HomeMy WebLinkAbout1997-02-18; City Council; 14059; CONTRACT FOR THIRD PARTY ADMINISTRATION OF WORKERS' COMPENSATION CLAIMS.-. d
CONTRACT FOR THIRD PARTY ADMINISTRATION
OF WORKERS’ COMPENSATION CLAIMS
RECOMMENDED ACTION:
Approval of Resolution No. o/ ’? - ?a
of workers’ compensation claims to TRISTAR Risk Management.
ITEM EXPLANATION
The contract with HCM Claim Management Corporation, administrator of the City’s workers’
compensation claims, expires on March 1, 1997.
Staff distributed a request for proposals for workers’ compensation benefits administration 01 December 2,1996, and subsequently received responses from eight firms. The proposals v
evaluated and ranked based on quality of the proposal, experience, staff qualifications and I(
of services available. The top four firms were interviewed by a panel consisting of
representatives from Human Resources and Risk Management. Key findings from the
evaluations of the top three candidates are summarized in the table below.
awarding the contract for the third party administra
GATES
TRISTAR HCM MCDONALD
San Diego County office Yes Yes No
Experience with local service Yes Some Some
Some Yes
State certified claims examiner Yes No Yes
Meets data reporting needs Yes Some Yes
Local references Chula Vista, Encinitas, S.D. School Dist None
Vista, Santee, San Diego
(claims staff), National City
Pricing from the three candidates is difficult to compare. Staff received several options basc
on number of claims filed, length of time files are open, length of contract, as well as numerc individually priced services and conditions under which fees could change. However, TRIS
proposed a three year contract at $60,000 per year, which compares favorably with the fee $60,756 under our current contract with HCM.
Based on the results of the evaluation process shown in the table above, reference checks,
the ability to enter into a three year contract below our current fee, staff is recommending th Council approve the agreement with TRISTAR shown as Exhibit 2.
FISCAL IMPACT
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AGREEMENT
THIS AGREEMENT, made and entered into as of the 1st day of March
1997, by and between the CITY OF CARLSBAD, a municipal corporation, hereinaftc
referred to as 'City", and TRISTAR Risk Management, hereinafter referred to a
"Contractor."
RECITALS
City requires the services of a third party administrator to manage and administc
the City's workers' compensation claims, and Contractor possesses the necessary ski1
and qualifications to provide the services required by the City;
NOW, THEREFORE, in consideration of these recitals and the mutual covenan
contained herein, City and Contractor agree as follows:
1. CONTRACTOR'S OBLIGATIONS
A. Program Development
1. Consult with the City's personnel and assist in developing the
necessary procedures, practices and coordination to implement the
City's Workers' Compensation Program and to meet legal
requirements of the State.
2. Provide the City with information on changes or proposed changes in
statutes, rules and regulations affecting the City's responsibility unde
a legally uninsured workers' compensation program.
3. Review with the City program progress, including identification of
problem areas and recommend solutions thereto.
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B. Claims Administration
1. Review and process all claims for Workers’ Compensation benefits in
accordance with the requirements of the Department of Industrial
Accidents for reporting and notification.
2. Determine compensability of claimed injuries and illnesses in
accordance with the State’s Workers’ Compensation laws.
3. Monitor treatment programs for injured Employees, including the
review of all “Doctor‘s First Report of Work Injury” to assure that
treatment is related to a compensatory injury or illness.
4. Maintain case liaison with treating physicians to assure that
Employees receive proper care and to avoid over-treatment situations
5. Review and make recommendations to the City in its utilization of in-
house medical experts.
6. Consult with the City’s personnel and provide guidance and evaluatior
of the physical capabilities of injured Employees to return to work.
7. Determine eligibility for, and authorize payments of medical benefits,
and authorize examinations to determine the nature and extent of
disability where appropriate.
8. Determine the eligibility for and authorize payment of temporary
disability compensation in coordination with medical advice and
rehabilitation efforts .
9. Determine the degree of permanent disability, if any, of injured worke
utilizing the advisory rating of the Disability Evaluation Bureau.
Io. Authorize payment of permanent disability compensation and death
benefits in accordance with advisory ratings, Orders of the Workers’
Compensation Appeals Board, or Compromise and Release
Ag re eme nts .
11. Refer litigated cases to attorneys. Assist in the preparation of litigate1
cases, negotiations of Compromise and Release Agreements and
subrogation actions. Continually monitor the effectiveness of defensc
cou nse I.
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12. Maintain current estimates of costs of all anticipated benefits and
related expenses on each case.
