Need for Policy and Procedural Guidelines (PPG)
- To provide specific and uniform guidelines for Medical Officers and responsible personnel on processing and settling PTD claims.
- To cover evaluation of cases under BOT-determined categories ensuring claimant’s inability to continue work or earn the same income is properly assessed.
Objectives of the PPG
- Guide Medical Officers in the recognition of illnesses/injuries qualifying for PTD benefits.
- Establish clear procedural responsibilities for each stage of PTD claims processing.
Definitions
- Disability: Loss or impairment of physical/mental faculties reducing or eliminating ability to perform current gainful occupation.
- Permanent Total Disability: Permanent, complete, and irreversible incapacity preventing the member from work or earning the same income.
General Policies on PTD Eligibility
- PTD includes:
- Complete loss of sight in both eyes.
- Loss of two limbs at or above ankle/wrist.
- Permanent complete paralysis of two limbs.
- Brain injury leading to incurable imbecility, insanity, or incapacitation.
- Other cases as decided by the BOT.
- Evaluation criteria include:
- Complete, irreversible, and permanent injury/illness.
- No reasonable probability of recovery at time of evaluation.
- Established irreversible changes supported by medical evidence.
- Progressive and totally debilitating symptoms.
- Prevents earning the same income or engaging in occupation.
- Claimant provides proof of inability to work certified by HR including service record, leave certificates, and DTR for last 3 months.
Special or BOT-Determined PTD Cases
- Covers cases comparable to specified illnesses affecting earning capacity.
- Claimants must submit annual Medical Progress Reports (MPRs).
- Disability benefit suspension conditions:
- Reemployment without GSIS notification.
- Reemployment with income equal or higher than when disability benefits commenced.
- Recovery from disability as determined by GSIS.
- Failure to present for medical examination.
- Home visitation allowed if claimant cannot present themselves.
Evaluation and Review Structure
- Medical Evaluators and Reviewers assigned per area through Office Order.
- SVPs of Luzon, NCR, and VisMin Groups designate medical personnel, approve claims, resolve issues, monitor implementation, and submit reports.
- Medical Reviewers supervise evaluators, review claims, validate documents, maintain monitoring tools, and submit reports.
- Medical Evaluators gather medical evidence, conduct examinations, and perform preliminary evaluations.
Additional Responsibilities Regarding BOT-Determined Cases
- SVPs submit quarterly reports on special PTD claims to BOT.
- Medical Reviewers track timely submission of MPRs and notify claimants in advance.
Illnesses or Injuries List
- A reference list guides evaluation but does not guarantee PTD benefits without thorough incapacity determination.
- Reviewed every two years or as necessary.
- SVPs may recommend additions subject to BOT approval.
Processing Period and Appeals
- PTD claim processing period: 60 days from complete submission.
- Disapproved or suspended claims may be appealed to the Committee on Claims (COC) within 60 days.
- COC decisions may be appealed to the BOT within 60 days.
Administrative Sanctions
- Non-compliance with rules may result in disciplinary actions according to relevant provisions of the Administrative Code, Presidential Decrees, and Revised Rules on Administrative Cases in Civil Service.
System Requirements and Implementation
- Operations Groups must provide business needs to IT for system support and automation.
- User Acceptance Testing conducted by Operations Group, Information Security Office, and Internal Audit Services Office.
- Controller Group handles accounting entries related to claims.
- Internal Audit Services Office reviews compliance of procedures and systems.
Manual of Operations and Information Dissemination
- Necessary procedural changes to be incorporated into the Manual of Operations.
- Corporate Communications Office responsible for PPG information dissemination.
Procedural Guidelines Summary
- Claimant or representative submits PTD application with documents.
- Frontline Services logs and verifies non-medical eligibility; returns incomplete applications.
- Medical Evaluators conduct evaluations, request further evidence, and prepare Disability Evaluation Sheets (DES).
- Medical Reviewers review DES and recommend approval or denial.
- SVP concerned approves or disapproves claims and forwards for peer review.
- Peer reviews may comment but the approving SVP remains accountable.
- Approved/disapproved claims are logged and processed for payment or claimant notification.
- Records Management Department stores supporting documents.
Monitoring of Medical Progress Reports (MPRs)
- Medical Reviewers identify pensioners needing to submit MPRs and send reminders.
- Medical Evaluators monitor submission.
- Non-submission leads to suspension of pension and notification to membership department.
Suspension of PTD Pension in Case of Reemployment
- Frontline Services Division receives proof of employment and logs information.
- Claims Unit verifies salary comparison.
- Pension suspension process initiated if claimant earns equal or more than previous salary.
- Notification sent to pensioner and pension suspended accordingly.
Effective Date
- The Policy and Procedural Guidelines take effect immediately upon approval and supersede prior interim policies on PTD claims.