At Campisi LLP, our dedicated team of accident benefits specialists assist individuals who have suffered catastrophic levels of impairment from a car accident receive the care and support they require and can access under their auto insurance policies. We understand the devastating impact such severe and life-changing injuries can have on your life and the lives of your loved ones. We are here to make sure that you are treated fairly by your insurer.
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If you are a seriously injured car accident victim, the standard “no fault” benefits probably will not be adequate to provide for your ongoing care and rehabilitation needs. You will need to try to claim the enhanced benefits under your policy by proving that you have been catastrophically impaired (CAT). This is a complex process and your insurance company will try to deny your entitlement. You will need a Toronto/GTA personal injury law firm with experts in CAT claims. At Campisi LLP, we are pleased to provide a free consultation. We will communicate clearly to you the issues facing you in your rehabilitation and in seeking a CAT determination.
We are here to answer your questions.
WHAT ARE “NO FAULT” BENEFITS?
“No fault” benefits refer to the accident benefits that you receive from your own insurance company after you have been inured in a car accident. Years ago, if you were injured, you had to try to get payment from the other driver’s insurance company to cover the cost of your treatment, income replacement and other losses. For the sake of efficiency, and in recognition that over time, each insurance company would end up paying about the same in benefits, the “no fault” scheme was introduced. After you have been injured, you notify your insurer and submit an Application for Accident Benefits. They will pay reasonable and necessary amounts for treatment and assessments, income replacement, caregiver or non-earner benefits, attendant care, and housekeeping and home maintenance.
CAN I CONTINUE TO RECEIVE ACCIDENT BENEFITS UNTIL I NO LONGER NEED THEM?
Unfortunately, a limit of $65,000 for treatment, rehabilitation and attendant care (if required) is applied to a standard accident benefits claim. This might seem like a lot of money but it will run out very quickly in a serious claim. If you are approaching this limit and still need ongoing benefits, you will likely have to consider applying for a determination of catastrophic impairment (CAT).
WHAT IS CATASTROPHIC IMPAIRMENT OR CAT?
Catastrophic impairment is a category under the Statutory Accident Benefits Schedule (SABS) of the Insurance Act that applies to a variety of severe and generally permanent post-accident impairments. A CAT designation unlocks entitlement to greatly enhanced benefits. For collisions after June 1, 2016, a claimant can receive up to $1,000,000 in medical, rehabilitation and attendant care benefits, if required. The amount of available attendant care doubles from $3,000 to $6,000 per month.
WHAT ARE THE DIFFERENT WAYS TO QUALIFY AS CAT?
In some cases, a CAT designation can be relatively straightforward following the collision. For example, if an insured person meets the criteria set out in the SABS for any the following impairments they will be deemed CAT:
- paraplegia or quadriplegia (tetraplegia);
- amputation of a leg or severe impairment of walking mobility;
- amputation or total loss of use of an arm;
- loss of vision in both eyes; or
- a traumatic brain injury of sufficient severity.
Two other categories have been established to address situations where it is not possible to identify a single impairment that qualifies as CAT. These are Whole Person Impairment (WPI) and functional impairment from a Mental or Behavioural Disorder (MBD).
WHAT IS A WHOLE PERSON IMPAIRMENT (WPI) RATING?
The WPI rating system assumes a person without any impairment has a WPI of 0%. To meet the CAT threshold, a person’s WPI must be 55% or greater. This percentage is calculated by considering all the various impairments a person has suffered and assigning a percent value to each one.
WHAT IS A MENTAL OR BEHAVIOURAL DISORDER (MBD) RATING?
The MBD rating system evaluates loss of function from a mental or behavioural disorder in four key areas: 1) activities of daily living; 2) social functioning; 3) concentration, persistence and pace; or 4) deterioration or decompensation in work or work-like settings. For collisions after June 1, 2016, a person must experience impairment levels that significantly impede useful functioning (“Marked” impairment) in 3 of these areas to qualify.
WHAT IS THE PROCESS FOR QUALIFYING AS CAT?
If your injuries and ongoing impairment fall within one of the “straightforward” categories, your insurer will often make the CAT determination as part of adjusting your claim. However, because each of the categories sets out criteria to be met, they will put you through testing in all but the clearest cases. For example, vision loss must meet or exceed the following:
- Even with the use of corrective lenses or medication,
- visual acuity in both eyes is 20/200 (6/60) or less as measured by the Snellen Chart or an equivalent chart, or
- the greatest diameter of the field of vision in both eyes is 20 degrees or less.
- The loss of vision is not attributable to non-organic causes.
For many claims, particularly ones based on WPI or MBD, you must apply for a determination of CAT. In response, your insurer will schedule a series of appropriate assessments to determine your impairment level.
WHAT HAPPENS IF MY INSURER DETERMINES THAT I AM NOT CAT?
If the insurance assessors conclude that your impairments do not qualify for CAT under any of the categories, you will have to start a proceeding against your insurer and challenge the assessors’ findings. It is essential that you hire an experienced and decisive personal injury law firm like Campisi LLP to represent you in this complex proceeding. Often, the insurance company will want to settle your claim on a full and final basis rather than proceed to a hearing. We will provide you with clear and prudent advice so that you can determine whether settling is in your best interest.
We are happy to answer any questions you have regarding catastrophic impairment and your accident benefits claim generally.
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