13. Investigate or arrange for investigation of questionable cases and the
status of disabled Employees in order to adjust all cases and assist in
the trial or settlement of litigated cases.
C. Employee Services
1. Provide information and guidance to the City’s employees regarding
Workers’ Compensation benefits, injuries, and permanent disability
ratings, in accordance with the City’s policies.
2. Assist in resolving Employee problems relating to an injury in non-
litigated cases.
3. When appropriate, develop rehabilitation programs for injured
Employees for approval by the City, the Employee, and other
agencies, in order to provide rehabilitation, retraining, or reassignmen for Employees with physical or performance limitations resulting from
industrial injuries.
4. Consult with Employee groups and unions on problem cases in
accordance with the City’s policies, within a reasonable scope if so
requested by the Employer.
5. Develop and recommend policies and procedures to ensure that the
Employee’s ability,to work is consistent with the findings of the
Workers’ Compensation Appeals Board.
D. Fiscal and Claims Analysis
1. Provide the City’s administration with continuing information on the
progress of individual claims, including periodic meetings and
reporting.
2. Submit monthly loss analysis reports and loss control summaries in
statistical and narrative reports and with graphics to assist in the
evaluation of the City’s progress.
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2. CITY OBLIGATIONS
The City shall cooperate with the Contractor with respect to its duties hereunder
including, but not limited to, responding to Contractor's requests for information
promptly, meeting with Contractor and/or third parties, as may be needed, making
decisions on matters which, in the professional opinion of Contractor should be made
by the City and performance by the City of all obligations of this Agreement.
3. FEES TO BE PAID TO CONTRACTOR
The total fee payable for the services to be performed shall be $60,000 per yea
and a fee not to exceed $6,000 for the transfer of data from the current administrator i
Contractor. No other compensation for services will be allowed except those iter,
covered by supplemental agreements per Paragraph 8, "Changes in Work."
The fee excludes all allocated claim services incurred outside of the scope c
normal administrative adjustment services (as defined in paragraph I), such a
attorney fees and records, court dispositions, costs and materials for expert witnesse
su b-cosa or other outside professional investigation services, outside profession
assistance in matters of mandatory vocational rehabilitation, any special charges fc
work which may result from a State audit of the prior administrator's errors, costs fc
printed checks, and printing charges of specialized forms not elsewhere used I
Contractor, and costs associated with tape-to-tape transfer of City's current at
historical claim information.
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4. OFFICE OF BENEFIT ASSISTANCE AND ENFORCEMENT PENALT
ASSESSMENTS
Any penalties or assessments incurred as a result of an Office of Bene1
Assistance and Enforcement audit will be the responsibility and paid by the party i
fault, as set forth by Addendum A.
5. DURATION OF CONTRACT
This agreement shall extend for a period of three (3) years from March 1, 1997
The contract may be extended by the City Manager for two (2) additional one (1) ye;
periods or parts thereof, based upon a review of satisfactory performance and the Cit).
needs, and provided that any proposed revisions to the Agreement by either party a
submitted in writing no later than sixty (60) days preceding the expiration of tt
contract. The parties shall prepare extensions in writing indicating effective date ai
length of the extended contract.
6. PAYMENT OF FEES
Contractor will issue monthly billings, and payment of approved items on t
monthly invoice shall be mailed to the Contractor within 30 days of receipt of t
invoice.
7. CHANGES IN WORK
If, in the course of the contract, changes seem merited by the Contractor or i
City, and informal consultations with the other party indicate that a change in 1
conditions of the contract is warranted, the Contractor or the City may request a chan
in contract. Such changes shall be processed by the City in the following manner:
letter outlining the required changes shall be forwarded to the City by Contractor
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inform them of the proposed changes along with a statement of estimated changes i
charges or time schedule. A Standard Amendment to Agreement shall be prepared b
the City and approved by the City according to the procedures described in Carlsba
Municipal Code Section 3.28.1 72. Such Amendment to Agreement shall not rend6
ineffective or invalidate unaffected portions of the agreement.
8. COVENANTS AGAINST CONTINGENT FEES
The Contractor warrants that their firm has not employed or retained ar
company or person, other than a bona fide employee working for the Contractor, *
solicit or secure this agreement, and that Contractor has not paid or agreed to pay ar
company or person, other than a bona fide employee, any fee, commissio
percentage, brokerage fee, gift, or any other consideration contingent upon, or resultir
from, the award or making of this agreement. For breach or violation of this warrant
the City shall have the right to annul this agreement without liability, or, in its discretio
to deduct from the agreement price or consideration, or otherwise recover, the f
amount of such fee, commission, percentage, brokerage fees, gift, or contingent fee.
