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Home My WebLink About1993-04-27; City Council; 12191; SETTLEMENT OF WORKERS' COMPENSATION CLAIMS OF SHANNON BOWLINAB# 12, I ’??/ MTG. 4/27/93 DEPT. RM DEPT COMPENSATION CLAIMS OF SHANNON CITY TITLE: SETTLEMENT OF WORKERS’ BOWLIN CITY 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 I 18 19 20 a 22 23 24 25 26 27 28 0 0 RESOLUTION NO. 93-117 A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CARLSBAD, CALIFORNIA, AUTHORIZING THE EXPENDITURE OF FUNDS FOR SETTLEMENT OF THE WORKERS COMPENSATION CLAIMS OF SHANNON BOWLIN WHEREAS, Mr. Charles Loof, Defense Counsel for the City of Carlsbad in this matter, has recommended a settlement of the Workers Compensation claims of Shannon Bowlin; and WHEREAS, there are sufficient funds available in the Workers Compensation Self Insurance Fund to pay the settlement, NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of CarIsbad, California, as follows: I. 2. That the above recitations are true and correct. That the expenditure of $36,000 from the Workers Compensation Self- Insurance Fund is authorized for the settlement of said claims. That the Council accept the Compromise and Release, attached hereto as Exhibit 2. 3. / /I I I I I I f I 1 2 3 4 5 6 7 a 9 10 11 12 13 14 15 16 17 18 19 0 0 PASSED, APPROVED AND ADOPTED at a Regular Meeting of the Ci Council of the City of Carlsbad on the 27th day of April vote, to wit: 1993, by the following AmS: Council Members Lewis, Stanton, Nygaard and Finnila NOES: None ABSENT Council Member Kulchin ATTEST: d&i%~ A! ALETHA L. MU j 20 21 22 23 24 25 26 27 28 EXHlBll 0 0 - i WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA \ oos~ 631 Case~o. ?A QG sd\~h+ 005263J s/3-*lvo/v e !!L4 Applicant Order Approving Compromise and Releas VS 017y oc c?-&*h, f%,z c/u/4cH @cA,a IclA4JP6-m€iuT1 Defendants The parties o the abo e-entitled action having filed a Compromise and Release he in addition to all sums which may have been paid previously, and requesting that it be appro this Board having considered the entire record, including said Compromise and Release, n that it should be approved. IT IS ORDERED that said Compromise and Release be approved. Award is made in favor of: Z&+d~dd % &&;XI fi6-AlLs7 /#fi &Ed, 42 (993 settling this case for $ 3 6,eua. -- ( / 4 OMC56PP. 7h5 O~BWI '/IS N~LC j~b ~$19 jF I &&T fie4 QwaCnpTO Wr17H*s 6hr'y-fidg f-1 &Y5 OF 61s L f+$a PrDapYeS i3r ZE cry C,fuc;L J c7-r OK Dated c/lLi /i' c-") BY: id<& Scrvice by dadon parties as shown on Offioal Address Record effected on above date. DEPARTMENT OF INDUSTRIAL DIVISION OF INOUSTTRIAL DIA WCAB FORM 66 (RN. 5-4s) 92 R( CkENO. 92 RC SOCIAL SECURrPl NO. 549-' 0 STATE OF CALIFORNIA DEPARTENT OF INDUSTRIAL RELATIONS OIVlSlON OF WORKERS COMPENSATION WORKERS COMPENSATION APPEALS BOARD 0 ~ COMPR0M:SE AND RELEASE PLEASE SEE INSRUCTIONS ON REVERSE OF PAGE 2 BEFORE COMPLETING FORM 332 Valley Pines Drive 1200 Carlsbad Village Drive 3954 Murphy Canyon?%%d, Sui Shannon P. Bowlin Etna, CA 96027 City of Carlsbad, P.S.I. Carlsbad, CA 92008 im Manaaement CorDoration San Dieqo, CA 92123 HCM Cla 1. The injured employee claims that while employed as a 12/15/85 - 3/28/91 CT (elm on 212 0191 at Carl sbad (s)he sustained injury arising out of and in the course of employment to W c extremities and other as supported by the incorpor&e8 me&ca!? =Ye 2. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of S 3 I OC in addition to any sums heretofore paid by the employer or the insurer to the employee, less amounts set fol th in Paragr 3 Upon approval of this compromise agreement by the Workers' Compensation Appeals Board or a workers' compensation J in accordance with the provisions hereof, said employee releases and forever discharges said employer and insurar claims and causes of action, whether now known or ascertained, or which may hereafter arise or develop as a res including any and all liability sf said employer and said insurance carrier and each of them to the dependents, representatives, administrators or assigns of said employee. 