CAA_presentation

. . CAA Presentation The Intricacies of Accident Benefits for Accident Benefits Adjusters Presented by Reid Anderson Educational Consultants.

. . Stakeholders Stakeholders Involved in Making a Claim The Insured Person(s) Hereafter referred to as the "claimant" Insurance Company Can be an actual insurance company or an independent insurance broker or its representative Accident Benefits Adjuster An accident benefits or claims adjuster is the main point of contact a claimant has with the insurance company. The adjuster will guides the claimant through the claims process by determining what is covered by the policy..

. . Benefits Adjuster Specific Duties of an Accident Benefits Adjuster After verifying that insurance coverage applies to the loss, the adjuster notifies the insurer of a covered loss under policy terms. Claims evaluation must begin in a timely manner. Most insurance companies require that claims evaluations be initiated within mandatory timeframes, depending on the type of loss involved. The adjuster files any necessary paperwork, communicates with the claimant, and investigates the assignment of liability. Damages are physically inspected and assessed. An adjuster may travel to a repair shop to inspect a damaged vehicle..

. . Benefits Adjuster Specific Duties of an Accident Benefits Adjuster (cont.) The adjuster then researches market values and the replacement costs associated with each aspect of the claim to account for property damage, loss of personal items, or other expenses. A detailed damages report is then provided by the adjuster to the insurance company. An adjuster may also simultaneously negotiate with vendors or repair shops on cost and time needed for repair/replacement in order to coincide with a settlement offer for the claimant. If the claimant disagrees with a settlement offer, an adjuster may go back to reassess any new information or evidence. The process may also go to arbitration or mediation. At all times, the adjuster is responsible for protecting the interest of the insurance company. An adjuster's main focus is to prevent an overpayment or any payment on an exaggerated claim..

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. . Benefits Coverage Accident Benefits Coverage The amount and type of benefits available depend on the type of injury. There are three main categories for injuries: minor injuries, catastrophic, and non-catastrophic. To support a claim, a claimant may have to complete a claim form, also known as a Proof of Loss form (a sworn statement in support of a claim). The benefits adjuster then determines the extent to which a claim is covered by the insurance policy, and help guides the claimant through the claims process. A common dispute with the insurance company and the insurance adjuster is a difference of opinion with respect to the category of the injury. In some cases a physical examination of the claimants injuries by a medical doctor may be necessary..

. . Benefit Types Types of Accident Benefits Financial Intended to replace income loss by the claimant in they are unable to return to work and covers three types of income loss Recovery and Assistance Covers medical expenses and rehabilitation, caregivers, and attendants. Death Benefits Death and Funeral Benefits.

. . Financial Financial Benefits Income replacement benefit (IRB) —A claimant is eligible if they were earning income prior to the accident and are unable to return to work. The compensation a claimant will receive from IRB is 70 percent of their gross income up to $400 per week. It would commence a week after a loss, for the first two years if the claimant is unable to carry on working. After the first two years, the criteria is more stringent. Non-earner benefits — This type of accident benefit claim is designed to compensate injured accident victims who have completely lost their ability to return to their pre- accident lifestyle as a result of and within 104 weeks following the accident. Payable after 4 weeks at $185/week if the claimant is unable to carry on a normal life. Payable after age 18 and for a maximum of 104 weeks. Caregiver benefits — Only applies if the claimant was responsible for providing care to someone before the accident and can no longer provide that care. If they have been providing care to someone prior to the accident but can no longer continue due to injuries suffered. The claimant is eligible to a maximum of $250 compensation weekly, plus $50 for an additional dependent. They can immediately receive the benefit as long as the injury makes them unable to continue care giving benefits..

