HomeMy WebLinkAbout96-5798 (2)RESOLUTION NO. 96 -57 98
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A RESOLUTION OF THE CITY COUNCIL OF THE CITY OF HERMOSA BEACH,
CALIFORNIA ADOPTING DISABILITY RETIREMENT PROCEDURES FOR SAFETY
MEMBERS.
WHEREAS, Government Code Section 21025 sets forth requirements for agencies
contracting with the Public Employees' Retirement System to conduct hearings regarding
appeals of the agencies initial disability retirement determination in accordance with the
Administrative Procedure Act, and
WHEREAS, the City of Hermosa Beach is a contracting agency with the Public
Employees Retirement System, and
WHEREAS, the Public Employees Retirement System has recommended that agencies
adopt a formal procedure which describes their disability determination procedure and
incorporates the Administrative Procedures Act requirements.
NOW, THEREFORE, BE IT RESOLVED, that the City Council of the City of
Hermosa Beach, California does hereby adopt the attached Retirement Procedures for
Safety Members (Exhibit 1)
PASSED, APPROVED, and ADOPTED THIS 26th day of March, 1996
of the City Council and MAYOR of the City of Hermosa Beach, California
ATTEST:
City Clerk
APPROVED AS TO FORM:
City Attorney
disres/94-001
Page 1
STATE OF CALIFORNIA
COUNTY OF LOS ANGELES
CITY OF HERMOSA BEACH
I, Naoma Valdes, Deputy City Clerk of the City Council of the
City of Hermosa Beach, California, do hereby certify that the foregoing
Resolution No. 96-5798 was duly and regularly passed, approved and adopted
by the City Council of the City of Hermosa Beach at a Regular Meeting of
said Council at the regular place thereof on March 26, 1996.
The vote was as follows:
AYES:
Benz, Bowler, Edgerton, Reviczky, Mayor Oakes
NOES:
None
ABSTAIN:
None
ABSENT:
None
DATED: March 28, 1996
iL
Deputy City Clerk
DISABILITY RETIREMENT PROCEDURES
' FOR SAFETY MEMBERS
1. Introduction
Under State law, it is the responsibility of the City to make determinations
relating to disability retirement applications for its employees who are safety members
of the Public Employees' Retirement System and relating to reinstatement of such
retirees.
As authorized by Government Code Section 21034, the City Council of the City
has, with its Resolution No. N.S. 3283, delegated certain of its responsibilities to its
City Manager.
The following procedures have been established by the City pursuant to the
Council's Resolution.
2. Filina of Application for Disability Retirement by Employee
1. An employee's application for disability retirement shall be submitted to the City
Manager by the employee fully completing the appropriate forms supplied by the
Personnel Department, and filing these, along with any appropriate attachments,
with the Personnel Director of the City or other designee as appointed by the
City Manager. (Attachment 1).
(1) The P.E.R.S. Application for Retirement form (Attachment 2) shall be
completed, the employee shall send the original to P.E.R.S. at the
indicated P.E.R.S. address in Sacramento, and file a copy of the
completed form with the Personnel Director.
(2) In addition, the applicant must also complete the Application for Disability
Retirement -Safety Officer (Attachment 3), and file it with the Personnel
Director.
C. Both of these forms must be fully completed and signed by the applicant and
have attached any supporting documentation, in order for action to be taken by
the City.
3. Filing of Application by Disability Retiree for Reinstatement
Pursuant to Government Code Section 21101, an employee previously retired due to
disability from service with the City may apply for reinstatement on the basis that
he/she is no longer incapacitated, by submitting in writing to the Personnel Director all
facts and circumstances forming the basis for the application for reinstatement.
1
4. Recommendation by Personnel Director that Employee be Retired for Disability or that
Disability Retiree be Reinstated
The Personnel Director may initiate a recommendation to the City Manager that he/she
certify to the P.E.R.S. that an employee be retired for disability, or that a disability
retiree be reinstated, by submitting to the City Manager a written report setting forth the
facts and circumstances forming the basis for the Personnel Director's
recommendation, with a copy to the employee or retiree.
