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HomeMy WebLinkAbout1993-04-27; City Council; Resolution 93-117ll 1 2 3 4 a 0 RESOLUTION NO. 9 3 - 11 7 A RESOLUTION OF THE CITY COUNCIL OF “HE CITY OF CARLSBAD, CALIFORNIA, AUTHORIZING THE EXPENDITURE OF FUNDS FOR SETTLEMENT OF THE WQRKERS COMPENSATION CLAIMS OF SHANNON BOWLIN 5 WHEREAS, Mr. Charles Eoof, Defense Counsel for the City of Carlsbad in this 6 7 matter, has recommended a settlement of the Workers Compensation claims of Shannon c owl in; and a WEWEAS, there are sufficient funds available in the Workers Compensation Self 9 Insurance ~und to pay the settlement, Io: /I NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of 11 12 13 14 15 Carlsbad, California, as follows: 1. That the above recitations are true and correct. 2. That the expenditure of $36,000 from the Workers Compensation Self- Insurance Fund is authorized for the settlement of said claims. 16 17 3. That the Council accept the Compromise and Release, attached hereto as Exhibit 2. I I 18 l/ 19 I/ 20 1, 21 22 / J 23 11 / 24 11 25 26 f I 27 I” 28 II e 0 1 PASSED, APPROVED AND ADOPTED at a Regular Meeting of the Cit ~ II Council of the City of Carlsbad on the 27th day of April 1993, by the following 2 3 /I vote, to wit: 4 AYES: Council Members Lewis, Stanton, Nygaard and Finnila 5 NOES: None 6 ABSENT: Council Member Kulchin 7 a 9 10 11 12 13 14 a A! ATTEST: ALETIIA E. RAU 15 16 17 18 19 I 20 21 22 23 24 25 26 27 28 I1 0 a- EXH I B I' " WORKERS' COMPENSATION APPEALS BOARD STATE OF CALIFORNIA Case NO. ?J a~ uo 40 631 -S,W~ow t. !!!Lid YJ, Lj) + 0433 6 3J Applicant Order Approving vs. Compromise and Releas, @I?? 4 P?&b, t5,z C/dkM @ut#% kMP",-' Defendants I The parties o the ab e-entitled action having filed a Compromise and Release herc in addition to all sums whid may have been paid previously, and requesting that it be approv this Board having considered the entire record, including said Compromise and Release, no that it should be approved. &&L, 4# f493 settling this case for $ 3 6, aeG. -- IT IS ORDERED that said Compromise and Release be approved. Award is made in favor of: 3&+& ~rd < @ad; A/ PGr) l)u 57 /MG C / d OML5 &?4-9. - /firs Gam its DL~LL jwa VS~D iF ~47 /Fee* f+m #hJp"-b 37 /&-E. Crry C,wc;L G7-y ag- / I Q,+&u 6p-b ~.~~l7~~> 6a,'y- fiv'g [w) &Y5 .sG 64 G Dated .d/l// 9 7 Service by Ladon parties as shown on Official Address Record effected on above date. [l BY: Lfl<&-+&y J DIA WCAB FORM 68 (REV. 5-75) e/ M mi DEPARTMENT OF INDUSTRIAL RE! DIVISION OF INDUSTRIAL A( C0MPROM;SE AND RELEASE ’ PLEASE SEE INSTRUCTIONS ON REVERSE OF PAGE 2 BEFORE COMPLETING FORM 0 0 STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS 92 Rc DIVISION OF WORKERS COMPENSATION CkE NO. 92 R( WORKERS COMPENSATION APPEALS BOARD SOCIAL SECURITY NO. 549-1 332 Valley Pines Drive 1200 Carlsbad Village Drive 3954 Murphy Canyonv&sd, Sui Shannon P. Bowlin Etna, CA 96027 Citv of Carlsbad, P.S.I. Carlsbad, CA 92008 HCM Claim Manaaement CorDoration San Diego, CA 92123 APPLICANT (EMPLOYEE) ADORES CORRECT NUE OF EMPLOYER CORRECT NAME OF INSURANCECARRIER AODRESS 1. The injured employee claims that while employed as a Police Officer 12/15/85 - 3/28/91 CT [OCCUPATION ATTIME OF INJURY) on 2/20/91 at Carlsbad . CA [DATE OF INJURY) (CITVI (STATE1 (s)he sustained injury arising out of and in the course of employment to back. m - bed" extremities and other as supported by the incorporAe8 me%caF lye 2. The parties hereby agree to settle any and all claims on account of said injury by the payment of the sum of $ 3 iD I O0 in addition to any sums heretofore paid by the employer or the insurer to the employee, less amounts set forth in Paragri 3. Upon approval of this compromise agreement by the Workers’ Compensation Appeals Board or a workers’ compensation ju in