9. NONDl SCRIM I NATION CLAUSE
The Contractor shall comply with the state and federal laws regardii
nondiscrimination.
IO. TERMINATION OF CONTRACT
In the event of the Contractor's failure to prosecute, deliver, or perform the wc
as provided for in this contract, the City Manager may terminate this contract
nonperformance by notifying the Contractor by certified mail of the termination of t
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Contractor. The Contractor, thereupon, has five (5) working days to deliver sai
documents owned by the City and all work in progress to the Risk Manager. The Ris
Manager shall make a determination of fact based upon the documents delivered t
City of the percentage of work which the Contractor has performed which is usable an
of worth to the City in having the contract completed. Based upon that finding a
reported to the City Manager, the Manager shall determine the final payment of tb
con tract.
This agreement may be terminated by either party upon tendering thirty (3r
days written notice to the other party. In the event of such suspension or terminatio
upon request of the City, the Contractor shall assemble the work product and put sar-r
in order for proper filing and closing and deliver said product to City. In the event
termination, the Contractor shall be paid for work performed to the termination dat
however, the total shall not exceed the lump sum fee payable under paragraph 4. Tt
City Manager shall make the final determination as to the portions of tasks completc
and the compensation to be made.
11. HIRING OF EMPLOYEES
City agrees that during the term of, and for a period of (2) years after tl
termination of this Agreement, it will not, without written consent of Contractor hire a
employee of Contractor who was assigned to or performed any service for City
connection with this Agreement.
12. DISPUTES
If a dispute should arise regarding the performance of work under tl
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agreement, the following procedure shall be used to resolve any question of fact c
interpretation not otherwise settled by agreement between parties. Such questions,
they become identified as a part of a dispute among persons operating under th
provisions of this contract, shall be reduced to writing by the principal of the Contractc
or the City Risk Manager. A copy of such documented dispute shall be forwarded t
both parties involved along with recommended methods of resolution which would be c
benefit to both parties. The City Risk Manager or principal receiving the letter sh:
reply to the letter along with a recommended method of resolution within ten (IO) day
If the resolution thus obtained is unsatisfactory to the aggrieved party, a letter outlinir
the dispute shall be forwarded to the City Council for their resolution through the Offic
of the City Manager. The City Council may then opt to consider the directed solution 1
the problem. In such cases, the action of the City Council shall be binding upon tt-
parties involved, although nothing in this procedure shall prohibit the parties seekir
remedies available to them at law.
13. CLAIMS AND LAWSUITS
The Contractor agrees that any contract claim submitted to the City must t
asserted as part of the contract process as set forth in this agreement and not
anticipation of litigation or in conjunction with litigation. The Contractor acknowledgc
that if a false claim is submitted to the City, it may be considered fraud and tt
Contractor may be subject to criminal prosecution. The Contractor acknowledges tt-
California Government Code sections 12650 et seq., the False Claims Act, provides i
civil penalties where a person knowingly submits a false claim to a public entity. The
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provisions include false claims made with deliberate ignorance of the false informatio
or in reckless disregard of the truth or falsity of information. If the City of Carlsbad seek
to recover penalties pursuant to the False Claims Act, it is entitled to recover i.
litigation costs, including attorney's fees. The Contractor acknowledges that the filing (
a false claim may subject the Contractor to an administrative debarment proceedin
wherein the Contractor may be prevented to act as a Contractor on any public work '
improvement for a period of up to five years. The Contractor acknowledges debarme
by another jurisdiction is grounds for the City of Carlsbad to disqualify the Contract
from the selection process. f' (Initial)
The provisions of Carlsbad Municipal Code sections 3.32.025, 3.32.02
3.32.027 and 3.32.028 pertaining to false claims are incorporated herein by referencf
i;' (Initial)
14. STATUS OF THE CONTRACTOR
The Contractor shall perform the services provided for herein in Contractor's o\
way as an independent Contractor and in pursuit of Contractor's independent callir
and not as an employee of the City. Contractor shall be under control of the City ot
as to the result to be accomplished, but shall consult with the City as provided for in t
request for proposal. The persons used by the Contractor to provide services under tt
agreement shall not be considered employees of the City for any purposes whatsoevc
The Contractor is an independent Contractor of the City. The payment made
the Contractor pursuant to the contract shall be the full and complete compensation
which the Contractor is entitled. The City shall not make any federal or state
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withholdings on behalf of the Contractor or hidher employees or subcontractors. Thl
City shall not be required to pay any workers' compensation insurance c
unemployment contributions on behalf of the Contractor or his/her employees c
subcontractors. The Contractor agrees to indemnify the City within 30 days for any ta:
retirement contribution, social security, overtime payment, unemployment payment (
workers' compensation payment which the City may be required to make on behalf (
the Contractor or any employee or subcontractor of the Contractor for work done undt
this agreement or such indemnification amount may be deducted by the City from ar
balance owing to the Contractor.