5. Submission of Employee's Application or Personnel Director's Recommendation to the
City
The Personnel Director or other designees appointed by the City Manager shall within
ten (10) calendar days of receipt, submit the employee's application or the Personnel
Director's recommendation with all attachments, to the City Manager.
6. Acknowledgment of Apj:Acafion by City
Within fifteen (15) calendar days of receipt by the Personnel Director of the duly
completed application with supporting documentation, a notice (Attachment 4) shall be
sent by the City, to the employee and the representative designated in his/her
application (if any), acknowledging receipt of the application, and transmitting to the
applicant or his/her representative, a copy of these rules and procedures.
7. Investigation and Proposed Disposition
A. The Personnel Director, and such other officials, employees and/or agents of the
City as may be designated by the City Manager, shall have the authority and
duty to investigate the facts and circumstances pertaining to the employee's or
retiree's application as they, or any of them, deem appropriate. Such fact-finding
may include ordering the employee or retiree to submit to medical or psychiatric
examinations, securing by subpoena duces tecum or otherwise, medical and
other reports, records, and documentation for review, and taking statements by
deposition or otherwise of the employee, retiree, and/or other persons.
B. The Personnel Director or the designated officials, employees and/or other
agents shall thereafter based upon the investigation, submit a proposed
disposition of the application or recommendation to the City Manager. The City
Manager shall send a notice of such proposed disposition to the employee or
retiree with copies to the designated representative, if any. (Attachment 5).
This notice shall indicate the proposed disposition and that the City shall
certify such disposition to P.E.R.S. unless an objection is filed by the
applicant with the office by the applicant of the City Manager prior to the
expiration of fifteen (15) calendar days from the date of service of the
notice. A proof of service by mail shall be attached to the notice and shall
constitute conclusive evidence of the date of service.
8. Final Disposition of Application or Recommendation in Absence of Objection(
If no objection is received within the fifteen (15) calendar day period, the City Manager
shall certify the proposed disposition to the P.E.R.S. (Attachment 6)
9. Informal Conference if Obiection(s) Timely Filed
A. If timely objection is received, the Personnel Director or other designee as
appointed by the City Manager, shall schedule a conference to occur in no less
than ten (10) nor more than twenty (20) calendar days, with written notice to the
employee or retiree, the designated representative, if any, and such other
involved personnel or agents as he/she deems appropriate. Such notice shall
be deposited in the United States mail at least ten (10) calendar days prior to
such conference. The Personnel Director or other designee shall preside over
the conference. (Attachment 8)
B. The purpose of the conference shall be to afford the parties an opportunity to
reach agreement as to final disposition of the matter, and if no such agreement
is reached, to ascertain if any parties in interest request a hearing on the
application or recommendation and, if so, to frame issues, enter into stipulations,
and discuss dates for the commencement of the hearing. The parties will
endeavor to set a hearing no later than ninety (90) calendar days (if there is no
rehabilitation evaluation pending), or one hundred eighty (180) calendar days (if
the employee is being evaluated for rehabilitation), from the date of the
conference. Said time limitations are guidelines and are not jurisdictional
requirements.
Any requested appeal hearing shall be conducted by an Administrative Law
Judge (ALJ) of the Office of Administrative Hearing (OAH). The Personnel
Director or other designee shall initiate contact with the OAH and secure
appointment of an ALJ. The parties shall equally divide the costs of the ALJ.
10. Filinq and Service of Medical Reports and Documentary Evidence
No later than thirty (30) calendar days before the scheduled commencement of the
hearing, each party shall file with the Administratively Law Judge (ALJ), and serve on
the other party, any and all medical reports and records and other documentary
evidence to be relied upon in the presentation of their case. Unless good cause is
shown, any document, report or record not filed and served as herein provided, shall be
inadmissible at hearing, and no testimony upon which such report, document or record
is based may be admitted into evidence at the hearing. Either party may serve a
request for discovery upon the other party as provided for in Government Code Section
11507.6. In such case, the procedures contained in Government Code Sections
11507.6 and 11507.7 shall apply.