accordance with the provisions hereof, said employee releases and forever discharges said employer and insuranc claims and causes of action, whether now known or ascertained, or which may hereafter arise or develop as a res1 including any and all liability of said employer and said insurance carrier and each of them to the dependents, I representatives, administrators or assigns of said employee. (SA WH PARTS ,BODY R ItjJ RE 4. Unless otherwise expressly provided herein, approval of this agreement RELEASES ANY AND ALL CLAIMS OF APPLICANT’ DEATH BENEFITS RELATING TO INJURY OR INJURIES COVERED BY THIS COMPROMISE AGREEMENT. The parties have release of these benefits in arriving at the sum in Paragraph No. 2 5. Unless otherwise expressly ordered by a workers’ compensation judge, approval of this agreement DOES NOT RELEASE 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 undc DATE OF BIRTH ACTUAL EPRNINGS ATTlUE OF INJURY LAST DAY OFF WORK DUE TO TI 11/2/56 S763.41Iweekly DisDuted PAYMENTS MADE BY EMPLOYER OR INSURANCE CARRIER TEMPORARY DISABILITY INDEMNITY WEEKLY RATE PERIODS COKRED Fully compensated under LCS 4850 PERMANENT DISABILITY IND XTf TOTAL UEDICAL AND HOSPITAL BILLS $~&7SX%ii $10 , 100.59 BENEFITS CLAIMED BY INJURED EMPLOYEE BEGINNING AND ENDING DATES OF ALL PERIODS OFF DUE TO THIS INJURY MEDICAL AN0 HOSPITAL BILLS PAID BY EMPLOYEE Fully compensated in this settlement None TOTAL UNPAID MEDl OSPITAL ME E ESTIMATED FUTURE MEDICAL MPENSE “p PAV ”d.43” l4-a) TO BE PAID BY TO BE PAID BY: Applicant THE FOLLOWINJ&&”UNTS ARE TO BE DEDUCTED FROM THE SETTLEMENT AMOUNT: 7,560 &’ $- PAYABLETO Citv of Carlsbad $ PAYABLE TO $ PAYABLE TO $ PAYABLE TO $ PAYABLE TO $ PAYABLE TO A? 4w0s LEAVING A BALANCE OF $ w@s approved attorney fee (See Paragraph No. 91, payable to applicant. be other than in a lump sum, or there is additional information, specify On Separate page(s). ) Less any permanent disability advances paid to applicant from the date of preparation of this Compromise and Release to the date Of ~aw~~~r;l,t,,,g~,~~~~*GoE~~er Approving Compromise and Release - . e e i. Liens not mentioned in Paragraph No. 6 are to be disposed of as folloWS>pe at- 7 ~~ 8. For the purpose of determining the lien claim(s) filed for benefits paid pursuant to the Unemployment Insurance Cot furnished by lien claimants define! in Labor Code Sec. 4903.1. the parties propose reduction of the lien claim(s) in formulae attached. Not applrcable wy fi 9. Applicant's (employee's) attorney requests a fee of $ . Amount of attorney fee previously paid, if an! 10. Reason for Compromise, special provisions regarding rehabilitation and death benefit claims, and additional informati01 A. See Attached Page 2-A @ b.%p=" +&&-A" 4d "fA 4 ,c,"w &4-gg" fi-f+-aY,?ld, -F e Ab" - 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 emplc WCAB may in its discretion set the matter for hearing as a regular application, reserving to the parties the right to p the facts admitted herein, and that if hearing is held with this document used as an application the defendants shall them all defenses that were available as of the date of filing of this document, and that the WCAB may thereafter ei Compromise Agreement and Release or disapprove the same and issue Findings and Award after hearing has been ht regularly submitted for decision. Witness the sign THE APPLICANT'S (EMPLOYEE'S1 SIGNATURE U D BY TWO DISINTERESTED persons OR ACKNOWLEDGED BEFORE A NOT STATE OF CALIFORNIA 2 ~~~~~~~~ ~ ~ Cwntyof Sanaa 5 - on this day of AD., 79 , before me. - a Notary Public in and for the said Cwnty and State, residing therein, &&commissioned and sworn, persona/& appeared- known io me to be the person - whose name subscribed to me within Instrument, and acknowledged to me mat-he- executed me same. IN WmVESS WHEREOF, I have