The Contractor shall be aware of the requirements of the Immigration Refor
and Control Act of 1986 and shall comply with those requirements, including, but n
limited to, verifying the eligibility for employment of all agents, employee
subcontractors and Consultants that are included in this agreement.
15. CONFORMITY TO LEGAL REQUIREMENTS
The Contractor shall cause all final reports to conform to all applicat
requirements of law: federal, state and local. Contractor shall provide all necess2
supporting documents, to be filed with any agencies whose approval is necessary.
Contractor agrees to allow City or its designated representative to monitor, auc
review, and examine the methods, procedures, and results of Contractor.
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16. OWNERSHIP OF DOCUMENTS
All Claim file records, reports, and other documents and material pertaining to
the City’s claims shall be the property of the City and shall be delivered to the City or it!
designee by Contractor upon termination of this Agreement.
17. HOLD HARMLESS AGREEMENT
Contractor agrees to indemnify and hold harmless the City of Carlsbad and ii
officers, officials, employees and volunteers from and against all claims, damage
losses and expenses including attorney fees arising out of the performance of the wo
described herein caused in whole or in part by any willful misconduct or negligent act I
omission of the Contractor, any subcontractor, anyone directly or indirectly employed t
any of them or anyone for whose acts any of them may be liable, except where cause
by the active negligence, sole negligence, or willful misconduct of the City of Carlsbad.
Contractor shall at its own expense, upon written request by the City, defend ar
such suit or action brought against the City, its officers, officials, employees ai
volunteers. Contractors indemnification of City shall not be limited by any prior
subsequent declaration by the Contractor.
18. ASSIGNMENT OF CONTRACT
The Contractor shall not assign this contract or any part thereof or any monic
due thereunder without the prior written consent of the City.
19. SUBCONTRACTING
If the Contractor shall subcontract any of the work to be performed under tl
contract by the Contractor, Contractor shall be fully responsible to the City for the a(
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and omissions of Contractor's subcontractor and of the persons either directly c
indirectly employed by the subcontractor, as Contractor is for the acts and omissions (
persons directly employed by Contractor. Nothing contained in this contract sha
create any contractual relationship between any subcontractor of Contractor and th
City. The Contractor shall bind every subcontractor and every subcontractor of
subcontractor by the terms of this contract applicable to Contractor's work unles
specifically noted to the contrary in the subcontract in question approved in writing I:
the City.
20. PROHIBITED INTEREST
No official of the City who is authorized in such capacity on behalf of the City.
negotiate, make, accept, or approve, or take part in negotiating, making, accepting, (
approving of this agreement, shall become directly or indirectly interested personally
this contract or in any part thereof. No officer or employee of the City who is authorize
in such capacity and on behalf of the City to exercise any executive, supervisory,
similar functions in connection with the performance of this contract shall becon
directly or indirectly interested personally in this contract or any part thereof.
21. VERBAL AGREEMENT OR CONVERSATION
No verbal agreement or conversation with any officer, agent, or employee of tt
City, either before, during or after the execution of this contract, shall affect or mod
any of the terms or obligations herein contained nor entitle the Contractor to a1
additional payment whatsoever under the terms of this contract.
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22. SUCCESSORS OR ASSIGNS
Subject to the provisions of Paragraph 17, "Hold Harmless Agreement," a
terms, conditions, and provisions hereof shall inure to and shall bind each of the partie
hereto, and each of their respective heirs, executors, administrators, successors, an1
assigns.
23. EFFECTIVE DATE
This agreement shall be effective on March 1, 1997.
24. CONFLICT OF INTEREST
The Contractor shall file a conflict of interest statement with the City Clerk I
accordance with the requirements of the City's conflict of interest code incorporatin
Fair Political Practices Commission Regulation 18700 as it defines a consultant. Th
disclosure category shall be categories one (1) through four (4).
