Neutral Citation: 1994 ONICDRG 138
File No. A-007490
ONTARIO INSURANCE COMMISSION
BETWEEN:
SANTINA MALFITANO
Applicant
and
CAA INSURANCE COMPANY (ONTARIO)
Insurer
DECISION ON PRELIMINARY ISSUE
Issues:
The Applicant, Santina Malfitano, was injured in a motor vehicle accident on October 19, 1990. She applied for and received statutory accident benefits from the CAA Insurance Company ("CAA"), payable under Ontario Regulation 6721.
Mrs. Malfitano received the services of a Health Care Aide to assist her at home. She claims that she needed the Health Care Aide for an increasing number of hours, until her monthly expenses were approximately $5,500.
CAA takes the position that Mrs. Malfitano's claim is for care benefits under section 7 of the Schedule and, therefore, her benefits are limited to $3,000 per month. Mrs. Malfitano submits that her claim is for nursing services under section 6(1)(a) of the Schedule, which has no monthly limit.
The parties were unable to resolve their dispute through mediation, and Mrs. Malfitano applied for arbitration under the Insurance Act. The preliminary issue is:
Are the benefits that Mrs. Malfitano is seeking limited to $3,000 per month under section 7 of the Schedule?
Result:
Mrs. Malfitano's claim is properly brought under section 7 of the Schedule, not section 6(1)(a). Therefore, her benefits are limited to $3,000 per month.
Mrs. Malfitano is entitled to her expenses incurred in respect to this preliminary issue.
Hearing:
The hearing to deal with the preliminary issue was held in North York, Ontario, on June 27, 1994, before me, David R. Draper, arbitrator.
Present at the Hearing:
Applicant's
Kenneth Arenson
Representative:
Barrister and Solicitor
Insurer's
Lee Samis
Representative:
Barrister and Solicitor
Neil Reeves was also present, assisting Mr. Samis.
The Applicant, Santina Malfitano, was not present.
Exhibits:
The Exhibits are set out in Appendix A to this decision.
Cases considered:
Joseph N. Bush and Pilot Insurance Company, April 25, 1994, OIC File No. A-004687.
Imelda Gazzola and Canadian Surety Company, July 24, 1992, OIC File No. A-000324.
Anh Le and WeUington Insurance Company, November 25, 1992, OIC File No. A-000920.
Reasons for Decision:
The parties presented the following preliminary issue with the hope that it would significantly reduce the length of the arbitration hearing:
Are the benefits that Mrs. Malfitano is seeking limited to $3,000 per month under section 7 of the Schedule?
I was provided with the following uncontested, but limited, background information:
Mrs. Malfitano was involved in a serious motor vehicle accident on October 19, 1990, while a pedestrian. Her injuries included a head trauma, later diagnosed as a concussive injury, a fractured left knee, and an injury to her left shoulder.
Shortly after the accident, Mrs. Malfitano suffered a stroke that the doctors believe is related to the accident. The stroke left her unable to speak or write, and with paralysis of her right side. She has recovered only "a handful of words", and it is unclear how much she understands when others speak to her. She has regained some mobility, but has a right-side weakness. She walks with a cane and has limited use of her right hand.
Approximately six or seven months after the accident, Mrs. Malfitano developed post-traumatic epilepsy, also related to the accident. Her epilepsy is incompletely controlled by medication and, as a result, she continues to have periodic seizures.
At the time of her accident, Mrs. Malfitano was 67 years old, and was living with her husband, Mr. Santino Malfitano. She had some health problems, including rheumatoid arthritis and an ulcer, but both conditions were controlled by medication and did not significantly affect her activities. Mr. Malfitano had been previously diagnosed with cancer of the lung, but the cancer was in remission until recently.
Mrs. Malfitano has two daughters and a son, all independent adults. One of her daughters, Ms. Connie Carnevale, uses a wheelchair due to severe rheumatoid arthritis. She and her daughter live across the street from Mr. and Mrs. Malfitano. Until the accident, Mr. and Mrs. Malfitano helped their daughter, Ms. Carnevale, with tasks made difficult by her mobility impairment. The roles have been somewhat reversed since the accident. Ms. Carnevale has become actively involved in coordinating her mother's care.
Mrs. Malfitano has received different types of therapy, including physiotherapy and speech therapy. She has received regular care from her family doctor, Dr. Masi. In addition, a caseworker from Rehabilitation Management Inc. has helped coordinate her care. It is my understanding that CAA has paid for the services that were not otherwise covered.