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11. Hearing Continuances
Scheduled hearing dates may be continued by order of the ALJ pursuant to stipulation
of the parties or pursuant to written motion of one of the parties. A copy of such written
motion must be served on the other party. A continuance shall be granted and all
proceedings stayed if it is shown that the claimant (1) Has failed to disclose fully to the
City the nature, type or character of the disability upon which the application is based;
or (2) Has failed to disclose the name and address of the physician or other
practitioner, or facilities by whom or at which he/she was examined, treated, or
evaluated for any condition upon which a claim for disability is or may be based; (3)
Has failed to participate in or complete any examination or examinations by a health
practitioner selected by the City.
In such case, all proceedings shall be stayed until the claimant has made full disclosure
with respect to (1) and (2) above, and has cooperated in completing any medical
examinations or evaluations scheduled by the City.
12. Stipulated Settlement
At any time in the proceedings the parties may enter into stipulations and recommend
to the City Manager a final disposition regarding the retirement, rehabilitation, and/or
employment status of the employee or retiree.
13. Subpoenas
A. Any subpoenas shall be issued by the ALJ.
B. The parties may avail themselves of the subpoena process to ensure the
availability of witnesses.
14. Conduct of Hearing
A. The conduct of the hearing shall be under the direction of the ALJ. The ALJ
shall prepare written findings and a decision for presentation to the City
Manager.
B. The proceedings at the hearing shall be recorded by a certified shorthand
reporter.
C. The parties shall each prepare and serve on each other, and on the ALJ, a
statement of issues. The issues which may be considered at the hearing, shall
be limited to the following:
(1) Disability - Is the employee or retiree substantially incapacitated at the
present time from the performance of the essential duties of his/her
current or last job classification and if so, is such incapacity permanent or
of an uncertain and extended duration?
(2) If the employee is found to be disabled due to mental disorder, is he/she
competent to act on his/her behalf in legally binding retirement matters?
(3) Industrial Causation - If the employee is disabled, did the disability arise
out of and in the course of City employment?
(4) Should the employee be certified to P.E.R.S. for:
(i) industrial disability retirement, or
(ii) non -industrial disability retirement, or
(iii) regular service retirement, or
(iv) no retirement benefits?
(5) What is the effective date of any retirement?
(6) Has a rehabilitation program been offered to the employee, and if so,
what is the status of such program?
(7) Is there any third party liability related to the injury which caused the
disability?
D. The moving party shall proceed first, and shall have the burden of proof
E. The ALJ shall conduct the hearing in accord with Government Code Sections
11500 et seq.
F. The hearing shall continue from day-to-day until the proceedings are concluded
or continued to a date certain within the discretion of the ALJ.
G. The ALJ may hold the record open, at his/her discretion, for the submission of
briefs and/or the assignment of an Independent Medical Examiner (IME).
(1) Upon notification that the ALJ elects to assign an IME the parties shall
mutually agree upon an IME. In the event that no agreement is reached
upon an IME within seven (7) days, an IME shall be selected from a list of
five (5) IME's provided by the City's Workers' Compensation Third Party
Administrator by alternate striking of names until one name remains. The
party who strikes the first name from the panel shall be determined by lot.
(2) Any such IME will be furnished all documentary evidence presented, will
examine the employee or retiree at the expense of the City, and shall
report in writing to the ALJ. The ALJ will serve said report upon all parties
within fifteen (15) calendar days of receipt.
s
(3) Any party may request cross-examination by deposition of the IME within
ten (10) calendar days of service of the IME report, at such party's
expense, for the doctor's fee and cost of a court reporter. The court
reporter shall transmit the record directly to the ALJ, with copies to be
sent to a requesting party at that party's expense.
