortably, if not ideally, in his or her home. The focus of the assessments is to return the injured person, to the extent it is possible, to a pre-accident level of function as quickly, safely and economically as possible.
Injured people with catastrophic or near catastrophic injuries may require other assessments as well, including a housing accessibility report, an alternative housing report.
The insurance company normally pays for the home-site and work-site assessments if they approve the assessment in advance. To get approval of this type of assessment, the injured party or his or her lawyer has to arrange for the completion of a form called an "OCF-22: Application for Approval of an Assessment or Examination".
Keep in mind that the person conducting the assessment is often not a regulated health professional and therefore will not be permitted to complete the OCF 22. An occupational therapist, a case manager or even a family doctor or physiotherapist can complete the form.
The insurance company will review the OCF 22. If it is approved, the assessment can take place. The assessment will result in a report. After the report is written, another form called a "OCF 18: Treatment Plan" is filed with the insurer, detailing the estimated expense of the suggestions in the report. If the OCF 18 is approved, the work can begin.
ARE HOME MODIFICATIONS PERMITTED FOR NON-CATASTROPHIC INJURIES?
In some situations, the answer is yes. Where the injured person has suffered injuries that cause impairment but are on the less serious end of the spectrum, and if the renovations are not going to be extensive, an occupational therapist will perform a home assessment.
A home assessment is an assessment of the injured person's activities of daily living including from before the accident. This assessment looks at personal care, housekeeping, home maintenance and care giving tasks. The Occupational Therapist also provides a breakdown of any recommended assistive devices, home modifications and simple home renovations in the report. Examples of recommendations in this type of assessment include adding a stair railing, raising or lowering a bed or counter or adding hip-level storage in a kitchen.
If the renos suggested by the therapist are final, they can be filed with the insurer, together with an OCF 18 (Treatment Plan) that expenses the recommendations to get the insurer's approval to proceed.
HOW TO ACCESS THESE BENEFITS FOR CATASTROPHICALLY INJURED PEOPLE
If a person is seriously injured and needs significant home modifications like ramps, additions, elevators, walls moved, a home accessibility report is required.
A report on house accessibility is focussed on the housing requirements of the person injured. The report identifies the client's housing requirements, a description and pictures or drawings of the current home. It also outlines the home modifications and renovations that would be needed to meet the client's housing needs at the current house.
The home accessibility report includes costs as well as plans for the proposed renovations. The report addresses municipal by-laws and construction issues that are generally outside the scope of practice of an occupational therapist.
After the report is ready, and the person who is injured decides to go ahead with a proposed reno, a treament plan (OCF 18) is filed with the insurer to be approved.
There are situations where the renovations to an existing home simply to not make sense. In that circumstance, it can be better to simply purchase a new home for rather than try to renovate the current one.
The choice to purchase a new home versus renovating the current home can be based on some of the following considerations:
*Is the current home a rental or social housing?
* Are the renovations required so extensive that they will exhaust or exceed the policy limits or just not make financial sense?
* Are the renovation not allowed due to municipal restrictions?
* Was the injured person still living with parents at the time of the accident?
* Is the current home to far from required services for the person's disabilities?
The housing benefit under s. 15 of the Statutory Accident Benefit Regulation is one of the largest components of most injured people's AB claim.
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Brenda Hollingsworth and Richard Auger are lawyers representing accident victims in Ontario, Canada. Their law firm is Auger Hollingsworth, located in Ottawa. They are the authors of "An Injured Victim's Guide to Fair Compensation". To get free copy of this book, contact http://www.personalinjuryottawa.ca ; email info@personalinjuryottawa.ca or call 613.233.4529.
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