Who Pays for Health Care: Injuries from Motor Vehicle Accidents

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.

 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).

When someone is injured in a motor vehicle accident, the priority of payment for health care services is:

1. 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);
2. private supplementary health and disability insurer and private employer plans;
3. automobile insurers (statutory accident benefits available through injured person’s own automobile insurance policy);
4. money awarded in a lawsuit;
5. 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.

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.

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.

If you have questions about health services and motor vehicle accidents, or would like more information, please call 613-548-6663.

See also : Personal Injury Accidents : Recovering Healthcare Costs

The information on this fact sheet is not intended as legal advice. It is based on Legislation in the Insurance Act including amendments made through Bill 59 in November 1996. The contents are current as of today's date but are subject to change. Readers should satisfy themselves as to the currency/accuracy of the material at any particular time.

Catalogue Number 014389 / 014390

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