25. INSURANCE
The Contractor shall obtain and maintain for the duration of the contract and ar
and all amendments insurance against claims for injuries to persons or damage 1
property which may arise out of or in connection with performance of the WOI
hereunder by the Contractor, his agents, representatives, employees or subcontractor
Said insurance shall be obtained from an insurance carrier admitted and authorized
do business in the State of California. The insurance carrier is required to have
current Best's Key Rating of not less than "A-:V" and shall meet the City's policy fi
insurance as stated in Resolution No. 91-403.
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A. Coverages and Limits.
Contractor shall maintain the types of coverages and minimum limit
indicated herein, unless a lower amount is approved by the City Attorney or Cit
Manager:
1. Comprehensive General Liability Insurance. $1,000,000 combine
single-limit per occurrence for bodily injury, personal injury and property damage. If th
submitted policies contain aggregate limits, general aggregate limits shall appl
separately to the work under this contract or the general aggregate shall be twice th
required per occurrence limit.
2. Automobile Liability (if the use of an automobile is involved fc
Contractor's work for the City). $1,000,000 combined single-limit per accident for bodi
injury and property damage.
3. Workers' Compensation and Employer's Liability. Worker
Compensation limits as required by the Labor Code of the State of California ar
Employer's Liability limits of $1,000,000 per accident for bodily injury.
4. Professional Liability. Errors and omissions liability appropriate to tt
contractor's profession with limits of not less than $1,000,000 pl
claim. Coverage shall be maintained for a period of five years followii
the date of completion of the work.
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B. Additional Provisions.
Contractor shall ensure that the policies of insurance required under thi
agreement contain, or are endorsed to contain, the following provisions.
1. The City shall be named as an additional insured on all policie
excluding Workers’ Compensation and Professional Liability.
2. The Contractor shall furnish certificates of insurance to the Cit
before commencement of work.
3. The Contractor shall obtain occurrence coverage, excludir
Professional Liability which shall be written as claims-made coverage.
4. This insurance shall be in force during the life of the agreement ar
any extension thereof and shall not be canceled without 30 days prior written notice 1
the City sent by certified mail.
5. If the Contractor fails to maintain any of the insurance coveragc
required herein, then the City will have the option to declare the Contractor in breach,
may purchase replacement insurance or pay the premiums that are due on existir
policies in order that the required coverages may be maintained. The Contractor
responsible for any payments made by the City to obtain or maintain such insuranc
and the City may collect the same from the Contractor or deduct the amount paid fro
any sums due the Contractor under this agreement.
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26. RESPONSIBLE PARTIES
The name of the persons who are authorized to give written notices or to receiv
written notice on behalf of the City and on behalf of the Contractor in connection wil
the foregoing are as follows:
For City: Title Risk Manaqer
Name Erin K. Letsch
Address 1200 Carlsbad Villaqe Dr.
Carlsbad, CA 92008
For Contractor: Title Vice President
Name Kevin C. Burke
Address 6133 Bristol Parkwav, Suite 300
Culver Citv. CA 90230-6632
27. BUSINESS LICENSE
Contractor shall obtain and maintain a City of Carlsbad Business License for tl
duration of the contract.
28. ENTIRE AGREEMENT
This agreement, together with any other written document referred to
contemplated herein, embody the entire agreement and understanding between t
parties relating to the subject matter hereof. Neither this agreement nor any provisi
hereof may be amended, modified, waived or discharged except by an instrument
writing executed by the party against which enforcement of such amendment, waiver
discharge is sought.
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Executed by Contractor this 2 1 st day of March , 1997.
CONTRACTOR: CITY OF CARLSBAD, a municipal
ATTEST:
(print na eitjtle)
By: LYdL 2 TaJ ' (sign here)
- atarse, Asst. Secretary ALETHA L. RAUTEmRRANZ
(print namehitle) City Clerk
(Proper notarial acknowledgment of execution by Contractor must be attached.)
(President or vice-president and secretary or assistant secretary must sign
corporations. If only one officer signs, the corporation must attach a resolution certifi
by the secretary or assistant secretary under corporate seal empowering that officer
bind the corporation.)
APPROVED AS TO FORM:
RONALD R. BALL
City Attorney
BY
h combined TRISTAR and City Agreement
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& ACKNOWLEDGMENT 0 1 ,I - CALIFORNIA ALL-PURP
-7c~Wps LJ C72rr e Awe?
