How to Handle Catastrophic Injury Claims -1-800-JUSTICE®

This video discusses catastrophic impairment as defined under the Statutory Accident Benefit Schedule, outlining the three levels of coverage for accident benefit policies. It clarifies the distinction between injuries and impairments, emphasizing that only specific conditions qualify as catastrophic impairments based on eight defined criteria. Each criterion addresses different types of impairments, including spinal injuries, amputations, vision loss, and traumatic brain injuries, with detailed requirements for qualification. The video also highlights the significant benefits associated with catastrophic impairment, including access to extensive medical treatment and additional financial support for caregiving and home maintenance. For more information, viewers can contact “Preszler Injury Lawyers” at “1-800-JUSTICE”.

A catastrophic impairment is a defined term under the Statutory Accident Benefit Schedule. There are three different levels of coverage under an accident benefit policy. The first level is for minor injuries, the second level is for non-minor injuries and non-catastrophic impairment injuries, and the third category, which is the subject matter of this discussion, is for catastrophic impairment claims.

Catastrophic impairment is a defined term, and many people contact us saying, "Oh, I have a catastrophic injury." However, there is a difference between an injury and an impairment. The Statutory Accident Benefit Schedule, which is the governing legislation that deals specifically with catastrophic impairments, sets out eight criteria under which a person who has sustained a catastrophic impairment can qualify. There are different tests for each criterion, and I am happy to go through those eight criteria because it is important to understand what they are.

The first criterion pertains to paraplegia or tetraplegia, which are self-explanatory. If you have a very severe spinal cord injury that results in paraplegia or tetraplegia, you would qualify under Criterion One. Criterion Two deals with amputations or impairment to a person's ability to ambulate or their mobility. If you lose a limb, or even if you do not lose a limb but the effect of the injury results in your inability to walk or requires the use of assistive devices to walk, that would be a Criterion Two claim.

Criterion Three is a very rare type of claim that deals with the loss of vision in both eyes. To qualify under Criterion Three, you must be blind, and these terms cannot be used in a layperson's sense. There are specific medical tests that determine whether you indeed have a loss of vision in both eyes.

The fourth criterion pertains to individuals over the age of 18 and focuses on traumatic brain injury. There is a two-part test that must be satisfied. First, you must demonstrate positive findings on accepted imaging, such as a CT scan or MRI, which must show evidence of a brain bleed or trauma. A radiologist or a neuroradiologist will interpret these findings. The second part of the test requires a variety of assessments generally conducted by an occupational therapist or a nurse, and a neurologist or qualified physician. They will use the Glasgow Outcome Scale or the Extended Glasgow Outcome Scale. You must satisfy both provisions under Criterion Four to qualify for catastrophic impairment.

Criterion Five applies to children or those under the age of 18 and deals with traumatic brain injuries involving minors. The tests are different, and there are specific criteria that must be met for a Criterion Five claim to be successful.

Criteria Six, Seven, and Eight are where the bulk of litigation stems from. Criterion Six deals with physical impairments, and the law states that these physical impairments must result in what is considered a whole person impairment of over 55%. A physician will use certain tests and methodologies to determine the level of impairment for specific parts of the body. If it totals over 55% whole person impairment, you will be found to be catastrophically impaired.

Criterion Seven deals with a combination of both mental and physical impairments that cause a person's impairment to rise above 55% whole person impairment. Most people's injuries or impairments are a combination of both physical impairments, such as residual issues from broken bones or neurological issues, and mental or behavioral disorders stemming from the accident. If the combined total reaches 55% or more whole person impairment, you qualify under Criterion Seven.

Criterion Eight is the final criterion and applies to mental and behavioral disorders. There are specific tests under this category, which look at four spheres of function: activities of daily living, social functioning, concentration, persistence, and pace, and adaptation in work settings. The purpose of Criterion Eight is to analyze how your mental and behavioral disorders, arising from the accident, impair your ability to function in these areas. The tests have become more onerous for a Criterion Eight case following the June 1, 2016 amendments. You now require three marked impairments or one severe or extreme impairment to qualify.

The benefits of qualifying for catastrophic impairment are significant. Rather than receiving $65,000 worth of treatment, which ends after five years, you can receive up to a million dollars worth of medical treatment and attendant care over the course of your life. This would be considered a lifetime benefit. Catastrophic impairment also opens up other avenues of recourse. For instance, you can receive a housekeeping and home maintenance benefit for life of up to $100 per week for persons who were not working at the time of the accident, or potentially for those who were working but not earning much.

You also have 30 days to re-elect following a designation of catastrophic impairment to a caregiver benefit. For example, if you are a stay-at-home parent with multiple children, you can receive up to $250 for the first child and $50 for each additional child per week. This money is designed to help pay for childcare through a professional service provider.