15. Costs
A. Except as otherwise described herein, each party shall bear its own costs
incurred by each such party, including the costs of their witnesses and
representatives, and the costs of a transcript of the hearing ordered by such
party, and shall share equally the mutually incurred costs of the hearing,
including the charges of the court reporter.
16. Findings and Conclusions:
Within thirty (30) calendar days of the closing of the record, the ALJ shall provide the
parties in interest and their representatives with its written findings of fact and
conclusions, and shall submit such findings and conclusions to the City Manager for
further action by the City Manager within one hundred (100) calendar days of receipt of
the findings. The City Manager may take any of the following actions:
A. The City Manager may adopt the ALJ's findings and conclusions by directing
that certification be made accordingly to the P.E.R.S. of the City's final
determination of the application or recommendation based on such findings and
conclusions, with copies of such certification to the parties and their
representatives, if any, or
B. The City Manager may, based upon his/her independent review of the record,
modify and/or amend the findings and conclusions, and certify as appropriate to
the P.E.R.S. a final determination based on such modified and/or amended
findings and conclusions, with a copy of such certification to the parties and their
representatives, if any, or
C. The City Manager may direct that further evidence be taken and proceed to hear
such additional evidence or remand the matter to the ALJ for the taking of such
further evidence, and the issuance of a decision.
If the City Manager orders a transcript of the proceedings before the ALJ, the one
hundred (100) day period in which he/she must take the above actions will not
commence running until receipt of the transcript, provided the transcript is ordered
within one hundred (100) days of the ALSs decision.
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17. Reconsideration
Any party may move for reconsideration of the City Manager's decision within thirty. (30)
days after service of such decision.
18. Appeal
An aggrieved party may appeal the final determination in the manner and to the extent
provided by State law. f
94-009/psdret
Attachment 1
CITY OF HERMOSA BEACH
SAFETY OFFICER DISABILITY RETIREMENT APPLICATION
INSTRUCTIONS TO EMPLOYEE
Attached are copies of the forms that must be completed by you in order for you to apply for
disability retirement. A complete P.E.R.S. retirement application booklet and pamphlets
addressing industrial disability application procedures are available in the Personnel
Department.
"APPLICATION FOR DISABILITY RETIREMENT" (PERS-BEN-369D) and
"SURVIVOR CONTINUANCE QUESTIONNAIRE" (PERS-BAS-54)
a. Obtain a complete P.E.R.S. "Application for Disability Retirement"
package from the Personnel Office. Copies of PERS-BEN-369D
and PERS-BAS-54 are attached as "Attachment 2".
b. After you have completed these forms, turn in a copy to the Personnel Director
and mail the originals to the Public Employees' Retirement System as indicated
at the top of the form. It is important that you mail these forms to P.E.R.S. as
soon as possible as your retirement cannot be effective earlier than the first of
the month in which it is received by P.E.R.S.
2. CITY OF HERMOSA BEACH "APPLICATION FOR DISABILITY RETIREMENT -
SAFETY OFFICER"
a. In addition to the above P.E.R.S. forms, you must also complete this form, and,
along with a signed medical release for each physician and medical facility
listed, turn it in to the Personnel Director.
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MPERS
I
Benefit Application Services Division Reply to: Section 432
P.O. Box 2796
Sacramento, CA 95812-2796 Member's Name:
Telecommunications Device for the Deaf - (916) 326-3240
(916) 326-3232; FAX (916) 326-3934 Social Security No..
SURVIVOR CONTINUANCE QUESTIONNAIRE
The following information is necessary to ensure that all survivor benefits payable are made to your eligible
beneficiaries upon your death. Payments will be made in accordance with the Public Employees'
Retirement Law. Please answer all four questions and complete the required information for each section
that is answered "yes".