Name and Title of Officer (e.g., "Jane Doe, Notary Public")
personally appeared 3 umd~ 6 m~/q 6 m~ JC&2 36;7fPPyQ ' Name@) 01 Signer@)
and acknowledged to me that he/she/they executed th
same in his/her/their authorized capacity(ies), and that t
his/her/their signature(s) on the instrument the person(:
or the entity upon behalf of which the person(s) acte
executed the instrument.
WITNESS my hand and official seal.
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Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevei
fraudulent removal and reattachment of this form to another document.
Description of Attached Document
Title or Type of Document:
Document Date: Number of Pages:
Signer(s) Other Than Named Above:
Capacity(ies) Claimed by Signer(s)
0 Individual 0 Individual
0 Corporate Officer
0 Partner - il Limited I , General i .! Partner - 0 Limited 3 General
CJ Corporate Officer
Title(s) :
0 Guardian or Conservator [-:i Guardian or Conservator
Signer Is Representing: Signer Is Representing:
Reorder: Call Toll-Fre D 1994 National Nofary Assoctatiofl* 8236 Remrnet Ave , PO Box 7184 * Canoga Park, CA 91309-7184 Prod No 5907
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mnmrmM A
Gnder the guidelines of legislation regarding Workers’ Compensation in the State of California
effective January 1, 1990 there are procedures for the assessment of penalties in varying amounts for specific violations ot either clam pracQces or the timely, accurate, and effective provision
of benefits to the inwed Employees as determined through the audit process of the Office of
Benefit Assistance and Enforcement (OBAE).
Et has been clearly stated by OBAE that in the case of a self-insured Employer whose claims are
adminisrered by 8 thud pany admulistrator (TPA) that “the penalty imposed soall be jomt an<
several, and shall be served upon both the self-insured and third party adminiStrat0r.” This i
to say that both parties will have the obligation to resolve the paymenr of the assessment, pa:
the penalty assessed or to lodge the appropriate defense against 6-itch payment 2 the penalty i
felt to be either irrappropriate or umasor?able under the specific cllctlmtances that have give
rfse so the assessment of zhe penalty in question.
In the event that the penalty assessed is for work dcne or not done properly by a prk
administrator, where there has been a subsequent change in third party administrators the penalt
again will be issued as a joint md several document with notice being serve,d upon both the sei!
imurwl and the g& wfminiutrator.
The schedule of penalties has once again been refmed and it is possibie that it will be furtht
refined aa ORAR continues to draft its procedwe manual far the conduction of an audit ad 12
determination of penalty assesanem,
In order to determine h an orderly manner who should be responsible for the payment of 81 penalties assessed the fallowing guidelines will be utilized by TRISTAR Risk Managerne
(TRISTAR 1.
OF \I?OUnN ANn RE3 PONSIBLE PARTY
Failure to pay full 10% self-imposed penalty
As tbis would appear to bc a calculation crror, and thcrcforc thc responsibility of t
claims examiner, the penalty would be paid by the TPA.
However, in the event that the calculation error was based on incorrect infurmar; provided by the Employer, the penalty would apj?ear appropriate for payment by
Employer.
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Self-impose4 penalty not paid
If the penalty was not paid because the Employer had not notified the "PA of the return
of the claim form from the Employee &efi tlh ped~y would bc; paid by he Employer.
Where the failure tu pay the self-imposed penalty is a calculation error by the claim examher and all information ha! been timely prnvidecl the examber rhe payment of the
assessment would be the responsibility of the TPA.
Failure to advance permanent dhabilfty when due
Where the file is clearly documented and the failure to pay is an examiner error then th
penalty assessed is the "PA responsibility.
If the knowledge of permanent disability is withheld from the examiner by either thc Employer or a doctor specitlcally selected by the iAnployer the penalty is the Employc responsibility .
No EmpIoyer data recehd on Employee claim form
It should 'oe nored that for Ws assessment to apply rhe claim form must have bee returned to the Emptoyer and the Employer in sending the Carrier/TPA copy of the for:
will have neglected to complete the appropriate information required. This penalty wou
be appropriate for Employer payment.
Artditiudly, il should be UUM that from he tu he the TTA may receive 8 chi
fom &om sources other than the Employer {it. doctors or Applicant's Attorney).
Whe~ that happen9 the "PA wilt document the file that the chim fonn was origh'
received from a sow other than the Employer, forward a copy of the claim foi
corupktc by the Employee to the Euployer for coupletion of the appropriate inforimti €or rem to the "PA. If the form is not returned to the TPA with the requir infomution the Employer wilt be responsible for the payment of the assessment.
