Factors Considered When Determining Catastrophic Impairment

Published: July 8, 2014 | Last Reviewed: October 14, 2026

Some motor vehicle accident injuries heal with time and treatment. Others can permanently affect a person’s ability to work, live independently, care for family members, and carry out everyday activities.

In Ontario, however, an injury is not considered a catastrophic impairment simply because it is severe or life-changing. The Statutory Accident Benefits Schedule (SABS) sets out specific medical and functional criteria that must be met before an impairment can be classified as catastrophic.

These criteria include certain spinal cord injuries, severe loss of mobility or use of a limb, loss of vision, qualifying traumatic brain injuries, and physical, mental or behavioural impairments that meet prescribed thresholds.

The distinction matters because a catastrophic impairment determination can significantly increase the medical, rehabilitation and attendant care benefits available to an injured person.

To apply, the injured person generally submits an OCF-19: Application for Determination of Catastrophic Impairment, supported by the appropriate medical assessment. The timing of that application, the evidence required, and the test used will depend on the nature of the impairment.

Keep reading to learn the key criteria for catastrophic impairment, when you can apply for a designation, what accident benefits may be available, and what happens if your insurer challenges the determination.

Key Takeaways: Catastrophic Impairment in Ontario

• A serious injury does not automatically qualify as a catastrophic impairment. The injured person must meet one of the specific criteria set out in Ontario’s SABS.
• Catastrophic impairment criteria include certain spinal cord injuries, amputations or severe loss of mobility or limb function, loss of vision in both eyes, qualifying traumatic brain injuries, and severe physical, mental or behavioural impairments.
• The timing of an application depends on the criterion being used. Some impairments can be assessed relatively early, while the 55% whole-person impairment and severe mental or behavioural impairment tests may require more time and evidence about long-term recovery.
• A person seeking catastrophic impairment status generally applies using an OCF-19. The insurer normally has 10 business days to respond and may require an insurer examination under section 44 of the SABS.
• Standard medical, rehabilitation and attendant care coverage is substantially higher for catastrophic impairments, with up to $1 million in combined coverage under a standard policy.
• If the insurer disputes the catastrophic impairment application, the disagreement may ultimately be brought before the Licence Appeal Tribunal – Automobile Accident Benefits Service (LAT-AABS).

What Are the Criteria for Catastrophic Impairment in Ontario?

Medical professionals assessing the severity of a car accident survivor’s impairments rely on several criteria to make their determinations. Ontario’s Statutory Accident Benefits Schedules (SABS) outline these criteria, and insurance providers use them to determine who is eligible for accident benefits commensurate with catastrophic impairments.

A motor vehicle collision survivor is considered to have sustained a catastrophic impairment if they meet at least one of the following criteria:

• Paraplegia or Tetraplegia
• Severe impairment of ambulatory mobility or use of an arm, or amputation
• Loss of Vision of Both Eyes
• Traumatic Brain Injury meeting the Glasgow Outcome Scale-Extended (GOS-E) criteria
• Physical Impairment or Combination of Physical Impairments (which results in 55% or more of whole person)
• Mental or Behavioural Impairment (excluding Traumatic Brain Injury) Combined with a Physical Impairment (which results in 55% or more impairment of the whole person)
• Marked impairment in three or more areas of function that precludes useful functioning, or an Extreme impairment in one or more areas of functioning due to mental or behavioural disorder

If the survivor of a motor vehicle collision meets any of the criteria above, their physician may recommend that they receive the higher amount of accident benefits available to catastrophically impaired car accident victims.

When Can You Apply for a Catastrophic Impairment Designation?

An injured person who believes their impairment meets the catastrophic criteria can apply to their automobile insurer using an OCF-19: Application for Determination of Catastrophic Impairment.

The timing of that application depends heavily on which catastrophic impairment criterion applies.

Some impairments may be clear relatively early from hospital records, diagnostic imaging, and specialist assessments. Others require more time before the long-term effects of the injury can be assessed reliably. Certain traumatic brain injury criteria depend on a person’s functional outcome at specified points after the accident. The 55% whole-person impairment tests and the severe mental or behavioural impairment criteria can require even more time, because the SABS includes specific timing rules and, in some cases, requires medical evidence that the impairment is unlikely to improve below the catastrophic threshold.

As a result, not every catastrophic impairment claim is ready to be advanced immediately after the collision.

Some applications may be made relatively early, while others are supported only after the person’s medical condition and long-term functional limitations become clearer.

What Accident Benefits Are Available To Catastrophically Impaired Collision Survivors?