In August 1991, Spectrum Health Care was contracted to provide services to Mrs. Malfitano in her home. Initially, a "Health Care Aide" came to the home for 14.5 hours per week. The Health Care Aide helped Mrs. Malfitano with her daily activities, including ensuring that she took her medications, assisting with her personal hygiene, and applying ointment. CAA paid for these services.
I was not given any information about Spectrum Health Care, or the designation, "Health Care Aide". It was agreed that the Health Care Aide who has been assisting Mrs. Malfitano is not a nurse, but I was not given her professional qualifications, if any, or whether she was supervised in her work.
In the fall of 1992, the caseworker from Rehabilitation Management Inc. and the family doctor, Dr. Masi, began to discuss Mrs. Malfitano's need for additional care. On June 15, 1993, Dr. Masi wrote to CAA, stating (Exhibit 1):
Mrs. Malfitano requires extensive assistance for all activities including feeding, mobility, and simple matters of self care. In addition she has been having problems swallowing which I believe is a direct condition resulting from her neurological injury.
Because of medical conditions of their own, neither her husband or daughter will be able to provide the care that she requires and I believe they will be even less able to assist her in future than they are currently able to provide. Hence Mrs. Malfitano may require 24 hour nursing care to allow her to stay at home. [emphasis added]
It is not clear from this letter whether Dr. Masi included the services of a Health Care Aide within "nursing care", or if he felt that Mrs. Malfitano needed the services of an R.N. or an R.N.A.
In June 1993, the involvement of the Health Care Aide increased to 11.5 hours per day. In a letter, dated July 19, 1993, CAA asked Mrs. Malfitano's lawyer, Mr. Arenson, for clarification of the services that were being requested (Exhibit 5). On August 11, 1993, Dr. Masi signed a form, provided by Mr. Arenson, stating (Exhibit 3):
In my opinion these [sic] patients need the following services or supplies: 24 hour nursing care
These services or supplies are necessary for the treatment, occupational retraining or rehabilitation of the patient.
Again, it is not clear what Dr. Masi meant by "nursing care". On September 7, 1993, CAA sent Dr. Masi a letter asking him for clarification (Exhibit 4). He was asked whether, in his opinion, Mrs. Malfitano required the services of an R.N., an R.N.A., or "some type of Homemaker/Companion". In a letter, dated September 27, 1993, Dr. Masi stated (Exhibit 2):
Mrs. Malfitano will require assistance for activities of daily living plus monitoring of blood pressure on occasion. I believe an RNA will be able to provide the necessary care but because of her periodic seizures I do not feel that a homemaker/companion would be able to properly monitor her on-going condition.
It appears from this letter that Dr. Masi was specifically recommending the services of an R.N.A. I find, however, that Mrs. Malfitano and her family did not pursue this claim. Instead, the hours of the Health Care Aide were increased to 13.5 hours per day, seven days per week, starting in October 1993. The family continued to do what they could to help, particularly during the night when the Health Care Aide was not present.
CAA continued to pay for the Health Care Aide for some period, even though the monthly cost exceeded $3,000. CAA's position, however, is that its liability is limited to $3,000 per month by section 7(2) of the Schedule, and that any excess amount was paid in error (Exhibit 6). CAA reduced Mrs. Malfitano's benefits to $3,000 per month, but subsequently agreed, pending the resolution of the dispute, to pay for the Health Care Aide to continue at 13.5 hours per day, seven days per week. Mr. Arenson acknowledged that by paying for these services, CAA was fulfilling its obligation to pay Mrs. Malfitano's claim under section 6 of the Schedule, pending the resolution of the dispute, as required by section 6(7).
Mr. Arenson stated that Mr. Malfitano's health has deteriorated and, as a result, the family requires more assistance, particularly during the night. In the Application for Appointment of an Arbitrator, dated January 18, 1994, the following claim is advanced:
Mrs. Malfitano requires 24 hr. care. Her family doctor has called for RNA level of care, but to conserve resources, the proposal is that this be provided partly by an existing healthcare aide and partly by a new RNA.
This claim is also reflected in the letter from the pre-hearing arbitrator, dated March 18, 1994, confirming the pre-hearing discussion.
