Who Determines if I have a Catastrophic Injury?

Who Determines if I have a Catastrophic Injury?

In order to start the process of determining if you have a catastrophic injury you must submit an OCF-19 form to your insurer. A physician, or a neuropsychologist in the case of a traumatic brain injury, must complete this form. Sometimes, the use of an occupational therapist, psychologist and speech language pathologist may supplement or add to the assessment by your treating health care provider as to whether you have sustained a Catastrophic injury. The Occupational Therapist or Psychologist are particularly useful if you are claiming your impairment is catastrophic based on mental or psychological issues.

Some injuries are deemed catastrophic right away such as a paraplegic, amputee, or a child with a brain injury who has been admitted to hospital. Other injuries may require you to wait two years before submitting the OCF-19 such as a traumatic brain injury for an adult or someone claiming to have a whole body impairment of 55% or more. You can read more about this in the SABS.

Once the OCF-19 is submitted the insurer will either accept that you are catastrophic or the insurer will require that you submit to a number of different medical assessments to make the determination. If the medical assessments, under section 44 of the SABS, deem you to have sustained a catastrophic impairment then your policy limits will go up significantly.

If the assessments conclude that you are not catastrophically impaired then you can fight their decision by filing a claim with the Licensed Appeal Tribunal (LAT). You will likely have to get your own assessments to show that your injuries are catastrophic. You can request the insurer to pay for your own assessments under section 25 of the SABS. Normally it is in your best interest to get your assessments in first so please be mindful of this. 

Unfortunately OHIP funded services are not enough to cover your medical needs after a serious car accident. For example, OHIP will not cover physiotherapists, massage therapists, speech language pathologists, OTs or psychologists. It will not cover the cost of a lot of the medications you need, assistive devices and home modifications. So, it may be in your best interest to pursue the catastrophic impairment claim because of the significant benefits you could receive.