4. Unless otherwise expressly provided herein, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLlCANl DEATH BENEFITS RELATING TO INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties haVt release of these benefits in arriving at the sum in Paragraph No. 2 WPLICIHT (EMPLOYEE) MORES CORRECT NAME OF EMPLOYER CORRECT NAME OF IMSURANCECPRRIER tOORES5 Police Officer [OCCUPATION ATTIME OF INJURY) [STATE) 8 CA (MTE OF INJURY) np (WBOOYW L 5. Unless otherwise expressly ordered by a workers' compensation judge, approval of this agreement DOES NOT RELEAS' CANT MAY NOW OR HEREAFTER HAVE FOR REHABILITATION OR BENEFITS IN CONNECTION WITH REHABILITATION. 6. The parties represent that the following facts are true: (If facts are disputed. state what each party contends un DATE OF BIRTH ACNU EMNINGSATTIME OF INJURY LAST IXY OFF WORK DUE TO 11/2/56 $763.41/weeklv Dismted PAYMENTS MADE BY EMPLOYER OR lNSURANCE CARRIER TEMPORARY OlSABlLlTY INDEMNITY WEEKLY RATE PERIODS COVERED Fully compensated un!er LCS 4850 PERMANENTOlSABlLllY IN0 NlTY TOTAL MEDICAL AND HOSPIIU BILLS &7S'%ii $10,100.59 BENEFITS CLAIMED BY INJURED EMPLOYEE BEGINNING AN0 ENDING DATES OF ALL PERlobs OFF DUE TO THIS INJURY MEDICAL AND HOSPITAL BILLS PAID BY wpior None Fully compensated in this settlement ESflWTED FUTURE MEOlOU EXPENSE --p% fay CIMc.4LLr- v-0 TO BE PAID BY: Applicant TOTAL UNPAIO ME01 TO BE PAID BY. THE FOLLOWIN PAYABLETO City of Carlsbad s s* s PAYABLE TO $ $ PAYABLE TO s MOUNTS ARE TO BE DEDUCTED FROM THE SETMMENT AMOUNT PAYABLE TO 7,566 & PAYABLE TO PAYABLE TO Ed) 490 LEAVING A BALANCE OF $ d@s approved attorney fee (See Paragraph No. 91, payable to applica be other than in a lump sum, or there is additional information, speclfy on Separate pageb) .I Less any permanent disability advances paid to applicant from the date of preparation of this Compromise and Release to the date of &a&~g#$,~g& tk~~pA~~der Approving Compromise and Release - a 0 0 i. Liens not mentioned in Paragraph No 6 are to be disposed of as followm 7 8 For the purpose of determining the lien claim(s) filed for benefits paid pursuant to the Unemployment Insurance COC furnished by lien claimants define9 in Labor Code Sec. 4903 1. the parties propose reduction of the lien claim(s) in formulae attached. Not applicable Amount of attorney fee previously paid. if an) 9 Applicant's (employee's) attorney requests a fee of S 10 Reason for Compromise. special provisions regarding rehabilitation and death benefit claims, and additional informatio A. See Attached Page 2-A c; wy @ s.~p-=--T- -6-r- Ad 92 dYY- 2L kz&Ly de pa m-p 8-rT w-=T- A~U~W * 11. It is agreed by all parties hereto that the filing of this document IS the filing of an application on behalf of the emp WCAB may in its discretion set the matter for hearing as a regular application. reserving to the parties the right to the facts admitted herein. and that if hearing is held with this document used as an application the defendants sha them all defenses that were available as of the date of filing of this document, and that the WCAB may thereafter f Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearing has been I Witness the SI THE APPLICANTS (EMPLOYEETI SIGNATURE 0 BY Two DISINTERESED persons OR ACKNOWLEOGEO BEFORE A NO - , beforeme, t STATE OF CALIFORNIA Carnlyof -0 on mls day of AD., 79 - a Notary Public in and for the sard County and State. residing therein, &ly commrssroned and Mm, personally appeared. mom, tome to be theperson- mse name subscfrbed to the wrthrn Instrument, and acknowredged to me mat-he- executed the same. IN WmJESS WHEREOF, I haw hereunto set my hand and affixed my officral seal the day and paf in thrs Certrflcate frrst a1 written. NocaryPuMic m and for said Countyam State or Calirornia DIA WCAB FORM 15 (REV UW) [PACE 21 e m L APPLICANT: Shannon P. Bowlin COMPROMISE AND RELEA! CASE NO. : 92 §DO. et a1 - XX A) This settlement includes any and all claims for medic ternporarydisability, vocationalrehabilitationtempora disability and reimbursements through the date of t Order Approving Compromise and Release. a/ Initials - XX B) It is