OCF-19: TIPS FOR FILLING OUT THE APPLICATION FOR DETERMINATION OF A CATASTROPHIC IMPAIRMENT (ONTARIO)

In the event you or a loved one has been injured in a motor vehicle accident, you are entitled to Accident Benefits through the Statutory Accident Benefits Schedule (also known as "SABS"). There are three categories of Medical and Rehabilitation Benefits and Attendant Care Benefits which are based on the degree of injury you have sustained: catastrophic, non-minor, and minor injury. For the purpose of this article, we will provide an overview of the catastrophic injury application form. These applications are generally referred to as CAT applications. The application for the determination of catastrophic impairment is a complicated and cumbersome task.

There are a number of different ways it can go depending on the way in which your lawyer decides to proceed and depending on your instructions. For instance, your family doctor could fill out the OCF-19. In other cases, it may make sense for a different physician to fill out the OCF-19 such as a hired expert or a neuropsychologist. There is no question, that the CAT determination process is one of the most complicated parts of any claim in the no-fault accident benefits regime.

If you do pursue the OCF-19 being completed, your insurance company will most likely fight against the CAT determination tooth and nail by hiring their own assessors. The insurance company does this because your Attendant Care Benefits and Medical Rehabilitation Benefits increase exponentially if you are found to suffer a catastrophic impairment, which costs them money and affects their bottom line.

Some injuries are automatically deemed catastrophic upon the insurance company receiving the OCF-19, such as amputee, paraplegia, or quadriplegia. A traumatic brain injury in an adult or a person to have a 55% whole person impairment may have to wait two years before submitting the OCF-19.

Download: OCF-19

Determine Whether Or Not Your Injuries Are Catastrophic In Nature

Once an OCF-19 form is submitted to the auto insurance company, they can either accept the application and deem the injured victim catastrophically impaired, or, the insurance company can require the accident victim to attend a series of medical assessments for the purpose of determining whether the criteria for catastrophic Impairment are met. These medical assessments are conducted under section 44 of the SABS and are typically referred to as "section 44 assessments" or “Insurer Examinations”. If these assessments conclude that the criteria have been met, then the insurer must designate the injured victim as catastrophically impaired and extend their benefits to include CAT benefits.

If these assessments come back as non-CAT, then the injured person can dispute this by hiring their own experts and obtaining their own reports. The personal injury lawyer will therefore advocate that your injuries are catastrophic in nature using medical professionals to back this argument up, whereas the insurance company will argue that your injuries do not meet the CAT criteria. An adjudicator at the License Appeal Tribunal will decide whether the criteria are met unless the parties resolve it before a hearing.

The most common criteria that are submitted under an OCF-19 are spinal cord injuries, paraplegia, quadriplegia, amputations of an arm or a leg, loss of vision, traumatic brain injuries and brain impairments, and injuries that together comprise a significant disability and meet a certain threshold of the impairment of the whole person (whole person impairment). There are a number of factors that come into play when assessing whether an injured victim’s injuries are catastrophic. It is not uncommon for the plaintiff’s lawyer to argue that the injuries are catastrophic, and the defendant to argue the contrary, leading to a number of assessments and examinations to follow from both sides.

A personal injury lawyer should be able to offer guidance on how to best go about determining whether the injuries are catastrophic under the most recent Accident Benefits guidelines. There are significant consequences to the OCF-19 determination, particularly, when it comes to the money available to fund an injured person's treatment. It is the duty of personal injury lawyers to advocate for accident victims and fight for the benefits that the insured person deserves.

