This presentation provides an overview of accident benefits and the claims process for insurance adjusters. It discusses the key stakeholders in a claim, including the insured person, insurance company, and accident benefits adjuster. It outlines the specific duties of an accident benefits adjuster, which include notifying the insurer of covered losses, investigating claims, assessing damages, negotiating costs, and protecting the insurer's interests. The presentation also covers the different types of accident benefits, including financial benefits like income replacement, non-earner benefits and caregiver benefits. Recovery and assistance benefits as well as death and funeral benefits are also explained. The exclusions, application process and resources available are summarized.

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

2. 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.

3. 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.

4. 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.

5. Benefits Adjuster

6. 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.

7. 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

8. 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.

9. 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

10. 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.

11. 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)

12. 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-1)
• 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.

13. Claims Process

14. 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.

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

16. Learning Consultant - Insurance
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to interview for the position of
Learning Consultant Insurance
at CAA.