If there’s one thing that is underestimated by the general public, it is the enormous cost of medical care following an accident or disabling illness. Most people aren’t aware of the benefits available to them, and don’t know the questions to ask to learn about available sources of funding. Here is a list of 6 sources of health care funding options that you may benefit from after an injury or a disabling illness:
1. Employer Sponsored Health Benefits (Collateral Benefits)
These benefits can vary greatly from patient to patient. There is no “standard” benefit package. In a unionized situation these benefits are negotiated as part of the remuneration package; in a non-unionized environment the benefit package are tailored to the needs of the workforce and economic restraints of the employer. Often patients have never reviewed their policy to determine what coverage is available and when asked many do not even have a copy of the policy booklet. The patient should be encouraged to request from his or her employer a copy of the most recent “Benefit Book” or description of benefits. This document will list the available coverages which can include:
(a) medical devices and equipment;
(c) occupational therapy
(e) massage therapy
(i) speech language pathology
Unfortunately, benefits available from employer sponsored benefits are often grossly insufficient to meet the care needs of individuals with ongoing care needs. Many policies have caps on coverage which can be set at as little as $500 in coverage per year.
2. Auto Insurance
Ontario has in place a comprehensive system of no-fault insurance which provides extensive coverage for medical needs. Coverage is available under two tiers depending upon the injuries sustained – the non-catastrophic tier with $50,000 in medical care available and the catastrophic tier with $1,000,000 in medical care available. These benefits are available to everyone who is involved in an auto accident in Ontario or is involved in an accident outside Ontario but was insured under an Ontario policy of auto insurance. Coverage is available to anyone who:
(a) Is a driver of an automobile involved in a collision (regardless of fault);
(b) A passenger of an automobile involved in a collision (even if vehicle is uninsured);
(c) A pedestrian injured by or injured because of a motor vehicle;
(d) A cyclist or any other user of the road injured by or because of a motor vehicle;
(e) An individual injured in any way connected to a motor vehicle (ie slipping and falling while closing a car door).
It is important to note that coverage is available to anyone who fits the criteria above whether or not the individual is insured under a policy of auto insurance themselves. A qualified personal injury lawyer can assist the patient in determining the identity of the most appropriate insurer to pay the benefits.
(i) Minor Injury Guideline:
A Minor Injury is any injury that does not meet the definition of a “Non Catastrophic Impairment” or a “Catastrophic Impairment”. Coverage available to pay for the items listed under “Non Catastrophic Impairment”, but with a cap of $3500.00.
(ii) Non-Catastrophic Benefts:
A non-catastrophic injury is any injury that does not meet the definition of “Catastrophic Impairment”. This coverage is available to pay for the following:
(a) Medical Rehabilitation:
- Medical Expenses (prescriptions, devices, etc)
- Massage Therapy
- Psychological Treatment
- Occupational Therapy
- Chiropractic Treatment
- In Home Assistive Devices (grab bars, perching stools, etc.)
- Driver Retraining Programs
- Damaged Clothing
- Speech Language Pathology
- Necessary Assessments
(b) Attendant Care:
A benefit available to pay for an attendant (often a PSW) to assist the patient in their home. These benefits depend upon need, and are payable to a maximum of $3,000 per month.
(iii) Catastrophic Benefits:
An injury is considered to be “catastrophic” if it meets one of the following criteria:
1. Paraplegia or Tetraplegia (quadriplegia) that meets the following criteria:
a. A Score of A, B, or C on the ASIA Impairment Scale
b. A Score of D on the ASIA Impairment Scale, and:
i. Item 12 on the Spinal Cord Independence Measure applies
ii. The insured requires surgical diversion, an implanted device, or a catheter for urinary/bowel function
2. Severe impairment of ambulatory mobility, OR use of an arm, OR amputation that meets the following criteria:
a. Trans-tibial (below knee) amputation of a leg
b. Amputation of an arm of another impairment causing the total and permanent loss of use of an arm
c. Severe and permanent alteration of prior structure and function involving one or both legs granting a score of 0 to 5 on the Spinal Cord Independence Measure
3. Loss of vision of both eyes that meets the following criteria:
a. Even with corrective lenses or medication:
i. Visual acuity in both eyes is 20/200 or less
ii. The greatest diameter of the field of vision in both eyes is 20 degrees or less
b. The loss of vision is not attributable to non organic causes
4. If 18 or older at the time of the accident, a traumatic brain injury was sustained that meets the following criteria:
a. The injury shows positive findings on a computerized axial tomography scan, an MRI, or any other medically recognized diagnostic technology indicating intracranial pathology that is a result of an accident, including, but not limited to, intracranial contusions or hemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.b. When assessed for the Glasgow Outcome Scale, a rating of:
i. Vegetative state (VS) one month or more post accident
ii. Upper Severe Disability (Upper SD) or Lower Severe Disability (Lower SD) six months post accident, or,
iii. Lower Moderate Disability (Lower MD) on year or more after the accident
5. If Under 18 at the time of the accident, a traumatic brain injury was sustained that meets the following criteria:
a. Insured accepted for admission at a public hospital with an injury that showed positive findings on a computerized axial tomography scan, an MRI, or any other medically recognized diagnostic technology indicating intracranial pathology that is a result of an accident, including, but not limited to, intracranial contusions or hemorrhages, diffuse axonal injury, cerebral edema, midline shift or pneumocephaly.