hereunto set my hand and affm my official seal me day and year in this Certificate first abou mn. DM WCAB FORM 15 [REV. 2/90] [PACE 21 NotaryPublic ~fl ana for sard Countyand State of Caltfornra 0 e APPLICANT: Shannon P. Bowlin COMPROMISE AND RELEA CASE NO. : 92 SDO, et a1 EA) This settlement includes any and all claims for medic temporarydisability, vocationalrehabilitationtempora disability and reimbursements through the date of t Order Approving Compromise and Release. &/ Initials ZB) 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; Compensation Appeals of the Ord Approving Compromise and Release -+ k 9 -Initials ZC) DEATH BENEFIT CLAIM WAIVER: The applicant has been advised and fully understands th this Compromise and Release Agreement releases any a all claims of any dependents to potential death benefi relating to the injury or injuries overed by th Compromise and Release Agreement. + nitials ZD) A reasonable and substantial dispute exists between t parties as to: Nature and extent of the applicant disability, both temporary and permanent; need for pas present, and future medical treatment; reimbursement f self-procured expenses; etc. Rather than risk t uncertainties of litigation, the parties wish to sett this claim, and all its r sent and potential issues, t a lump sum certain. & Initials dr. DATE: .4/- 4 - E3 APPLICANT: '."' %X%.& ,fk!&[& DATE: 4- 6 '"9 3 _-- APP' S ATTY : [/ stc{ / -9 d;fi-& I PAGE 2-A . $ 0 0 PARAGRAPH 7 CONTINUED Shannon P. Bowlin City of Carlsbad, P.S.I. WCAB CASE NO.: 92 SDO, et a1 vs . Defendants have paid, or will pay, negotiate, or litigate the li 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. 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 adopl by the administrative director pursuant to Section 5307.1 and she be itemized separately in accordance with rules promulgated by I administrative director. ut Pursuant to Labor Code, Section 4( defendants reserve the right to adjust the charges for x-ra! laboratory services, and other diagnostic tests to fee schedulc Workers‘ Compensation Appeal Board to retain jurisdiction. X&c,.TL”, I p t&LdL, L4Tw- L+%?5 Applicant Attorney for Applicant Dated: $& -q3 Dated: + - 6.-7 3 . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 a e (VERIFlCAfION"146. 201J.J C. C. P.) STATE OF CALIFORNIA. COUNTY OF I am the ~~ ~ ~~ in the above entitled action or proceeding; I haw nod the for@ng ad kmw the cmtents themJ ad I crnuy kt the smnc is INI of my ow knode&c, exmp as to b m are therein stated upon my information or bekJ oad 01 to rhase matters I beliew ii to be INC. ~~ I declare, under pemity of perjury under the laws of the State of Cdgornia that the fo~oi~ is INC and correct. Executed on (dotel at (plocd Type or Print Name signalwe PROOF OF SERVICE BY MAIL (1013r, 201J.J C. C. P.) STATE OF CALIFORNIA. COUNTY OF San Diego action: my business address is: I am a resident of the cowry aforesaid: I am owr the ap of eithteen years and not a party 10 the vit~ 7851 Mission Center Court, Suite 210 San Dieqo, CA 921( on April 7, , I9 93 , Ise-,the virhin Fully Executed Comprc and Release & Order Approving Compromise and Release, Da. on the Parties herein in said action. by placing a true copy thereof enclosed in a sealed envelope with postage rhereon jidly prep United SIares mail at San Dieqo addressed as jollows: See attached service list I declarr. under penalty oJperjury under the laws OJ the State OJ Cali/ornia rhar rhe Joregoing is true and correct. ~ Executed on Apri1 7 I lgg3 01 San Dieqo I (date) iplacel Phyllis L. Baxter Type or Print Name ' e 0 SERVICE LIST FOR PROOF OF SERVICE April 7, 1993 Re: Shannon P. 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 ","" / 1200 Carlsbad Village Drive La Costa Chiropractic & 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.