Medical and Rehabilitation Benefits

When you’re involved in a motor vehicle accident, the injuries you sustain can be life-changing. In Ontario, the Statutory Accident Benefits Schedule (SABS) provides a certain amount of no-fault insurance coverage to accident victims. One form of coverage available is medical and rehabilitation benefits, which cover certain treatments that are not paid for by OHIP or private health plans.

SABS, and medical and rehabilitation benefits in particular, can be critical for recovery, returning to work, and restoring a victim’s quality of life. In this article, we’ll explain what medical and rehabilitation benefits are, what they cover, and how you can apply for them when you’re injured.

Although everyone injured in a motor vehicle accident in Ontario is entitled to apply for SABS, sometimes gaining coverage can be tricky. If your insurer is delaying or denying your medical and rehabilitation benefits, Preszler Injury Lawyers can help you access the full support you deserve. Contact us today at 1-888-608-2111 or fill out our online contact form now.

What Are Medical and Rehabilitation Benefits and What Do They Cover?

Medical and rehabilitation benefits are a type of benefit available to injured motor vehicle accident victims in Ontario through the SABS. They are meant to pay for reasonable and necessary goods and services to support your medical recovery and rehabilitation after a collision.

Medical benefits accessible to applicants include:

• Health Services: You may have medical, surgical, dental, optometric, nursing, hospital, or ambulance expenses covered.
• Therapies: Including chiropractic, psychological, occupational therapy, physiotherapy, speech-language pathology, and more.
• Prescriptions: You may have the cost of medication, prescription eyewear, dental devices, hearing aids, and other prescriptions covered.
• Medical Equipment & Devices: Medical and rehabilitation benefits may cover expenses related to wheelchairs, mobility aids, prosthetics, orthotics, or other necessary assistive devices.
• Transportation: If you require transportation to and from treatment sessions, including transportation for attendants, it may be covered by SABS (after a certain distance).
• Other Goods and Services: Any other necessary treatments may be covered so long as your insurer agrees upon them.

Rehabilitation benefits may cover expenses related to:

• Counselling: Including life skills, family counselling, social/rehabilitation counselling, financial counselling, employment counselling, and more.
• Assessments & Training: Vocational assessments or vocational or academic retraining.
• Modifications: Any workplace accommodations, communication aids, home modifications, vehicle modifications, or other necessary accommodations.
• Transportation: Costs related to travelling to counselling/training sessions.
• Other: Any other goods or services essential to your rehabilitation after an accident.

It’s essential to be aware of specific limitations that apply to medical and rehabilitation benefits. According to Ontario’s Minor Injury Guideline (MIG), any injuries sustained in motor vehicle accidents that are deemed “minor” are only eligible for up to $3,500 in coverage.

Non-catastrophic impairments, such as a broken bone, soft tissue injuries (non-minor), or chronic pain or psychological conditions, are eligible for up to $65,000 in coverage for up to 5 years (combined with attendant care). Catastrophic impairments, defined as injuries that result in a significant, lasting impact on an accident victim’s life, are eligible for up to $1,000,000 in coverage, payable over the injured person’s lifetime.

You may elect to pay for optional benefits through your auto insurance policy. In these cases, you may increase your non-catastrophic limit to $130,000 and the catastrophic limit to $2,000,000. Some policyholders may even increase their catastrophic coverage to $3,000,000 with optional purchases.

How to Apply for Medical and Rehabilitation Benefits in Ontario

Although SABS are no-fault benefits, you must still apply to receive them following a motor vehicle accident. Insurance providers may attempt to lower your SABS coverage by disputing whether your treatment is “reasonable and necessary”. At Preszler Injury Lawyers, our Accident Benefits lawyers can help injured accident victims negotiate with insurance companies to obtain the coverage they truly need.

To apply for medical and rehabilitation benefits, you’ll usually need to undergo several steps:

1. Application Process: You or your treatment provider must submit a Treatment and Assessment plan to your insurer, also known as an OCF-18 form. In your plan, you’ll outline what medical and rehabilitation treatments are necessary for your recovery. It must be filled out by a regulated health professional, such as a certified physician, physiotherapist, or other practitioner. Both you and the professional must sign the form, unless your insurer agrees to waive the signature requirement. Any treatment outlined in your plan must be deemed “reasonable and necessary” by your provider in order to be covered.
2. Insurer Approval: Once your OCF-18 is completed, your insurer must approve the treatment plan before any expenses are incurred. If you proceed with treatment before approval is granted, your insurer may not be obligated to pay. There are certain exceptions where prior approval is not required in order for treatment expenses to be covered. These include:
   • Emergency services, such as ambulance fees or urgent hospital care, that took place within 5 days of the accident
   • Prescribed medications
   • Low-cost medical goods that are under $250 per item
3. Case Coordination: If you have suffered a catastrophic injury in your accident, you may hire a case manager to coordinate your care. Costs associated with your coordinator may also be covered by your medical and rehabilitation benefits. For non-catastrophic cases, accident benefits lawyers can help coordinate your doctors, therapists, and insurers to better support your recovery.

It’s important to note the time limits that apply to medical and rehabilitation benefits. For non-catastrophic injuries, your benefits will be payable up to 5 years after your accident occurs. For catastrophic cases, the amount you are insured for will be payable over your lifetime. For minors who claim SABS before they turn 18, benefits will be payable up until the age of 28.

Contact Preszler Injury Lawyers Today For Help Accessing Medical and Rehabilitation Benefits

Medical and rehabilitation benefits exist to help injured people recover and rebuild their lives. Unfortunately, claiming medical and rehabilitation benefits through the SABS can sometimes be challenging. When insurers dispute your care plan or misclassify your injury under the MIG, it can result in denials of treatment, delays in approval, restricted benefits, or underfunding. At Preszler Injury Lawyers, our Ontario Accident Benefits lawyers are committed to helping accident victims get the coverage they need to move forward.

When you work with our firm, we’ll:

• Work with your treatment providers to prepare strong, justified treatment plans
• Challenge insurer denials and advocate for expanded coverage
• Gather medical documentation and evidence to demonstrate the severity of your injuries
• Make sure your optional benefits are maximized where possible
• Provide peace of mind so you can focus on recovery while we handle insurance negotiations
• And more

If your insurer has denied or limited your benefits, or if you’re unsure whether you’re receiving everything you’re entitled to, contact Preszler Injury Lawyers today. Our experienced personal injury team can help you secure the full support you deserve. For a free consultation, call 1-888-608-2111 or fill out our online contact form now.