In Ontario, an individual injured as a result of a motor vehicle accident can claim from the automobile insurance company for various benefits under the Statutory Accident Benefits Schedule (the “SABS”). The purpose of the SABS is to allow an insured individual access to necessary treatment and benefits in a timely manner. The benefits are vital to the claimant’s rehabilitation and recovery process and may include, among others, Medical and Rehabilitation Benefits, Attendant Care Benefits, Death and Funeral Benefits, and Income Replacement, Non-Earner, or Caregiver Benefits.
However, did you know that there are general exclusion clauses under the SABS that significantly limit a claimant’s rights and deprive them of certain benefits? These statutory exclusions are contained in section 31 of the SABS and are summarized below as follows:
Driver Exclusions
- Driver knew or ought reasonably to have known that he or she was operating the automobile while it was not insured under a motor vehicle liability policy;
- Driver was driving the automobile without a valid driver’s licence;
- Driver is an excluded driver under the contract of automobile insurance, or
- Driver knew or ought reasonably to have known that he or she was operating the automobile without the owner’s consent.
Passenger Exclusion
- Knew or ought to have known the driver was operating the vehicle without the owner’s consent.
Material Misrepresentation
- Made a material misrepresentation that induced the insurer to enter into a contract of automobile insurance; or
- Intentionally failed to notify the insurer of a change in a risk material to the contract.
Criminal Acts
- At the time of the accident, the claimant was engaged in an act for which later he or she was convicted of a criminal offence;
- At the time of the accident, the claimant was an occupant of the vehicle that was being used in connection with an act for which later he or she is convicted of a criminal offence; or
- Failure to provide a breath sample.
The onus is always on the insurance company to demonstrate that an exclusion applies. If found in breach of any one of the exclusions, a claimant is disentitled from applying for or claiming the following:
- Income Replacement Benefits;
- Non-Earner Benefits;
- Housekeeping & Home Maintenance Expenses;
- Lost Educational Expenses; and
- Visitor Expenses.
After a motor vehicle accident, many injured individuals are in a vulnerable position; physically, mentally, and financially. Loss of the excluded benefits can further impede a claimant’s recovery and have a detrimental impact. Given the severity, it is important that you consult a personal injury lawyer with knowledge and experience in the area of motor vehicle litigation.