The Statutory Accident Benefits Schedule (SABS) is always changing and it is important to consult with a personal injury lawyer to understand the status of the criteria to be deemed catastrophic. The criteria below is a summary of the different ways meets the definition of CAT:

1.  Paraplegia or tetraplegia;
2. Severe impairment of ambulatory mobility or use of an arm or leg, or amputation of an arm or leg;
3. Loss of vision in both eyes;
4. If the person is over 18: traumatic brain injury, provided that the brain injury is confirmed by medical imaging and a Glasgow Outcome Scale assessment determines that the injury results in one of the following ratings:
   1. Vegetative State, one month or more after the accident,
   2. Upper Severe Disability or Lower Severe Disability, six months or more after the accident, or
   3. Lower Moderate Disability, one year or more after the accident.
5. If the person is under 18 years of age: a traumatic brain injury, confirmed by medical imaging, and the person has been admitted into the hospital, or, the person has severely impaired neurological functioning;
6. A Physical Impairment or combination of physical impairments, that in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4^th Edition, 1993, results in 55 percent or more physical impairment of the whole person;
7. A mental or behavioral impairment, excluding traumatic brain injury, determined in accordance with the rating methodology in the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 6^th Edition, 2008, that, when the impairment score is combined with a physical impairment described above results in 55 percent or more impairment of the whole person;
8. An impairment that, in accordance with the American Medical Association’s Guides to the Evaluation of Permanent Impairment, 4^th Edition, 1993, results in a class 4 impairment (marked impairment) in three or more areas of function that precludes useful functioning or a class 5 impairment (extreme impairment) in one or more areas of function that precludes useful functioning, due to mental or behavioral disorder.

Ensure The Appropriate Parties Complete The Application

A physician is required to complete the majority of the OCF-19 form, and sometimes it is beneficial if the family doctor fills it out. However, although the family doctor may fill out this form, you will eventually have to hire a paid medical expert to provide a comprehensive medical-legal report. Often times, family doctors are trusted and impartial physicians, and therefore make a good candidate when filling out this form. This is not always the best decision and you should consult with a personal injury lawyer to decipher the best course of action and who is best fitted to fill out the form. For instance, if your family doctor is not invested in your care or unfamiliar with the Accident Benefits system and CAT criteria, they may not be the best candidate to fill out the form. If you or your loved one has suffered a traumatic brain injury, a neuropsychologist will have to complete it.

Why Is A CAT Determination Important?

As you can imagine, determining whether your injuries are indeed catastrophic in nature or not, largely has to do with making certain benefits available to you. Whereas for non-minor injuries, $65,000 is the max for medical rehabilitation and attendant care combined, injuries deemed catastrophic allow a maximum of $1,000,000 in benefits available for medical rehabilitation (the number increases with optional benefits).

It is not uncommon for benefits to be depleted quicker than one would hope, and therefore, it becomes critical to receive a CAT designation whenever possible. This allows accident victims to have their income replacement needs met, attendant care needs addressed, and provide them with the treatment and rehabilitation they deserve.

OHIP-funded health care for accident victims that have been seriously injured in a car accident will inevitably fall short of being enough. For instance, OHIP does not cover physiotherapy, occupational therapy, massage therapy, assistive devices, psychologists, and other health care services. Serious injuries can be life-long and devastating for injured victims and their families emotionally and financially.

Seek Legal Help

Catastrophic claims can be the most complicated and costly when it comes to motor vehicle accidents. Insurers are often reluctant to agree to a file being designated CAT, which in turn triggers a number of assessments and examinations, which can cost a lot of money on both sides. Our law firm covers all disbursements up until trial or settlement, to ensure we get you the best possible results. If your injuries are serious enough, we will advocate for your catastrophic determination to ensure you receive the benefits that you need and deserve.

If you have suffered physical impairment or a severe disability, contact our law firm to assist you in filling out the various OCF forms and discuss the merits of your case. We strongly recommend you contact an experienced law firm when having the OCF-19 Application for Determination of Catastrophic Impairment submitted to your insurance company.

If you need legal advice on a personal injury matter, contact our office for a free no-obligation evaluation of your case. Our law office services Hamilton, Toronto, Oakville, Mississauga, Brantford, and the rest of Southern Ontario. We off free consultations and are happy to assist you with your Application for Accident Benefits.