Catastrophic Impairment and the OCF-19 Form

Individuals who meet the definition for minor injury under the Statutory Accidents Benefits Schedule (SABS) are entitled to maximum of $3,500 for medical and rehabilitation benefits.

Catastrophically injured individuals are entitled to significantly more than that. But in order to receive that designation, many of those individuals will be subject to a grueling assessment process.

An important part of that assessment process is the OCF-19 form. If you or a loved one has been catastrophically injured in an accident, you should understand how this form functions.

What Is a Catastrophic Injury?

Individuals who are injured in motor vehicle accidents are entitled to benefits under Ontario’s SABS. There are three categories of injury defined by the SABS: minor, non-catastrophic, and catastrophic. A catastrophic impairment includes:

  • Traumatic brain injury
  • Paraplegia or tetraplegia
  • Amputation or severe impairment of an arm
  • Loss of vision in both eyes
  • Impairment(s) which effect 55% or more of the whole person
  • A mental or behavioral impairment combined with a physical impairment that effects 55% or more of the whole person

Catastrophic impairments have a more significant impact on an individual’s ability to function than any of the other categories. Physical impairments of a catastrophic injury can also have a significant impact the individual’s psychological functioning. For these reasons, individuals who are catastrophically impaired are entitled to more substantial benefits under the SABS.

What Are Catastrophically Injured Individuals Entitled To?

Individuals determined to be catastrophically impaired receive:

  • Medical and rehabilitation benefits
  • Attendant care benefits
  • Care-giver benefits
  • Income replacement benefits
  • Non-earner benefits (for those who don’t qualify for income replacement benefits)
  • Lost education expenses
  • Housekeeping and home maintenance benefits
  • Visitor’s expenses

Catastrophically impaired individuals are entitled to the maximum amount in each category. In terms of medical, rehabilitation, and attendant care benefits, that maximum is $1 million. In addition to receiving the maximum dollar amount of each category, catastrophically impaired individuals are entitled to these benefits for a longer duration of time.

If you or someone you love has been catastrophically injured, it’s essential to fill out all of the paperwork diligently in order to ensure you receive the maximum benefits available.

Catastrophic Injury OCF-19 Forms

The first step in receiving a catastrophic injury designation is submitting an ‘Application for Determination of Catastrophic Impairment’ (OCF-19) to the auto insurance company. The OCF-19 form is the key component of requesting the extensive benefits available under the SABS.

If the accident occurred between November 1, 1996 and May 31, 2016, the two-page OCF-19 form should be used. If the accident occurred on or after June 1, 2016, the six-page OCF-19 form is required. 

Who Should Fill Out the Form?

The OCF-19 form must be filled out by a physician or treating specialist. Some individuals will opt to have their family doctor fill out the form. But this isn’t always the best choice.

If a family physician is filling out the form, they should meet two qualifications. First, they should be invested in the care of the individual. Second, they should be familiar with the SABS and catastrophic injury criteria.

If both of these criteria are not met, it might be best to have another physician fill out the form. And, in the case that the injury in question is a traumatic brain injury, a neuropsychologist has to fill out the form.

Knowing who should fill out a form isn’t a small matter and requires the help of an experienced personal injury lawyer. This is especially true considering that once the OCF-19 is sent to the insurance provider, it will begin a long and potentially grueling process.

CAT Designation and Insurance

Once the OCF-19 form is completed by the appropriate physician or treating specialist, it’s sent to the auto insurance company of the injured party. The insurer must approve the OCF-19 in order for the injured individual to be designated catastrophically impaired.

There are some injuries that automatically receive catastrophic designation. These are:

  • Paralysis (paraplegia or quadriplegia)
  • Amputation that result in complete loss of function of an arm or leg
  • Loss of vision in both eyes
  • Severe brain impairment that results in 55% impairment of a person
  • Mental or behavioral disabilitythat results in 55% of a person becoming impaired in three or more functional areas

If the individual’s injury does not meet any of those criteria, the insurance company has two options: they can approve the application, or they can fight the designation. More often than not, the latter is what occurs.

Insurance Examinations

It’s in an insurance company’s best interest to fight against a catastrophic impairment designation because the benefits are so substantial. To fight the claim and try to prove that someone is not catastrophically impaired, an insurance company can require the individual to undergo insurance examinations (IEs).

IEs may be one or a series of medical assessments setup by the insurer. In many cases, an injured individual will have to go through a number of IEs performed by different physicians and specialists because determining catastrophic impairment is a multi-disciplinary task.

Insurers must designate an individual as catastrophically impaired if these IEs find that the criteria for catastrophic impairment has been met. But if the IEs conclude that an individual is not catastrophically impaired, the injured party still has options.

For example, the injured individual can hire experts and obtain reports regarding their injury and have those reviewed at the License Appeal Tribunal (LAT). The LAT will then decide whether or not the criteria has been met.

Call Sharma Law Before Filling Out an OCF-19

The OCF-19 form is an extremely important part of catastrophic injury designation. The approval of this form is essential to receiving the benefits that catastrophically injured individuals are entitled to. But receiving that approval is not as easy as handing it to a family doctor and submitting it.

Unless an individual is automatically approved due to the nature of their injury, there’s a good chance that insurance companies will try to fight this designation. For that reason, you need an experienced personal injury lawyer on your side. Call Sharma Law to advocate on your behalf if you’ve been catastrophically injured.

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