At some point prior to the hearing, Mrs. Malfitano's daughter-in-law took a leave of absence from her employment to provide assistance to Mrs. Malfitano when the Health Care Aide was not present. Mr. Arenson indicated that a claim will be made under section 7 of the Schedule for the daughter-in-law's lost income.
The claim presented at the hearing was for 24 hour care. Mr. Arenson provided estimates from Spectrum Health Care of the cost of various additional services. The cost of continuing the services of the Health Care Aide for 13.5 hours per day, seven days per week, would be approximately $5,500 per month. The cost of an R.N.A. for 24 hours a day, seven days a week would be approximately $16,594 per month. The family's proposal for 24 hour care, divided between the Health Care Aide and an R.N.A., would cost approximately $13,100 per month.
The Legislation
The relevant sections of the Schedule provide (emphasis added):
6.-(1) The insurer will pay with respect to each insured person who sustains physical, psychological or mental injury as a result of an accident all reasonable expenses resulting from the accident within the benefit period set out in subsection (3) for,
(a) medical, psychological, surgical, dental, hospital, chiropractic, nursing and ambulance services and the services of physiotherapists;
(4) Subject to subsections (5) and (6), the insurer, before making a payment for an expense under subsection (1), may require the insured person to submit a statement signed by the insured person's qualified medical practitioner or psychological advisor stating that the expense is necessary for the insured person's treatment or rehabilitation.
(7) In case of a dispute concerning an expense described in clause (1)(a), (b) or (d), the insurer will pay the expense pending resolution of the dispute.
(8) The maximum amount payable under this section is $500,000 with respect to each insured person.
7.-(1) The insurer will pay with respect to each insured person who sustains physical, psychological or mental injury as a result of an accident, for the care, if any, required by the insured person.
(a) the reasonable cost of a professional care-giver or the amount of gross income reasonably lost by a person other than the insured person as a result of the accident in caring for the insured person; and
(b) all reasonable expenses resulting from the accident in caring for the insured person after the accident.
(2) The maximum amount payable per month under this section is $3,000 a month with respect to each insured person.
(3) The maximum amount payable under this section is $500,000 with respect to each insured person.
Although benefits under both sections 6 and 7 are limited to a total of $500,000, section 7(2) creates a monthly limit of $3,000 for care benefits. The monthly limit is the source of the dispute in this case.
The Applicant's Position
I would summarize Mr. Arenson's submissions on behalf of Mrs. Malfitano as follows:
Sections 6 and 7 of the Schedule are distinct sections. Mrs. Malfitano is entitled to choose which section she is relying upon. She requires nursing services, which are compensable under section 6(1)(a). Section 7 is intended for less sophisticated forms of care, such as that provided by a non-professional, or a professional homemaker/companion.
Nursing services include different levels of care, including services by an R.N., an R.N.A., or a Health Care Aide. Mrs. Malfitano complied with section 6(4) of the Schedule by providing a statement of a qualified medical practitioner that nursing services are necessary for her treatment or rehabilitation.
If CAA feels that the claim under section 6(1)(a) is unreasonable, the proper response is to challenge Dr. Masi's statement, and not to insist that Mrs. Malfitano make her claim under section 7.
The Insurer's Position
Mr. Samis submitted on behalf of CAA that section 7 of the Schedule is a specific section dealing with "care". As a specific provision, it takes priority over the more general provisions of section 6. Therefore, section 7 is the relevant section, whoever provides the care. Mrs. Malfitano should not be able to avoid the monthly limit in section 7 by having a professional that is mentioned in section 6, such as a nurse, provide care services. Mrs. Malfitano's claim has always been for "care", within the meaning of 7 and, therefore, the $3,000 monthly limit applies.
Previous Arbitration Decisions
The scope of "care" and the interaction between sections 6 and 7 of the Schedule have been considered in a number of previous arbitration decisions.
In Imelda Gazzola and Canadian Surety Company, July 24, 1992, OIC File No. A-000324, Senior Arbitrator Naylor was asked to decide whether the Applicant's son was caring for her, within the meaning of section 7, during his visits to the hospital. The insurer maintained the son's activities were simply visits, and did not amount to care. The following comments of Senior Arbitrator Naylor are of interest:
It was suggested that "care" and "caring for the insured person" is equivalent to attendant care - the provision of services by an attendant of a constant or regular nature relating to nursing and personal care, such as assistance with eating, dressing and personal hygiene, in, for example, the insured person's home or a residential home. It may be that these are the usual circumstances under which a claim for care benefits under s. 7 will arise. However, each case must be determined in light of its own particular circumstances - in the circumstances, was a service rendered to an applicant, and a benefit derived therefrom, that can be characterised as "caring for the insured person"?
