Insurance Terms Explained

The form that opens your claim. Your insurer must send it to you after you report the accident, and you generally have 30 days from receiving the package to complete and return it. The 30 days runs from when you receive the forms, not from the day of the collision.

It asks about your employment, your income, and the household tasks you can no longer manage. Take it seriously and do not minimise your difficulties, because this early document follows the claim.

Completed by a regulated health professional, this is the form that sets out your injuries and whether you meet the tests for income replacement or non-earner benefits.

Our clinicians complete OCF-3s. It is one of the most consequential forms in the whole process, because it is often what determines whether income support begins.

The form your provider submits to request funding for treatment or an assessment. It sets out what is proposed, how much of it, and why.

Your insurer has ten business days to respond. Each discipline submits its own OCF-18, so your counselling, physiotherapy and dietitian care are approved separately rather than together.

The form used to apply for catastrophic status, which raises the limit on medical, rehabilitation and attendant care benefits substantially.

It has to be completed by a physician or, for some criteria, a psychologist, and it is supported by assessment evidence from the disciplines relevant to the criteria being claimed.

The invoice your provider submits to be paid for approved treatment. You do not complete it and you will not usually see it.

It is the reason approved treatment costs you nothing out of pocket: the provider bills your insurer directly rather than asking you to pay and claim back.

Used to calculate attendant care benefits, which fund help with personal care where an injury makes that necessary.

It is completed by an occupational therapist or a registered nurse. We can coordinate this through our community partners where a file requires it.

Where you qualify for more than one weekly benefit, you must elect which one you will receive. You cannot draw two at the same time, and the OCF-10 is the form on which that choice is recorded. Your insurer must notify you of the right to elect, and you then have 30 days to make the choice.

It matters more than it appears. The benefits differ in amount and in how long they last, and the election is difficult to change afterwards. This is one of the clearest examples of a decision worth taking legal advice on before you sign.

Since 1 July 2026 this affects fewer people. Income replacement, non-earner and caregiver benefits became optional coverages that have to be purchased, so an election only arises where you actually hold more than one of them. Policies that existed before that date keep their coverage on renewal unless the holder actively opted out, so many people are still in that position. Check your policy declarations page, or ask us and we will go through it with you.

The form used to claim back expenses you have paid yourself because of the accident, such as prescriptions, medical supplies, mileage to appointments, or help you had to pay someone for.

Keep your receipts from the beginning. We will explain what is claimable, which is usually more than people expect, and submit these on your behalf.

A framework that caps treatment funding at $3,500 for injuries classed as minor, such as sprains, strains and whiplash without complication.

Many people are placed in the MIG early, often before anyone has properly assessed them, and $3,500 does not go far. A documented psychological injury is one of the recognised routes out of it, which is why proper assessment early matters so much. That documentation usually comes from an assessment by a Registered Social Worker or psychotherapist, or, where a formal diagnosis is needed, from a psychologist, physician or nurse practitioner. Our complete guide to psychological injury after a car accident covers what that assessment involves.

If you have been told you are in the MIG and you do not think it reflects your injuries, that decision can be challenged with clinical evidence.

The category most claims fall into once they are out of the MIG. The current limit is up to $65,000 combined for medical and rehabilitation care.

That is a substantial difference from $3,500, and it is usually enough to fund a proper course of treatment across more than one discipline.

The most serious category, with up to $1,000,000.00 available for medical, rehabilitation and attendant care combined.

Catastrophic status is determined against defined criteria, which include certain physical injuries, brain injury, vision loss, and levels of mental or behavioural impairment. It requires a multidisciplinary assessment, usually involving several medical specialists alongside psychological and functional assessment.

We coordinate and complete these assessments, including the psychological and functional components.

Pays a proportion of your income if you are unable to work because of accident-related injury. Under a standard policy this is 70 per cent of your gross weekly income up to a maximum of $400.00 a week, unless higher optional coverage was purchased. Payments begin after the first week.