. . Recovery & Assistance Recovery and Assistance Benefits Medical and rehabilitation — Covers medical and therapeutic expenses not covered under OHIP. Common treatments include physiotherapy, chiropractic, massage, acupuncture, medications, assistive devices, and home and vehicle modifications. There is a maximum amount available depending upon the severity of the injuries (e.g. minor injury, non-catastrophic injury or catastrophic injury), unless the claimant has optional benefits. Qualified case manager services —A professional paid to co-ordinate medical, rehabilitation, and attendant care benefits. Housekeeping and Home Maintenance — Maximum of $100 per week for life if the claimant has sustained catastrophic injuries. Lost education expenses — Up to a maximum of $15,000 Attendant care benefits — If the claimant is unable to manage their own personal care as a result of accident related injuries, they can make a claim for attendant care benefits to pay for a nurse to help them in the home. Enhanced Accident Benefits — Pays additional income, medical and rehabilitation expenses.

. . Death & Funeral Benefits Death and Funeral Benefits Death benefits include: $25,000 lump sump payable to an eligible spouse $10,000 lump sum payable to each dependent including a supported former spouse $25,000 divided equally among dependents, if there is no spouse. Funeral benefits — Maximum of $6,000 for funeral expenses..

. . Exclusions Exclusions to Insurance Benefits In some cases, an insurance company may deny payment of Income Replacement, Non- earner and Compensation for other expenses. Cases include: Driving without valid insurance Driving without a valid driver's licence Driving while specifically excluded from driving under their insurance policy Driving a vehicle without the owner's consent Cases of fraud Driving a vehicle while committing a crime (whether or not the crime is related to the operation of the vehicle) ENIED.

. . Application Process Applying for Accident Benefits A benefits adjuster will provide the claimant with an Accident Benefits Application Package that includes the following five forms: Application for Accident Benefits (OCF-I) Employer's Confirmation of Income (OCF-2) Disability Certificate (OCF-3) Permission to Disclose Health Information (OCF-5) Treatment Confirmation Form (OCF-23) Once the Accident Benefits Application Package has been reviewed, the insurance company lets the claimant know which benefits they qualify for..

. . Claims Process ACCIDENT BENEFITS CLAIM PROCESS AUTOMOBILE ACCIDENT ACXIDENT INVESTIGATION CLIENT FILES A CLAIM CLIENT APPLIES FOR BENEFITS MEDICAL EXAMINATIONS OFFERED SETTLEMENT REJECTED MEDIATION MEDIATION SUCCESFUL MEDIATION FAIL s CLIENT MAY RETAIN LEGAL COUNSEL.

. . Tort Claims When an Insured Person Files a Tort Claim A claimant is also entitled to bring a claim against the negligent driver who was at fault for the car accident if they sustained a serious and have sustained serious and permanent damage as a result of the car accident. The claimant has two years from the date of the accident to commence this tort action. The compensation which they receive for pain and suffering (known as a "non-pecuniary damages award") is subject to an increasing deductible which on January 1 , 2018 went up to $37,983.33. However, if the non-pecuniary damages surpass $126,610.07, the deductible disappears. These numbers are adjusted periodically. Claims by spouses or relatives for the loss of the care, guidance and companionship of an injured person, are subject to a deductible as well. Currently that number is $18,991.67, disappearing if the Family Law Act claim exceeds $63,304.51. In a tort claim, a claimant can also claim for past lost income, future lost income, impairment of your ability to earn income, loss of competitive advantage in the workplace future care costs and out-of-pocket expenses and business losses. These claims are not subject to a $30,000 deductible..

. . 1. 2. 3. 4. 5. 6. References https://www.fsco.gov.on.ca/en/auto/brochures/pages/brochure_claims.aspx http://www.fsco.gov.on.ca/en/auto/forms/Documents/SABS-CIaims-Forms/1224E.4. pdf https://www.fsrao.ca/consumers/auto-insurance/after-accident-understanding-claims- process https://petkerlaw.com/accident-benefits-and-tort-claims-whats-the-difference-and-how-do- they-intersect/ https://singerkwinter.com/insurance-claims/accident-benefit-claims/ https://www.siskinds.com/excluded-benefits-under-ontarios-no-fault-accident-benefits- regime/.