It should be noted that section 7 does not use the term "attendant care". The Concise Oxford Dictionary includes numerous definitions of the word "care", none of which provides much help. It defines "caring", an adjective, as, compassionate, esp. with reference to the professional care of the sick or elderly
It is noteworthy, however, that, in the context of the No-Fault Benefits Schedule, "care" is not equivalent to nursing services. Nursing services are separately covered by s. 6(1)(a) of the Regulations. There is no requirement under s. 7 that a medical or other professional certify that the care services are required for the rehabilitation or treatment of the Applicant, as there is under s.6(4). Nor is there any provision specifically excluding persons in hospital from receipt of care benefits.
Senior Arbitrator Naylor held that "care" requires something more than visits, but that "each case must be evaluated in light of its particular circumstances, having reference to the particular services required and rendered."
In Anh Le and Wellington Insurance Company, November 25, 1992, OIC File No. A-000920, the Applicant was receiving weekly benefits under section 13(1) and child care benefits under section 13(4) of the Schedule. She also claimed housekeeping and babysitting expenses under section 6(1)(f), which provides for benefits for "other goods and services, whether medical or non-medical in nature, which the insured person requires because of the accident."
Arbitrator Mackintosh held that an applicant can receive benefits under section 6(1)(f), in addition to receiving benefits under sections 13(1) and (4). She found, however, that most of the services being claimed as "housekeeping" were better described as "care". The services consisted of providing personal care to the applicant and attending to her personal needs arising from her physical and emotional condition.
Arbitrator Mackintosh rejected the applicant's submission that sections 6 and 7 are interchangeable, stating:
It is true that both sections 6 and 7 fall under Part II of the Schedule and deal with expenses that may be recovered "with respect to each insured person who sustains physical, psychological, or mental injury as a result of the accident". However, section 7 Care Benefits specifically carves out of section 6 Supplementary Medical and Rehabilitation Benefits, those expenses related to the personal care of the insured person. Section 7 does not contain reference to medical verification found under section 6(4). Section 7 places a monetary cap on payment of Care Benefits to the maximum of $3,000.00 per month with respect to each insured person, which does not exist for section 6 benefits. To assume, as counsel for the Applicant has, that sections 6 and 7 are overlapping or interchangeable, is to rob each section of the particular requirements and limitations imposed by the legislation, thereby rendering them meaningless. [emphasis added]
Mr. Samis, on behalf of CAA, relied on the highlighted sentence above in support of his submission that section 7 is the more specific provision.
Sections 6 and 7 were recently considered in Joseph N. Bush and Pilot Insurance Company, April 25, 1994, OIC File No. A-004687. After spending some time in hospital, Mr. Bush was discharged to his home, where he was cared for by his wife. The issue in the arbitration was the amount of benefits that should be provided to compensate Mrs. Bush for her services.
Arbitrator Palmer concluded that Mrs. Bush should be compensated at minimum wage, under section 7(1)(b) of the Schedule, as a "reasonable expense" resulting from the accident. In some months, this resulted in care expenses of more than $3,000. The applicant submitted that he should receive "top up" benefits under section 6(1)(f). Arbitrator Palmer rejected this submission, citing the interpretation in Anh Le that sections 6 and 7 are not interchangeable.
Arbitrator Palmer observed that the $3,000 limit, "in cases of severe injury, is clearly inadequate to provide 24 hour care, even by relatives or other persons receiving minimum wage, in a home setting. However, that is what the legislation has provided."
Mr. Samis submitted that the decision in Bush clearly supports the position that care benefits are limited to $3,000 per month, even if the reasonable care expenses exceed that amount.
In Bush, Arbitrator Palmer also considered whether the services provided by Mrs. Bush were nursing services. The insurer was interested in having the services characterized as nursing services because if they were, collateral benefits were available:
If the "nursing" services had been provided to Mr. Bush under section 6(1)(a) of the Schedule, presumably by a qualified registered or practical nurse, the necessity for those professional services could have been subject to the scrutiny and opinion of a qualified medical practitioner or psychological advisor under section 6(4) of the Schedule. Here, however, Mrs. Bush has provided non-professional nursing services and other care to her husband and she will be compensated, in my view, under section 7, but only to a limit of $3,000.00 per month.