b. Insured was accepted for in patient admission to a program of neurological rehabilitation in pediatrics
c. One month post accident the insured’s level of function does not exceed vegetative
d. Six months post accident the insured’s level of function does not exceed a severe disability
e. Nine months post accident the insured’s level of function remains seriously impaired to the point where the insured is not age appropriately independent
6. Subject to section 2 and 5, a physical impairment or combination of physical impairments that results in a 55% whole person impairment of the insured.
7. Subject to section 2 and 5, a mental or behavioural impairment, excluding a traumatic brain injury, when combined with a physical impairment results in a 55% whole person impairment of the insured.
8. Subject to section 3 and 5 an impairment due to a mental or behavioural disorder that results in a Class 4 Impairment (marked impairment) in three or more areas of function, or, a Class 5 Impairment (extreme impairment) in one or more areas of functioning
If a patient meets the definition of catastrophic impairment coverage is available for all of the medical benefits available to non-catastrophic impairment coverage, but in addition there is coverage for a case manager to oversee the care of the patient, transportation costs, and housekeeping expenses.
Additionally, benefits are available to pay for an attendant to assist the patient in their home. The benefits again depend upon need, and are payable to a maximum of $6,000 per month.
3. Ontario Disability Support Program (ODSP)
If you are receiving Ontario Disability Support Program Income Support, you may be eligible to receive the following health benefits:
(i) Prescription drug coverage
(ii) Dental coverage
(iii) Vision care
(iv) Mandatory Special Necessities benefit:
- Coverage for medical supplies
- Coverage for medical transportation
(v) Pregnancy/Breast-feeding Nutritional Allowance
(vi) Extended Health Benefit, health coverage when you are no longer financially eligible to receive Income Support and have high health costs
If you are injured during the course of your employment, you may be eligible to receive the following health benefits:
(i) Health Care
(ii) Prescription Drugs
(iii) Medical Devices and Orthotics
(iv) Transportation Costs associated with work related injury or illness
Please note that an individual cannot receive WSIB benefits and Auto Insurance benefits at the same time.
5. Ontario Works Benefits
If you are receiving Ontario Works, you and your family may be eligible for certain health-related benefits, such as:
(a) Prescription drug coverage
(b) Dental coverage for children
(c) Vision Care
(d) Eye Examinations
(e) Diabetic or surgical supplies and dressings
(f) Travel and transportation for medical purposes
(g) Assistive Devices
(h) Extended Health Benefits
You may be eligible for these benefits if:
- you were eligible for Ontario Works in the month before accessing Extended Health Benefits
- you no longer qualify for financial help under Ontario Works because your income from other sources is too high
- you are no longer eligible for Ontario Works because you received a payment for loss of income under the 1986-1990 Hepatitis C Settlement Agreement.
6. Tort Compensation
Obtaining tort compensation involves using the civil justice system to obtain monetary compensation for injury. It can involve:
(a) Slip/trip and fall accidents;
(b) Dangerous premises accidents;
(c) Dog bites;
(d) Any situation where the negligence of one person results in injury to another.
Our civil justice system as it relates to injury claims relies on insurance. Behind every lawsuit or potential lawsuit is an insurer. These insurers are often obliged or willing to pay for care (It’s often in their best interest). Additionally, many residential and commercial property insurance policy have “voluntary payment of medical expenses” provisions which pay for medical expenses as they are incurred regardless of a finding of fault or responsibility.
Commencing a tort claim can be a significant source of funding for medical care. In order to access this source of funding a patient will require the services of a qualified personal injury lawyer.