1. Are you currently married? ❑ Yes ❑ No
Spouse's Full Name Social Security Number Birthdate Date of Marriage
2. Do you have any unmarried children under 18? ❑ Yes ❑ No
Child's Full Name Social Security Number Birthdate
3. Do you have any unmarried children who were disabled prior to their
18th birthday and who have remained disabled until the present time? ❑ Yes ❑ No
Child's Full Name Social Security Number Birthdate
4. Are your parents dependent upon you for at least one-half of their support? ❑ Yes ❑ No
Parent's Full Name Social Security Number Birthdate
I certify that the information provided in this form is correct.
Signature
Home Phone Number
PERS-BAS-54 (Rev. 10/93)
Date
Business Phone Number
NAME
ADDRESS:
1
2
3
4
5
X
Attachment 3
CITY OF HERMOSA BEACH
APPLICATION FOR DISABILITY RETIREMENT - SAFETY OFFICER
Social Security No
Phone No. ( )
Date disabling injury or illness arose:
Date last worked:
Place of injury (if applicable):
Date employed by City
Date employed by City as safety employee:
Department, Classification held:
Spouse's name
Current employment status with City:
Working hours per week
Sick leave with compensation [Approximate date leave
ends]:
Industrial leave with compensation [Effective date]:
Resigned or terminated from City service [Effective date]
Sick leave without compensation
Other [Please specify]:
7. Describe the duties assigned in your latest job classification:
8. Describe the actual duties which you were assigned and which you performed at the time
your disability arose.
9. Describe the nature of the injury or disease which you claim permanently incapacitated you
from performing your duties
10
10. State specifically the duties which you cannot now perform because of your disability.
11. If you claim that your disability is the result of a job -related in injury, explain the
circumstances surrounding the occurrence of the injury, including location, time, names and
addresses of all witnesses and of the initial attending physician, and a detailed description of
what happened.
12. If you claim that your disability is the result of a job -related illness or disease, explain to
the best of your ability all facts as to how you contracted the illness or disease
including the job -related factors, dates, times and locations.
11
13. List the names of all doctors or other individuals consulted for diagnosis or treatment
relating to the subject injury or disease, together with a signed release allowing each of
those doctors to provide your medical records to the City. (A copy of the release form is
attached to this application form. If more release forms are needed, they may be
obtained from the Personnel Director).
14. Have you ever received treatment for a similar injury or illness? Yes No
If yes, please furnish dates of treatment and the name and address of any doctors,
hospitals or clinics who provided treatment to you. Complete a medical release form
for each of these doctors, hospitals or clinics.
12
15. List the names of all doctors or other individuals, hospitals or clinics you have
consulted for diagnosis or treatment of any injury or illness during the period of five
years prior to subject injury or onset of the subject disease to date. Complete a medical
release for each of these doctors, hospitals or clinics.
16. List all employment:
(1) during the five-year period prior to becoming employed with the City (if employed
less than 10 years with the City);
(2) during the period of your City employment (other than City employment); and
(3) between the last day with the City and the filing of this application.
Please list the name and address of any employer, including any self-employment, and
the beginning and ending dates of any such employment.
13
17. Have you applied for Worker's Compensation for the subject injury?
Yes No
If yes state the date the application was filed
18. Do you have any preexisting injury, disease or condition which you now claim is being
or has been accelerated or aggravated by the subject injury or disease?
Yes No
If your answer is yes, please state:
(1) the nature of the injury or disease;
(2) the date of the occurrence of such injury or the onset of such disease; and
(3) the attending physician or physicians for such injury or disease. Complete a
medical release form for each of these physicians.
14
19. Attach a copy of all relevant medical information, including doctors' reports of
examinations proving the existence of your disability. The medical information may be
forwarded separately, but must be received in a timely fashion and in no event later
than 20 days before a scheduled formal hearing.
20. Will you accept another position with the City which you could perform?
Yes No
Date: Signature:
15
[Employee Name]
[Employee Address]
Re: Disability Retirement Application for [Employee]
Dear
Attachment 4
This is to acknowledge that your application for disability retirement was received by
the City of Hermosa Beach on [date].