Mr. Arenson relied on this paragraph in support of the submission that nursing services are compensated under section 6, not section 7.
Conclusion
This case raises a different issue than those considered in Gazzola, An Le, and Bush. The issue in this case is whether the services being claimed by Mrs. Malfitano are "nursing services" or "care". Mrs. Malfitano is entitled to present her claim as she wishes, but I do not accept that either she or CAA can simply choose how the services should be characterized. "Nursing services" and "care" are separate terms, each covering a range of services for which accident benefits are available. If the services that Mrs. Malfitano is claiming are considered "nursing services", her benefits must be determined under section 6(1)(a); if they are "care", her benefits must be determined under section 7, and are limited to $3,000 per month.
Neither "nursing services" nor "care" is defined in the legislation. In my view, the dividing line between them is not obvious. It seems to me, however, that a number of factors help distinguish "nursing services" from "care", although none of them are determinative. These factors are:
Where are the services provided?
Do the services involve active treatment or rehabilitation?
Who provides the services?
Where are the services provided?
The purpose of care benefits under section 7 of the Schedule is to enable insured persons to reasonably compensate someone who is helping them with the daily, personal tasks that they are unable to do as a result of their accident. This type of care will often, but not necessarily, be required in the person's home. In contrast, the services covered by section 6(1)(a) - "medical, psychological, surgical, dental, hospital, chiropractic, nursing and ambulance services and the services of physiotherapists" - generally are not performed in the person's home. In my opinion, therefore, services performed in the person's home suggest "care" rather than "nursing services".
However, nothing in section 6(1)(a) limits nursing services to services provided in an institutional setting. It is possible, therefore, for an applicant to succeed with a claim under section 6(1)(a) for "nursing services" if he or she can establish that, as a result of the accident, "nursing services", and not "care", are required, and that it is reasonable for those nursing services to be provided in his or her home.
Do the services involve active treatment or rehabilitation?
The focus of section 6 is on active treatment and rehabilitation. Before paying benefits under section 6, an insurer may require a statement from the applicant's medical practitioner or psychological advisor that "the expense is necessary for the insured person's treatment or rehabilitation." No similar statement is required for care benefits. This suggests that the focus of "care" in section 7 is on services required to help the person with his or her daily activities, rather than on active treatment or rehabilitation.
In addition, there is no time limit under section 7, whereas benefits under section 6 are generally limited to a period of ten years from the date of the accident. At the maximum rate for care benefits of $3,000 per month, the lifetime limit of $500,000 would not be reached for nearly fourteen years. It appears, therefore, that one of the purposes of section 7 is to meet chronic needs, and is not tied to active treatment or rehabilitation.
I also believe that there is a professional aspect to the services covered by section 6(1)(a). The injured person must require the particular medical or therapeutic services listed in the section. It is not enough that the services include some aspect of the professional services. For example, a taxi driver who drives an injured person to the hospital does not provide "ambulance services" simply because an ambulance also would have taken the person to the hospital.
Who provides the services?
In my view, the focus of sections 6(1)(a) and 7(1) is primarily on the services provided, rather than on the person who provides them. I do not accept, as suggested by Mr. Arenson, that every service performed by a nurse is "nursing", within the meaning of section 6(1) (f). The nurse must be providing "nursing services".
It also is not clear that only a qualified nurse can provide nursing services. Section 6(1)(a) deals with "medical psychological, surgical, dental, hospital, chiropractic, nursing, and ambulance services" (the anomaly is that it also covers "the services of psychotherapists"). Although the term, "nursing services", suggests services provided by a nurse, the section does not specifically state that nursing services must be provided by a qualified nurse.
In Ontario, nurses and registered nursing assistants are regulated by the Health Disciplines Act, R.S.O. 1990, c. H.4. Section 77(1) of the Health Disciplines Act provides:
77.- (1) No person shall hold himself, herself or itself out as competent to practise as a registered nurse or as a registered nursing assistant or otherwise as the holder of a certificate under this Part unless such person is the holder of the appropriate certificate under this Part.
Unlike medicine, however, there is no prohibition against non-nurses providing nursing services.