Faflure to respond to written Employee request for treatment with 20 days
If she written request is received by the TPA the payment of this penalty will be paid
the 'I'YA, However, if the wntten request 1s received by the Employer and it is
communicated add sent to the "PA on the date of Employer receipt the pwafty sho
be paid by the Employer.
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Failure to pay requested and uncontested medical mileage
If the mileage request is sent by the Employee directly to the TPA rather than to an
other party, the TPA will pay the penalty assessment. If the rdleage request is sent fit
to the Employer and that Employer does not commdcate and send the mileage reque to the "PA on the date of the Employer receipt of the mileage request, the penalty w
be paid by the Employer.
Payment at less than maximum T.D. rate without documentation in addition to tl
Employer's Report
This penalty assumes that there is not ample documenration to support such a payrnei
It is TRISTAR 's procedure to pay all temporary disability benefits as maximum urd( an adequate wage statement has been provided and in our possession at the time that a
indemnity benefit is paid. In light of this policy the payment of the penalty assess&
the responsibility of t?~ TPA unless the wage information provided by the Emphyei
inaccurate and in that case the Empioyer would be responsible for the payment of assessment.
Failure to pay flrst T.D. payment withia 14 days of date of knowledge of injury e
disabuty
"his date of knowledge is determined to be the Employer's date of knowledge. \Nh
tbe information has been provided to the TPA by the fifth day following the Employc
date of knowledge, the penalty assessed by OBAE will be paid by the TPA. Where
TPA is not provided notice and sufficient information within five days of the Employ
date of knowledge, or where it is determined after investigation or discovery that
Employer's date of knowledge was actually earlier than stated, the penalty will be
responsibility of the Employer.
Failure to comply with any rule or regulation of the A.D.
This is certain to be the area of most discussion in any penalty assessment. The TI
ability to control the receipt of much of the information identified is difficult il impossible, In light of the ambiguous nahue of this penalty, the determination of
is responsible for payment will have to be determined on a case by case basis.
following guidelines on spe!cific mas will be the starting point for detem
responsibilityb
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No Employee Claim Form, or document is given to Employee by Employer, Or sent b
claims administrator
The legal obligation to provided a claim form to an injured Employee has been placa
on the Employer. TRISTAR has provided guidelines for the documentation of the clair form use of both the Claim Form log and the six part Claim Fonn. It will not k
TRISTAR 's policy to provide the Claim Form except on specific request by tk
Employee or the Employee representative, however it is felt that the appropriai
procedure would bc for the claims examiner to advise the requesting party to notify tl:
Employer wue at the same rime the claims erraminer will call the Employer identifyir
the request so that documentation provision of the Claim Form can be maintained at t.l
Employer's premises.
If the Employer utilizes the suggested procedures then all files should have appropria
documentation of the Claim Form and no penalty should arise. If the Employer is r
following the suggested procedures or has not provided the TPA with any proof that t
Claim Fonn has been provided for the claim file this penalty will be paid by t
Employer.
Untimely provisfoa of the Claim Form to the Employee by the Employer
Penalty assessment will be the Employer's responsibility. -- I
No Employer Report
Penalty assessment wiU be the Employer's responsibility.
No, or missing medical reports
In many cases obtaining medical reports from doctors can only be achieved after i made absolutely clear that there will be no payment fur medical services unless appropriate repopts are provided. Even then, some doctors resist the obligation. W'k the offending medical facility is selected by the Employer, pcaalties assessed will be
responsibility of the Employer. If the medical provider has kfl selected by the T'
the "PA witl be responsible,
Incomplete car no record of payment (inciudes mtaslng bifl6)
Penalty assessment will be the TPA's responsibi.&y,
Xo copy of W.C.A.B. Order and Award
if there is proof that service of the W.C.A.B. Order and Award was provided the :
payment of the penalty will be the "A's responsibility.
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No copy of Application for Adjudication of Claim
Where there is proof that sexvice of the applicatian was provided &e TPA, or where th
Emplayer iS served a copy of that application provided the "PA, tche penalty assessrner will be TPA's responsibility.
No DIA @WC) 500 sent
Penalty assessment will be the TPA's responsibility,
BIA (DWC) 500 sent, but inaccurate @ON, DOK, BNL'#, periods rates, etc.)
Where the TRA has access TO accurate information and provides inaccurate informatic
the TPA will be responsible for penalties. Where date of notice and date of lcnowfedi
are not accurately provided to the TPA by the Employer or their representative, ped- assessment wiU be the Employer's responsibility.
No DL4 (DWC) 510 sent
Penalty assessment will be the Employer's responsibility.