We understand that you have sent the original completed P.E.R.S. Form PERS-BEN-
369D "Application for Disability Retirement" directly to the Public Employees' Retirement
System for filing. If this is not the case, please do so immediately in order to protect your
interests. If you have any questions or need any help in this regard, please feel free to
contact the Personnel Director.
Attached is a copy of the Rules and Procedures for the processing of this application.
[or]
We are sending a copy of the Rules and Procedures for the processing of this application to
your representative.
Your application is being processed. You or your representative will be contacted soon
regarding your application.
In the meantime, if you have any questions regarding your application, please contact
Sincerely,
Personnel Director
Enclosure: Disability Retirement Procedures (Safety Officer)
cc: Applicant's attorney or other representative
Appropriate City officials or representatives
16
[Employee Name
[Employee Address]
Re: Disability Retirement of [Employee]
Dear
Attachment 5
I have received the proposed disposition of , dated
[Date], with respect to your application/the City's recommendation for disability retirement,
intend to certify to the P. E. R. S. that
It is my intention to implement this proposed disposition and certify it to the Public
Employees' Retirement System within 15 calendar days unless I hear from you or your
designated representative that you take exception to such disposition.
If you do not agree with the proposed disposition, please so inform me in writing by
[Date]. Please specify in what specific respects you object and the reasons for the objections.
Sincerely,
City Manager
cc: Applicant's attorney or other representative
Appropriate City officials or representatives
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Attachment 6
Public Employees' Retirement System
P.O. Box 1953
Sacramento, CA 95809
Re: Disability Retirement of [Employee]
Social Security No.
Pursuant to the authority delegated to me on [Date] by Resolution N.S. 3283 of the City
Council of the City of Hermosa Beach (a certified copy of which is attached), and after a
review of medical and other relevant evidence, I hereby make the following determination
concerning the employee's/City's application for disability retirement:
[Employee] is/is not substantially incapacitated for the performance of his/her essential
duties in the position of [Job Title] for a permanent or extended and uncertain duration,
2. Such incapacity is/is not a result of injury or disease arising out of and in the course of
his/her employment.
3. [Employee] was/will be separated form his/her employment after expiration of leave
rights under Government Code Sections 21025.2 and 21025.4 effective [Date], and no
dispute as to the expiration of such leave rights is pending.
We are/are not offering a rehabilitation plan for [Employee].
We are/are not aware of third party liability related to the injury which caused the disability.
Sincerely,
City Manager
cc: Applicant
Applicant's Attorney or Other Representative Appropriate City Officials
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Attachment 7
AUTHORIZATION FOR DISCLOSURE OF MEDICAL RECORD INFORMATION
Subject's name:
Last First MI
The undersigned hereby authorizes and requests
to provide
Birthdate:
(Heath Service Provider)
(Identity of Third Party or Name(s) of Any Duly Authorized Representative)
with access to my medical records for the purpose of review and examination and requests
that you provide such copies thereof as may be requested. The foregoing is subject to the
following limitations:
❑ 1. Covering records for the period to
(Date) (Date)
❑ 2. Confined to the following specified information:
3. No limitations placed on dates, history of illness, or durations and therapeutic
information, including any treatment for alcohol and drug abuse. (Signer to initial for
authenticity of this response)
❑ 4. This authorization is also extended to the securing of any and all employment
records, such as payroll, wage, commission and bonus records, personnel records
and group insurance records.
Expiration date of this authorization if any:
Signature:
If signed by personal representative,
state relationship and authority to do so.
Date
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Attachment 8
[Employee Name]
[Employee Address]
Re: Disability Retirement of [Employee]
Dear
This is to acknowledge receipt of your objection to the proposed disposition in this
matter.
An informal conference shall be held on [Date] at [Location]. The parties are invited to
attend and may be represented at their own expense.
Sincerely,
City Manager
cc: Applicant's attorney or other representative
Appropriate City officials or representatives
OVA