The Accident Benefits Application

The application process is complicated and often overwhelming to anyone not previously exposed to the procedures the SABS regulations have required. Our services will assist the claimant complete the necessary forms and coordinate completion of the needed employer (OCF-2) and physician (OCF-3) forms.

There is responsibility on the insurer from the outset to make benefits available to the claimant. The following case from the Financial Services Commission of Ontario (FSCO) outlines the point;

In the case of State Farm Mutual Automobile Insurance Company and L.F., (FSCO P02-00026, June 3, 2004), Director's Delegate Makepeace considered the insurer's obligation under section 32 of the Schedule. She held that once an insurer receives an application for accident benefits, it "... is expected to adjust the claim and determine what benefits may be available based on the information received. The process is designed to ensure that an unsophisticated claimant receives the appropriate benefits. The SABS is clear about this. The insurer bears the obligation to provide sufficient information to enable the consumer to claim benefits." In my view, the insurer's obligation includes assisting a claimant to gain access to an enhanced level of benefits.

In practice however, insurers often provide a standard letter to the insured outlining what benefits are available to them. Note that the decision quoted above discusses the insurer's obligation "based on the information received". It is therefore of great importance that the application be as complete as possible in order to assist the insurer in managing the claim. Often delays in provision of services or benefits are caused by the injured party(s) not understanding that the application must be completed as soon and as completely as is reasonably possible.

Family members may be eligible for benefits and support for issues caused by the accident. In each persons case a full application, including medical support for the need of benefits or interventions must be completed.


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