Ontario SABS Files: Medical Records Requirements

The Ontario SABS Landscape

If you're working in Ontario auto insurance, you're working under the Statutory Accident Benefits Schedule (SABS) — Ontario Regulation 34/10 under the Insurance Act.

SABS governs accident benefits for people injured in motor vehicle accidents in Ontario. It specifies what benefits are available, who qualifies, and what medical documentation is required.

This post covers the medical records requirements under SABS — what you need to know to navigate Ontario auto insurance claims.

What Are Accident Benefits Under SABS?

Accident benefits are available to anyone injured in an auto accident in Ontario, regardless of fault. They include:

1. Income Replacement Benefits (IRB)

• For employed individuals who cannot work due to the accident
• Pays up to 70% of gross income, subject to a maximum
• Requires medical evidence of inability to work

2. Non-Earner Benefits (NEB)

• For individuals who were not employed at the time of the accident
• Pays a fixed weekly amount after a waiting period
• Requires medical evidence of complete inability to carry on a normal life

3. Medical and Rehabilitation Benefits

• Pays for reasonable and necessary medical and rehabilitation expenses
• Minor injury: Up to $3,500
• Non-catastrophic: Up to $65,000 (non-minor injury)
• Catastrophic: Up to $1,000,000
• Requires medical evidence of necessity

4. Attendant Care Benefits

• Pays for attendant care services
• Non-catastrophic: Up to $65,000
• Catastrophic: Up to $1,000,000
• Requires Form 1 (Assessment of Attendant Care Needs)

5. Caregiver Benefits

• For individuals who were primary caregivers at the time of the accident
• Pays for replacement caregiver services
• Requires medical evidence of inability to provide care

6. Housekeeping and Home Maintenance Benefits

• Pays for housekeeping and home maintenance services
• Non-catastrophic: Up to $100/week
• Catastrophic: Reasonable and necessary
• Requires medical evidence of inability to perform these tasks

7. Death and Funeral Benefits

• Pays a lump sum to survivors and covers funeral expenses
• Requires proof of death and relationship

Medical Documentation Requirements Under SABS

1. Disability Certificate (OCF-3)

What it is: A form completed by a regulated health professional (physician, nurse practitioner, chiropractor, physiotherapist, occupational therapist, or psychologist) that certifies the claimant's disability.

When it's required:

• To apply for Income Replacement Benefits
• To apply for Non-Earner Benefits
• To apply for Caregiver Benefits
• To apply for Housekeeping and Home Maintenance Benefits

What it documents:

• Whether the claimant is substantially unable to perform the essential tasks of their employment (for IRB)
• Whether the claimant suffers a complete inability to carry on a normal life (for NEB)
• Whether the claimant is unable to provide care (for Caregiver Benefits)
• Whether the claimant is unable to perform housekeeping tasks (for Housekeeping Benefits)

Key considerations:

• The certifying professional must have examined the claimant
• The certification must be based on objective clinical findings
• The certification must be provided within the time limits specified in SABS

2. Treatment and Assessment Plan (OCF-18)

What it is: A form submitted to the insurance company requesting approval for medical and rehabilitation treatment or assessment.

When it's required:

• Before providing treatment or assessment for non-minor injuries
• For treatment plans exceeding $3,500 (minor injury guideline)

What it documents:

• The proposed treatment or assessment
• The rationale for the treatment
• The expected duration and frequency
• The cost
• The goals of treatment

Key considerations:

• Must be completed by a regulated health professional
• Must be based on an assessment of the claimant
• Must be submitted to the insurer for approval
• Insurer has 10 business days to approve, modify, or decline

3. Application for Accident Benefits (OCF-1)

What it is: The initial application form for accident benefits.

When it's required:

• To initiate an accident benefits claim

What it documents:

• Claimant information
• Accident details
• Benefits being applied for
• Employment information (for IRB)
• Caregiver status (for Caregiver Benefits)

Key considerations:

• Must be submitted within 7 days of the accident (or as soon as practicable)
• Must be accompanied by supporting documentation (e.g., proof of income for IRB)

4. Attendant Care Needs Assessment (Form 1)

What it is: A form completed by an occupational therapist or nurse that assesses the claimant's attendant care needs.