The test changes at 104 weeks. For the first two years the question is whether you are substantially unable to perform the essential tasks of your own job. After that it becomes whether you are completely unable to engage in any occupation you are reasonably suited to by education, training or experience. Most disputes about income replacement happen at this point, and what decides it is documented function.

Important since 1 July 2026: income replacement is now an optional coverage that has to be purchased, rather than part of every standard policy. Existing policies keep their coverage on renewal unless the holder actively opts out, so many people are still covered. Check your policy declarations page, or ask your insurer or broker.

For people who were not employed at the time of the accident, such as students or those out of the workforce, where the accident leaves them continuously unable to live a normal life.

Under a standard policy this is $185 a week, payable after a four-week waiting period and for a maximum of two years. Also an optional coverage since July 2026. Psychological injury counts towards this test, and documented function is what decides it.

Funds your treatment: counselling and psychotherapy, psychological assessment, physiotherapy, dietitian services, medication, devices and equipment.

These remain mandatory in every Ontario auto policy, so this category of coverage cannot be removed regardless of what else your policy includes. Approval for any specific treatment still depends on your diagnosed injuries and on the insurer agreeing it is reasonable and necessary.

Funds a person to help with personal care, such as dressing, bathing and supervision, where an injury makes that necessary. Calculated using the Form 1.

Also mandatory in every policy.

Caregiver benefits help where you were the primary carer for a dependent and can no longer manage. Housekeeping benefits fund help with the domestic tasks you can no longer do.

Both became optional coverages in July 2026, so whether they apply depends on the policy.

Compensation for certain family members, and help with funeral costs, where someone dies as a result of a collision.

Since 1 July 2026 these are optional coverages rather than being included in every policy. Policies in force before that date keep them on renewal unless the policyholder agrees in writing to decline them, so many families are still covered. The optional benefits now generally extend only to the named insured, listed drivers and their dependants, so a passenger, pedestrian or cyclist may not have access to them.

We provide grief counselling to families in these circumstances. Whether it can be funded through a claim depends on the policy and the circumstances, and we will look into that with you rather than leaving you to work it out.

If you are in this situation, please call us and we will explain the options gently and without pressure.

The Ontario regulation that sets out what accident benefits exist, who qualifies, and what the limits are. When a letter refers to a section of the Schedule, this is what it means.

It applies regardless of who caused the accident, which is why you claim accident benefits from your own insurer rather than the other driver’s.

The person at your insurance company who manages your claim, decides on funding requests, and communicates the insurer’s position.

They are not a clinician. Their decisions are made on the documentation in front of them, which is why clear clinical reporting matters so much.

An assessment arranged and paid for by your insurer, sometimes called an independent medical examination. You may be asked to attend one, and in most cases attendance is required.

It is reasonable to ask who the assessor is, what the appointment involves, and how long it will take. Tell your own clinicians it is happening, and tell them afterwards how it went.

The independent tribunal that resolves disputes between claimants and insurers about accident benefits. If treatment or a benefit is denied and cannot be resolved directly, this is where the disagreement is decided.

You generally have two years from the date of a denial to start a dispute at the Tribunal. People often let that slip because they assume a denial is final. It is not, and many are reversed when challenged with proper clinical evidence.

You do not need a lawyer to bring a LAT dispute, though most people use one or a licensed paralegal, and our reporting is prepared so that it stands up in that process.

A separate legal claim against the person who caused the accident, for pain and suffering and for losses not covered by accident benefits. Accident benefits and a tort claim can run at the same time.

Accident benefits come from your own insurer regardless of fault. A tort claim depends on fault and is usually handled by a personal injury lawyer.

An arrangement where a provider treats you now and is paid later out of a settlement, rather than asking you to pay up front.

We can invoice on a protected account where a claim or another matter remains open. It is one of several ways treatment can continue when funding is denied or delayed.