Findlay Personal Injury Lawyers | September 1, 2025 | Personal Injury

Table of Contents

What is a Catastrophic Injury?

Under the Statutory Accident Benefits Schedule (SABS), a catastrophic impairment is defined through precise medical criteria. According to the current regulations, catastrophic injuries include:

  • Paraplegia or tetraplegia
  • Severe impairment of ambulatory mobility or use of an arm
  • Amputation or other impairment causing the total physical loss of an arm or leg
  • Loss of vision in both eyes
  • Traumatic brain injury
  • 55% or more physical impairment of the whole person
  • Mental or behavioural impairment (excluding traumatic brain injury) that, when combined with physical impairment, results in 55% or more impairment of the whole person

Even with serious injuries, the catastrophic designation isn’t automatic. It requires extensive medical documentation and often specialized assessments by physicians. For many accident victims, the designation process becomes an unexpected battle during their recovery.

Catastrophic Injuries vs. Non-Catastrophic Injuries

Benefit Type Non-Catastrophic Injury Settlements Ontario Catastrophic Injury Settlements Ontario
Medical, Rehabilitation, and Attendant Care Benefits Up to $65,000, including Attendant Care Benefits Up to $1,000,000, plus an additional $1,000,000 for Attendant Care Benefits
Benefit Period Temporary Lifetime
Housekeeping and Home Maintenance Not Available (except as an optional benefit) Up to $100/week (lifetime)

How Ontario Insurance Companies Handle Catastrophic Injuries

When a claim involves potentially catastrophic injuries, Ontario insurers typically implement a specialized handling protocol. Initially, they assign experienced adjusters who specialize in handling serious injury claims.

The insurer’s first step involves reviewing medical documentation. Under Ontario regulations, a formal Application for Determination of Catastrophic Impairment (OCF-19) must be submitted along with supporting medical evidence. Insurance companies carefully analyze these submissions, looking for any inconsistencies or gaps in the documentation.

Following the application, most insurers exercise their right to have claimants undergo Independent Medical Examinations (IMEs). These assessments are conducted by healthcare professionals selected and paid by the insurance company. While technically “independent,” these examinations frequently result in opinions that favour the insurer’s interests. Under Ontario law, refusing to attend these examinations can jeopardize your benefits.

The timeline for catastrophic injury determinations varies. While Ontario regulations require insurers to respond to catastrophic impairment applications within 10 business days, final determinations often take 6–12 months or longer, especially when insurers request multiple rounds of medical assessments or additional documentation.

Why Insurance Companies Dispute Catastrophic Injury Claims

Financial Implications

The primary motivation behind insurer resistance is simply money. There is a big financial difference between catastrophic and non-catastrophic injury settlements in Ontario. When an injury receives a catastrophic designation, the insurer’s potential liability increases from approximately $100,000 to over $1,000,000 in benefit obligations. This tenfold increase gives insurers a big financial incentive to dispute the designation.

Technical Classification Criteria

The specific medical criteria for catastrophic impairment in Ontario’s SABS regulations provide multiple avenues for dispute. For example, determining whether someone meets the 55% whole person impairment threshold involves complex calculations across multiple body systems.

Insurers tend to focus on technical compliance with assessment guidelines rather than the practical impact of injuries. A victim might be profoundly disabled in daily life but fail to meet specific diagnostic thresholds in the regulation. Insurance companies exploit these technical requirements, arguing that devastating injuries that don’t precisely fit the regulatory definition cannot qualify as catastrophic regardless of their actual impact.

Independent Medical Examinations

Insurance companies in Ontario strategically deploy Independent Medical Examinations to challenge catastrophic injury claims. These assessments, while presented as neutral evaluations, often work against claimants for several reasons:

  • Insurers select examiners known for conservative opinions regarding disability
  • Examinations typically involve brief interactions that may not capture the full scope of impairment
  • Assessors review files specifically looking for inconsistencies in medical records
  • Examination reports frequently emphasize capabilities over limitations
  • Some assessment companies rely heavily on insurance contracts, potentially influencing their neutrality

While the SABS regulations permit these examinations, their implementation often creates an imbalance where claimant-supporting medical opinions from treating physicians are countered by assessments that favour the insurer.

Surveillance and Social Media Monitoring

Insurance companies often conduct surveillance and social media monitoring in catastrophic injury cases. While presented as efforts to prevent fraud, these tactics frequently focus on capturing moments that contradict disability claims. A claimant having a rare good day or pushing through pain to participate in a family event can find these moments used to challenge their entire claim, despite being unrepresentative of their overall condition.

How a Catastrophic Injury Lawyer Can Help

A catastrophic injury lawyer brings specialized knowledge about what injuries qualify for catastrophic designation under Ontario law. They evaluate your injuries against specific SABS criteria, identify qualification pathways even in complex cases, and recognize when mental or behavioural complications might independently qualify. This expertise proves invaluable when building a claim strategy.

Catastrophic injury attorneys connect clients with appropriate specialists who understand SABS requirements, ensure medical reports address specific qualifying criteria, and commission independent medical-legal reports when necessary. The difference between successful and unsuccessful catastrophic injury settlements in Ontario often hinges on the quality and comprehensiveness of medical documentation.

When insurance companies require independent medical examinations, a catastrophic injury lawyer provides support by preparing clients for assessments, reviewing examiner qualifications, and challenging biased IME reports with expert rebuttals. Without this guidance, many claimants unknowingly undermine their eligibility for a catastrophic designation.

If insurers dispute catastrophic designations, a catastrophic injury attorney can provide structured advocacy through the litigation process. They compile comprehensive evidence packages, secure expert testimony, challenge insurer evidence, and prepare for hearings when settlements aren’t possible. The procedural complexity of catastrophic injury disputes makes proper legal representation valuable.

If you’re struggling with serious injuries following an accident, don’t face the insurance system alone. Contact Findlay Personal Injury Lawyers for a free consultation to discuss your catastrophic injury claim.

FAQs About Catastrophic Injuries

What Constitutes a Catastrophic Injury?

In Ontario, catastrophic injuries are defined in the Statutory Accident Benefits Schedule. They include paraplegia or tetraplegia, severe impairment of mobility, amputations, brain injuries, 55% or more whole person impairment, Class 4 or 5 mental/behavioural impairments, or severe vision loss.

What is a Catastrophic Head Injury?

A catastrophic head injury in Ontario’s insurance framework refers to a brain injury that meets specific criteria. This includes scoring VS (Vegetative State), Upper SD (Upper Severe Disability), Lower SD (Lower Severe Disability), or Lower MD (Lower Moderate Disability) on the Glasgow Outcome Scale, or demonstrating physical brain impairment resulting in 55% whole person impairment.

Can a Non-Catastrophic Injury Later Be Classified as a Catastrophic Injury?

Yes, injuries initially classified as non-catastrophic can later be reclassified as catastrophic. Some injuries evolve over time, with complications or deterioration warranting reclassification. Additionally, the full extent of injuries may not become apparent until after an extended medical assessment. Ontario regulations permit catastrophic impairment applications at any time,

although practical limitations apply. If you’ve reached maximum medical improvement and believe your condition meets catastrophic criteria, you can apply for reassessment regardless of initial classification. This often requires updated medical evidence demonstrating how your condition meets specific catastrophic thresholds.