2016 SABS Training Overview

Statutory Accident Benefits Schedule – Effective September 1, 2010 (O. Reg. 34/10)

The following amendments to benefit limits in the SABS apply only to policies issued or renewed on or after June 1, 2016. Existing contracts remain subject to the current limits until the contract is terminated or renewed.

Medical, Rehabilitation & Attendant Care Benefit

For policies issued on or after June 1^st 2016

• The new standard benefit combines Medical, rehabilitation and attendant care and revises the limits as indicated above
• The new standard medical, rehabilitation and attendant care benefit duration is reduced from 10 years to 5 years for non-CAT impairments; except in cases involving children under 18 at the time of the accident, insured persons that sustain a catastrophic impairment, or those who have purchased the additional optional $1 million medical, rehabilitation and attendant care benefit. 
• Attendant care is extended to 5 years from 2 years in non-catastrophic case

Non-earner Benefit

• As of June 1, 2016, the six-month waiting period is replaced by a four-week waiting period, but the benefit is no longer payable after two-years.

Optional Benefits

• A new combined optional medical, rehabilitation and attendant care benefit of $130,000 will be available to consumers in addition to the existing optional $1 million combined medical, rehabilitation and attendant care benefit that is available.
• A new optional benefit for catastrophic impairment of up to an additional $1 million for medical, rehabilitation and attendant care will be available, if the insured person sustains a catastrophic impairment.
• The current optional $100,000 medical and rehabilitation benefit and $72,000 attendant care benefit have been eliminated.

The following amendments to the SABS apply to accidents that occur on or after June 1, 2016.

Catastrophic Impairment Definition

• The definition of catastrophic impairment is revised to reflect more current and up to date medical information from the Superintendent’s 2012 report on the definition of catastrophic impairment, as well as feedback from government consultations.
• The definition includes new and/or updated definitions and criteria for traumatic brain injuries for adults and children, amputations, ambulatory mobility, loss of vision, and mental and behavioral impairments, and introduces a new process for combining physical with mental and behavioral impairments.
• The revised definition also provides for an automatic designation of catastrophic impairment for children with traumatic brain injuries in specified circumstances.

Professional Attendant Care Benefit Limited to Actual Expenses Incurred

If the actual expenses incurred for paid attendant care service providers are lower than the monthly amount assessed under Form 1, the insurer is liable to pay only for the incurred expenses.

The amendments have tweaked the attendant care benefit claim by confining entitlement to actual losses when an attendant care provider performs the services at a cost that is less than the actual amount stipulated on the Form 1 (“Assessment of Attendant Care Needs”).

Professional Services Guideline

The hourly rates in the Professional Services Guideline (PSG) are reviewed by the Superintendent of Financial Services every year. It was concluded after this year’s review that no update is required at this time. Therefore, the hourly rates in the current PSG will continue to apply.

The following applies effective June 1, 2016:

Section 3 - Neuropsychologist

On June 1, 2016, the definition of “neuropsychologist” in subsection 3 (1) of the Regulation is amended by adding “who has been registered to practice as a neuropsychologist in Canada for a minimum of five years” at the end. (See: O. Reg. 251/15, s. 2 (1))

Test for Other Goods and Services – Section 15 (1)

Other goods and services under clauses 15 (1) (h) and 16 (3) (l) are subject to a new requirement that an insurer agree that the goods and services are essential for the treatment or rehabilitation of the insured person.

 “other goods and services of a medical nature that the insured person requires, other than goods or services for which a benefit is otherwise provided in this Regulation.  O. Reg. 34/10, s. 15 (1).”

And replaced with “(h) other goods and services of a medical nature that the insurer agrees are essential for the treatment of the insured person, and for which a benefit is not otherwise provided in this Regulation.”

(l) other goods and services that the insurer agrees are essential for the rehabilitation of the insured person, and for which a benefit is not otherwise provided in this Regulation, except, (i) services provided by a case manager; and (ii) housekeeping and caregiver services.

Attendant Care –Section 42

(12) If more than 104 weeks have elapsed since the accident, the insurer shall not require an examination under section 44 to determine the insured person’s entitlement to attendant care benefits and the insured person shall not submit nor be required to submit an assessment of attendant care needs to the insurer unless at least 52 weeks have elapsed since the last examination under section 44 relating to entitlement to attendant care benefits. O. Reg. 251/15, s.