further understood and agreed that the aforesa sum includes interest as provided by law for a period twenty-five (25) days from the date of service by t Workers f Compensation Appeals -,of the Orc Approving Compromise and Release FL 9 UTnitials Me3 - xx C) DEATH BENEFIT CLAIM WAIVER: The applicant has been advised and fully understands tl this Compromise and Release Agreement releases any i all claims of any dependents to potential death benefi relating to the injury or injuries overed by tk Compromise and Release Agreement. A reasonable and substantial dispute exists between parties as to: Nature and extent of the applican disability, both temporary and permanent; need for pa present, and future medical treatment; reimbursement self-procured expenses; etc. Rather than risk uncertainties of litigation, the parties wish to set this claim, and all its sent and potential issues, 4- nitials - XX D) a lump sum certain. & Initials DATE: J/ -4 - 73 APPLICANT : & . (2 %3',Ed .pd%l/l? I DATE: q-k -f? APP' S ATTY : dl 5LL( /,? &HA / PAGE 2-A t 0 0 PARAGRAPH 7 CONTINUED Shannon P. Bowlin City of Carlsbad, P.S.I. WCAB CASE NO.: 92 SDO, et a1 Defendants have paid, or will pay, negotiate, or litigate the 1. claims of: 1. Lee A. Wood, D.C. -$625.76 (AKA La Costa Chiropractic) 2. Kenneth C. Lay, M.D. - $982.40 (Paid) 3. Terry Petty, D.C. -$247.50 (Paid) 4. 5. 6. 7. vs . a. 9. 10. Labor Code, Section 4626 provides: "All charges for x-ra laboratory services, and other diagnostic tests provided connection with an industrial medical-legal evaluation shall billed in accordance with the official medical fee schedule ado1 by the administrative director pursuant to Section 5307.1 and SI be itemized separately in accordance with rules promulgated by administrative director." Pursuant to Labor Code, Section 1 defendants reserve the right to adjust the charges for x-ri laboratory services, and other diagnostic tests to fee schedu: Workers' Compensation Appeal Board to retain jurisdiction. I # ~L41.,7~~, 1 P &ZL &7ii L4Z - L+?f7+i Lt - tg-93 Attorney for Applicant Applicant Dated: Y-& -q3 Dated: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 l5 16 17 18 19 20 21 22 23 24 25 26 27 28 m a (vERlFlCATION4. 2015.5 C. C. P.) STATE OF CALIFORNIA. COUNTY OF I am the in the abow entdtlcd action or procedhg. I haw nod the forqoing Md kunv Ik mIms Ikmj ad I mtfi tkr tk m u IN of my mR kiwdd#t. exccpr as 10 lklx m are themn stated upon my infomuon or betkt and 01 to thaw matters I bclirw it to 6. tnu. I declare. under pdty of pcqury under the laws of the State of Cdifornlo that the fewgorug u true and cmct. Exemid on at (Itel lplorrl Type or Fnni Name sigmm PROOF OF SERVICE BY MAIL (1013r. 20153 C. C. P.) STATE OF CALIFORNIA. COUNTY OF San Diego I om a midm 01 the county aforesaid. 1 M ow? :he age of eighteen years and not a party IO he b action: my buriness address IS: 7851 Mission Center Court, Suite 210 San Diecro, CA 923 on April 7, , 19.-, 93 I sed the within Fullv Executed ComD1 and Release & Order Approvinq Compromise and Release, D: on the Parties herein United Stam mad at m sard action. by placmg a INC copy thereof enclosed in a sded enwlopr with postage thereon /urrv p” oddressd as fdlous: San Diego See attached service list I declare. under penalty of ptyury under the laws of the State of California that the fortgory IS INC and correcl. Exca,tdorr April 7, 1993 at San Dieqo Idarc/ (placet Phyllis L. Baxter Type or Print Name a 0 c SERVICE LIST FOR PROOF OF SERVICE April 7, 1993 Re: Shannon B. Bowlin vs. City of Carlsbad, P.S.I. HCM Claim Management Corporation 3954 Murphy Canyon Road, Suite D205 San Diego, CA 92123 Attn: Karen Church City of Carlsbad Carlsbad, CA 92008 Attn: Jim Elliott Anthony Abbott, Esq. 125 W. Mission Avenue, Suite 106 Escondido, CA 92025 La Costa Chiropractic 61 Associates, Inc. 6986 El Camino Real, Suite F Carlsbad, CA 92009 Attn: Lee A. Wood, D.C. Kenneth C. Lay, M.D. 2850 Sixth Avenue, Suite 212 San Diego, CA 92103 Petty Chiropractic Clinic 700 South Main Yreka, CA 96097 Attn: Terry L. Petty, D.C. /1200 Carlsbad Village Drive .-r