Failure to pay or object to medical/legd expense Within 60 days of receipt of billing, (MI
be reasonable objection)
If first receipt is TPA's receipt the "PA will bear the responsibility. If the Employer t
first receipt arid does not immediately provide TPA with the Sllling Employer bears f
responsibility for the assessment.
Failure to pay or object to medicat expenses within 60 days @lust be reasonable),
See above mdiCavlegal expeq.
Each papent due, Failure to pay within 10 days my bdd@ due, which is not spa above. Includes Maintenance Allowance, Interest on Awards, subsequent to fi T
payments.
If all. available and accurate information has been provided the TPA then this assessrr
would be the rqonsibility of the "PA. Where the required Wonnation is within
knowledge of the Employer but has not been provided the TPA the Employer will 1:
the responsibility of the assessment.
No daim 1% prodded within 5 days of request
Penalty assessment will be the TPA's responsibility.
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Each denied dah not designated on Claim log
?emlty usessment will be the =A's responsibility.
Ea& other omission or misd&gnation on claixn log
Penalty msessment wilt be the TPA's responsibility.
Faiiurt to comply with Rehab tixne and notice requirements bch ocxurrence
FA respansibiliry where all required information is available. Where "PA does not have information that is available to the Employer and tfrttt information has not been provided to be PA, Employer will bear the responsibility for this assessment.
Faiiw to pay or appeal Notice of Assessment Wn 15 days of the issue date
Any penalties will have to be evaluated on an individual bask and determination madl
both as to appropriateness of the penalty and identification of the party responsible. Thc
need to 3ct promptly ie imperative and any party that delays action in such decerminrztioi
of liability or the need to appeal any notice of assessment will bear the responsibility o
this penalry. If liability for the penalty assessment is agreed upon and payment !
appropriate the party responsible for the payment of the assessment will pay the penal0
Failure to comply with or appeal any find order of the W.C.A.B. within 30 days of servit
If the issue is siply the late paymem of an uncontested W.C.A.B. Order or Award th
penalty would be the responsibility of the TPA if the TPA had the Order within the tin me atlowed for payment or compliance of same. If the TPA did not haw service i
the Order but the Employer did have service of tlhe Order but did not make such (3rd available to the TPA within the time frame allowed such penalty would be t
mspumibilily uf the bphycr.
insufficient documentation to support dediai of liability far a claim
The &tamhation to deny a claim is generally the result of both TPA and ]Employ
invoivcmcnt. Where tht TPA act unifaterally in thc dcnial of a clh this penalty wot
be thc TPA's responsibility, mere the Employer has partidpat& in the decision + penalty would be a shared responsibility. In the event that the Employer Insists uy
denial of a dah against recommendation of the "PA then tile entire penalty would
the Employer responsibility.
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No documentation indfcating service of deniai on the injured worker or &/her agent
Penalty assignment will be the TPA’s responsibility.
Failure to compIy with or appeal any lawful writtea request of the A.D. regarding a cXai
filed within 30 days
These penalties are the TPA’s responsibility provided that tlte TPA has access to tl information requested. I€ the idoxmation or action request& req~kes information witb
the control of the Employer and that infomtim is not provided to the TPA in a time
manner so that the written request can be complied with in the time allowed the penal assessment will be the respmibility of the Employer.
Failure by a claims admidstrator, to provide a claim form wfthin 24 hours upon requt of an rsfured worker or hlsfher agent.
Penalty assessment will be the TPA’s responsibility.
,.
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RESOLUTION NO. 97-72
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF CARLSBAC
CALIFORNIA, APPROVING THE CONTRACT FOR THIRD PARTY
ADMINISTRATION OF WORKERS’ COMPENSATION CLAIMS
WHEREAS, the City desires to continue to utilize the services of a third party
administrator for its workers’ compensation claims program; and
WHEREAS, the City desires to have TRISTAR Risk Management administer tt
City’s workers’ compensation claims program;
NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of
Carlsbad, CA, as follows:
1.
2.
That the above recitations are true and correct.
That the City hereby authorizes Mayor Claude A. Lewis to execute the
agreement with TRISTAR Risk Management.
PASSED, APPROVED AND ADOPTED at a Regular Meeting of the City Coun
of the City of Carlsbad on the 18th day of February 1997, by the following vote, to wit
AYES: Council Members Lewis, Finnila, Nygaard, Kulchin, and Ha
NOES: None
ABSENT: None
ATTEST:
ALETEA L. RAUTENKRANZ, Cit$ Clerk