Anyone who is injured in a motor vehicle collision should be entitled to no-fault accident benefits, regardless of which party was responsible for causing the collision. However, the amount of benefits available to injured accident survivors is based on each individual’s needs.

These are determined by assessing the severity of the injuries they have sustained and the effects they have had on their overall quality of life.

The minimum amount of benefits available to accident survivors who have sustained minor or non-catastrophic injuries is substantially lower than the coverage offered to catastrophically impaired survivors of motor vehicle collisions.

The available coverage included in basic auto insurance plans is as follows:

• Accident victims who sustained minor injuries might be able to receive $3,500 for medical and rehabilitation benefits.
• Accident victims who sustained non-minor, non-catastrophic injuries might be able to receive $65,000 over 5 years for the combined total costs of medical, rehabilitation, and attendant care benefits.
• Accident victims who sustained catastrophic injuries can receive up to $1 million in combined medical, rehabilitation, and attendant care benefits for life, including up to $6,000 per month specifically for attendant care.

A catastrophic designation also opens up benefits that aren’t available at the non-catastrophic level at all. These include:

• Caregiver benefits of $250 per week for the first dependant who needs care, plus $50 per week for each additional dependant, to help replace caregiving duties the survivor can no longer perform.
• Housekeeping and home maintenance benefits of up to $100 per week, payable for life.
• The services of a case manager to help coordinate care and treatment.

Motorists who have purchased extra insurance coverage could be entitled to higher benefit amounts. To learn more about the coverage available through your individual insurance plan, speak to your insurance broker.

Can Insurance Companies Challenge Catastrophic Impairment Determinations?

Yes. Submitting an OCF-19 does not automatically mean that an insurer will accept that an injured person has sustained a catastrophic impairment.

Once a properly completed OCF-19 is submitted, the insurer generally has 10 business days to respond. It must either:

• determine that the impairment is catastrophic; or
• determine that it is not catastrophic, provide the medical and other reasons for that decision, and advise the injured person if an insurer examination under section 44 of the SABS is required.

An insurer examination, sometimes referred to as an independent medical examination or IME, allows a healthcare professional selected by the insurer to assess whether the applicable catastrophic impairment criteria have been met. The examiner may review medical records, conduct physical, psychological, mental or functional assessments where appropriate, and provide an opinion on the injured person’s condition.

Once the insurer receives the section 44 examination report, it generally has another 10 business days to provide a copy of the report and notify the injured person whether it has determined that the impairment is catastrophic or not catastrophic, together with the medical and other reasons for its decision.

When Do Catastrophic Impairment Claims Get Denied?

The injured person’s healthcare professionals and the insurer’s examiner may reach different conclusions. Disputes can arise over issues such as:

• whether the correct catastrophic impairment test was applied;
• whether the available medical evidence satisfies the statutory criteria;
• whether physical, mental or behavioural impairments were assessed correctly;
• whether impairments were combined appropriately when applying the 55% whole-person threshold;
• whether enough time has passed for a particular catastrophic impairment test to be used; and
• whether the injured person’s condition is likely to improve below the catastrophic threshold.

The injured person bears the burden of providing evidence that the applicable catastrophic impairment criteria have been met.

Depending on the case, this can involve medical records, specialist reports, diagnostic imaging, functional assessments and competing expert opinions.

If the disagreement cannot be resolved, the injured person can apply to the Licence Appeal Tribunal – Automobile Accident Benefits Service (LAT-AABS). The LAT-AABS resolves disputes about an insured person’s entitlement to, or the amount of, statutory motor vehicle accident benefits.

The LAT process can include a case conference and, if the matter does not settle, a hearing before an adjudicator.

Contact Our Catastrophic Injury and Impairment Lawyers For A Free Consultation

A catastrophic impairment determination can have a significant impact on the treatment, rehabilitation, attendant care and other support available to someone who has suffered life-changing injuries in a motor vehicle accident.

These claims can also become complex. Different catastrophic impairment criteria use different medical tests, assessment methods and timing requirements, and insurers may dispute whether those thresholds have been met.

In addition to helping our clients prove their catastrophic impairment determinations to their insurance providers, our catastrophic injury lawyers have combined decades of experience pursuing civil claims against negligent drivers whose wrongful actions led to life-altering injuries.

If someone else’s misconduct behind the wheel was responsible for your collision, you may be entitled to additional compensation.

If your insurer has denied your OCF-19, requested an insurer examination, disputed whether your injuries qualify as catastrophic, or you need help determining the benefits available under your policy, contact Preszler Injury Lawyers online for a free, no-obligation consultation, or call 1-888-608-2111 today to speak with our team.

We’re here to help.