People in a variety of occupations provide services that overlap with those provided by nurses. The National Occupation Classification, prepared by Employment and Immigration Canada, lists the following occupation groups and specific occupational titles (emphasis added):
3414 Nurse Aides and Orderlies
Health Care Aide
Hospital Porter
Long-Term Care Aide
Nurse Aide
Nursing Attendant
Orderly
Patient Care Aide
Personal Care Attendant
Psychiatric Attendant
Psychiatric Aide
Ward Aide
6471 Visiting Homemakers, Housekeepers and Related Occupations
Companion
Foster Parent
Home Support Worker
Home-health Aide
Housekeeper
Personal Aide
Visiting Homemaker
I do not accept that the services of people in these occupations qualify as "nursing services" simply because they include some services that might have been provided by a nurse. Such an interpretation would unreasonably restrict the scope of section 7, which creates a specific benefit for "care", which can be provided by a non-professional or a "professional caregiver".
In my opinion, therefore, services provided by someone other than a qualified nurse should generally be treated as "care" rather than "nursing services". There may be exceptions where the services are provided in association with a nurse, or so closely supervised by a nurse that it would be unreasonable to regard them as anything but nursing services.
I have concerns about deciding this preliminary issue without a full factual basis. I have done so, however, at the request of the parties, and in appreciation of their desire to avoid a lengthy hearing.
Mrs. Malfitano's situation is difficult because she has serious health-care needs. Based on the information provided and the factors set out above, however, I conclude that the services being claimed are best described as "care", rather than "nursing services".
Mrs. Malfitano needs active treatment and therapy, but those needs are being addressed by her family doctor and a number of therapists. The Health Care Aide and Mrs. Malfitano's family have provided her with ongoing assistance with her daily tasks so that she can remain in her home. Although there is some health-care component to these services, the primary focus is "care". I would describe the services as "skilled home care". In my opinion, however, this type of care fits within the scope of "care" provided by a "professional caregiver".
The strongest evidence that Mrs. Malfitano requires active treatment at home is Dr. Masi's statement that she will require "blood pressure monitoring on occasion." I am not persuaded, however, that this is sufficient to bring her claim for 24 hour care within the scope of "nursing services".
I conclude, therefore, that Mrs. Malfitano's claim is properly for care benefits under section 7 of the Schedule, and limited to $3,000 per month.
Three days have been scheduled for the arbitration hearing in this matter: August 22, 23 and 25, 1994. A further pre-hearing discussion should be scheduled to determine what issues remain in dispute.
Expenses
An award for expenses may be made under section 282(11) of the Insurance Act, R.S.O. 1990, c.I.8., as amended by the Insurance Statute Law Amendment Act, 1993, S.O. 1993, c.10, which provides as follows:
282 (11) The arbitrator may award to the insured person such expenses incurred in respect of an arbitration proceeding as may be prescribed in the regulations to the maximum set out in the regulations.
In spite of Mrs Malfitano's lack of success on this preliminary issue, I believe that it is appropriate for her to recover her expenses. There is no suggestion that her claim was frivolous or vexatious, or that she unduly delayed the proceedings. In fact, she agreed to deal with this issue as a preliminary issue, presumably saving considerable hearing time.
Expenses are calculated according to Schedule 1 of the Dispute Resolution Practice Code and in Ontario Regulation 664, R.R.O. 1990. The parties are encouraged to reach an agreement as to the expenses. However, if an agreement cannot be reached, I remain seized of this matter and either party may apply for an assessment of the expenses.
Order:
Mrs. Malfitano's claim is properly brought under section 7 of the Schedule, not section 6(1)(a). Therefore, her benefits are limited to $3,000 per month.
Mrs. Malfitano is entitled to her expenses incurred in respect to this preliminary issue.
David R. Draper
Arbitrator
Date
APPENDIX A
Exhibit 1 -
A photocopy of a letter, dated June 15, 1993, from Dr. Masi to CAA.
Exhibit 2 -
A photocopy of a letter, dated September 27, 1993, from Dr. Masi to CAA.
Exhibit 3 -
A photocopy of an "Opinion of Physician or Psychologist (Accident Benefits)" form, signed by Dr. Masi on August 11, 1993.
Exhibit 4 -
A photocopy of a letter, dated September 7, 1993, from CAA to Dr. Masi.
Exhibit 5 -
A photocopy of a letter, dated July 19, 1993, from CAA to Mr. Arenson.
Exhibit 6 -
A photocopy of a letter, dated November 3, 1993, from CAA to Mr. Arenson.