When a person is injured in a motor vehicle accident, the Statutory Accident Benefit Schedule requires the automobile insurer to pay for non-professional health care services (such as personal support and homemaking services, attendant care services, and community support services). These services may be provided at home or in community settings such as supportive housing units, long-term care homes and complex continuing care hospitals.
Typically, non-professional services can be arranged or provided through local Community Care Access Centres (CCACs), long-term care homes or other third-party agencies funded by the Ministry of Health and Long-Term Care (ministry). Clients who may require these services include those with serious or catastrophic physical injuries, closed head or acquired brain injuries and the elderly.
Automobile insurers should arrange non-professional health services for their clients and pay the service provider directly.
It is only after statutory accident benefits have been exhausted, or the level of service required exceeds specified maximums, that the ministry may consider funding these services, subject to assessment of the client and applicable ministry limits.
The ministry's subrogation unit is responsible for monitoring compliance of payment responsibility for persons injured in motor vehicle accidents and who require health services.
The Ministry of Health and Long-Term Care pays for:
- Medical costs (all physician services)
- Hospital services
- Mental health facilities
- Air ambulance
- Several professional in-home health services such as nursing, occupational therapy, physiotherapy, speech-language pathology, social work and nutritional services provided in a range of settings including the home, school or community
- Any other ministry-funded services not covered under the Long-Term Care Act, 1994
Automobile Insurers' pay for:
Community Support Services, such as; Meals and transportation:
- Caregiver support
- Home maintenance and repair
- Social or recreational services
Attendant Care/Personal Support/Homemaking Services, such as;
Assistance with activities of daily living
- Assistance with personal hygiene
- House cleaning, laundry
- Preparing meals
Up to specified maximum limits (e.g. $3000 - $6000 per month and $72,000 per year to a maximum of $1 million if a catastrophic injury for attendant care; $l00 per week for homemaking).
Priority of Payments
When someone is injured in a motor vehicle accident, the priority of payment for health care services is:
- Ministry programs:
- OHIP services
- Professional services arranged or provided through CCACs such as nursing, physiotherapy, occupational therapy, speech-language pathology, social work and nutritional services (subject to eligibility and maximum amounts payable);
- Private supplementary health and disability insurer and private employer plans;
- Automobile insurers (statutory accident benefits available through injured person's own automobile insurance policy);
- Money awarded in a lawsuit;
- Provincial government plans are the last payer for:
- non-professional services arranged or provided through CCACs such as personal support and homemaking services, attendant care services;
- all services and benefits such as vocational rehabilitation and welfare payments, administered by the Ministry of Community and Social Services.
Recovering Health Care Costs
If the ministry has provided services, such as attendant care or personal support and homemaking, (that should have been paid for by the automobile insurer) the ministry will seek reimbursement directly from the automobile insurer.
The automobile insurer should contact the service provider directly to negotiate and pay for services.
What You Can Do?
If your clients' injuries are due to motor vehicle accidents, you should know which organization should be paying for required health care services.
You can help by :
- Knowing which health care services the Ministry of Health and Long-Term Care pays for, and which ones are paid directly by the automobile insurer.
- Ensuring your client has made a claim to his/her own automobile insurer.
- Verifying that your client has contacted the automobile insurer for provision and payment of attendant care, personal support and homemaking services.