When it's required:

• To apply for Attendant Care Benefits

What it documents:

• The claimant's functional limitations
• The tasks the claimant cannot perform independently
• The hours of attendant care needed
• The type of attendant care needed (professional, family, etc.)

Key considerations:

• Must be completed by a qualified assessor
• Must be based on a home assessment
• Must document the specific tasks and hours needed

5. Medical Reports

What they are: Narrative reports from treating physicians or specialists.

When they're required:

• To support OCF-3 (Disability Certificate)
• To support OCF-18 (Treatment and Assessment Plan)
• To support catastrophic impairment designation
• To respond to insurer examinations

What they should document:

• History of the injury
• Current symptoms
• Objective clinical findings
• Diagnosis
• Prognosis
• Functional limitations
• Treatment plan
• Ability to work or carry on normal life

Key considerations:

• Should be based on a recent examination
• Should include objective findings, not just self-report
• Should address the specific questions asked by the insurer

6. Specialist Reports

What they are: Reports from specialists (orthopedic surgeons, neurologists, physiatrists, psychiatrists, etc.).

When they're required:

• To support catastrophic impairment designation
• To support complex treatment requests
• To address diagnostic uncertainty

What they should document:

• Specialist assessment findings
• Diagnostic impressions
• Treatment recommendations
• Prognosis
• Functional implications

7. Imaging and Diagnostic Test Reports

What they are: Reports from X-rays, CT scans, MRIs, EMGs, nerve conduction studies, etc.

When they're required:

• To support diagnosis
• To support treatment requests
• To support catastrophic impairment designation

Key considerations:

• Should be recent and relevant
• Should be interpreted by a qualified radiologist or specialist

8. Functional Capacity Evaluation (FCE)

What it is: A standardized assessment of the claimant's physical abilities.

When it's required:

• To assess ability to return to work
• To support IRB claims
• To assess functional limitations

What it documents:

• Lifting, carrying, pushing, pulling capacity
• Sitting, standing, walking tolerance
• Ability to perform work-related tasks

Key considerations:

• Should be performed by a qualified occupational therapist or physiotherapist
• Should be based on objective testing, not just self-report

Catastrophic Impairment Designation

What it is: A designation that entitles the claimant to enhanced benefits (up to $1,000,000 for medical/rehabilitation and attendant care).

Criteria under SABS:

1. Paraplegia or tetraplegia
2. Severe impairment of ambulatory mobility or use of an arm
3. Severe impairment of vision
4. Severe impairment of speech
5. Severe impairment of cognitive function (brain injury)
6. Physical impairment combination (55% or more whole person impairment)
7. Mental or behavioral disorder combination (Class 4 or 5 impairment in 3 or more areas)
8. Combination of physical and mental/behavioral impairments

Medical documentation required:

• Comprehensive medical reports
• Specialist assessments
• Imaging and diagnostic tests
• Neuropsychological testing (for brain injury)
• AMA Guides impairment rating (for physical impairment combination)

Key considerations:

• Must be assessed by a qualified professional
• Must meet the specific criteria in SABS
• Insurer may require an insurer examination to confirm

Key Takeaways

1. SABS governs accident benefits in Ontario auto insurance.
2. Key forms: OCF-1 (Application), OCF-3 (Disability Certificate), OCF-18 (Treatment Plan), Form 1 (Attendant Care).
3. Medical documentation must be objective, recent, and relevant.
4. Catastrophic impairment designation requires comprehensive medical evidence.
5. Insurer examinations may be required to confirm disability or catastrophic status.
6. Time limits apply — submit documentation promptly.

What's Next?

In our next post, we'll tackle "WSIB Functional Abilities Form: Field-by-Field" — the second in our Canadian series.

This post is part of our series on Canadian medical-legal documentation. For more, see our HCAI OCF-18 and OCF-23 Guide.

Questions for Readers:

• What challenges have you faced with SABS documentation?
• How do you handle disputes over catastrophic impairment designation?
• What's your experience with insurer examinations?