Personal Injury Accidents: What You Should Know About Payments

If a person is injured in an accident caused by someone else’s negligence or wrongdoing, and makes a claim for damages or initiates a lawsuit, the Ministry of Health and Long-Term Care can recover its costs for health care and treatment through subrogation.

Subrogation is a legal term unique to Insurance Law. It means “the right to recover costs for an injury caused by the fault or negligence of another person.” The ministry’s right to subrogation is enforced through legislation.

The most common examples of personal injury accidents for which the ministry recovers health care and treatment costs are:
• slip and falls
• boating, air and rail accidents
• product liability or manufacturing defects
• medical malpractice or professional negligence
• dog bites
• municipal liability
• assaults
• some motor vehicle accidents
• class actions.

The ministry is notified by the injured person, their legal counsel or by the at-fault party’s liability insurer.
The ministry’s right of recovery applies to any incident regardless of the location.

The ministry can recover costs for:
• OHIP insured services up to the time of settlement or judgment, also for future insured health care services that an injured person may need.
• Extended care services typically arranged or provided through Community Care Access Centres (CCACs) in the home, school or community including professional and non-professional services. Subrogation does not apply for future non-professional health care services or benefits.

Injuries from Motor Vehicle Accidents
When a person is injured in a motor vehicle accident, the Statutory Accident Benefit Schedule requires the automobile insurer to pay for non-professional health care services:
• Community Support Services, such as; meals and transportation: caregiver support, home maintenance and repair and social or recreational services
• Attendant Care/Personal Support/Homemaking Services, such as assistance with activities of daily living: assistance with personal hygiene, house cleaning, laundry and preparing meals.

Automobile insurers should arrange non-professional health services for their clients and pay the service provider directly.

The ministry’s subrogation unit is responsible for monitoring compliance of payment responsibility for persons injured in motor vehicle accidents and who require health services.

Priority of Payments
When someone is injured in a motor vehicle accident, the priority of payment for health care services is:
1. ministry programs: OHIP services and professional services arranged or provided through CCACs;
2. private supplementary health and disability insurer and private employer plans;
3. automobile insurers (statutory accident benefits available through injured person’s own automobile insurance policy);
4. money awarded in a lawsuit;
5. provincial government plans are the last payer for non-professional services arranged or provided through CCACs and all services and benefits such as vocational rehabilitation and welfare payments, administered by the Ministry of Community and Social Services.

What You Can Do?
• knowing which health care services the Ministry of Health and Long-Term Care pays for, and which ones are paid directly by the automobile insurer.
• ensuring your client has made a claim to his/her own automobile insurer.
• verifying that your client has contacted the automobile insurer for provision and payment of attendant care, personal support and homemaking services.

The article is an extract of a publication on the Ministry of Health website.

Seyada Mahmoud is a Paralegal student at Centennial College in Toronto studying professional communications with Omar Ha-Redeye.

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