Registration Requirements
- Employers must register with the System using prescribed forms; employees registered through employers likewise.
- Public sector employers and employees must register by specified deadlines post-1975.
- Private sector employers auto-registered if previously registered; new employers and employees to register promptly.
- Only one registration is necessary for SSS, Medicare, and Employees' Compensation.
- Penalties for failure/refusal to register include fines (P1,000 to P10,000) and/or imprisonment; employer liable for benefits if report or contributions delayed.
Compensability Criteria
- Injury must arise out of and in the course of employment to be compensable.
- Sickness must result from occupational disease listed or proven to have increased risk from work conditions.
- Employers must require pre-employment and periodic medical examinations to detect occupational diseases.
- The Commission has the authority to approve additional occupational diseases based on employment hazards.
Liability and Exclusions
- No compensation if injury caused by employee's intoxication, willful self-harm or injury to others, or notorious negligence.
- Compensation from state insurance fund is exclusive, replacing other employer liabilities, except where other laws provide additional benefits.
- System benefits are payable even if third party is liable, with subrogation rights to the System.
- System not liable for unauthorized changes in medical services; employee must inform and get consent.
- Required medical reports must be submitted to continue receiving disability benefits or face suspension.
Employer's Contribution
- Contributions fully paid by employer; deductions from employee wages are void.
- Public sector contribution: 1% of actual salary, capped at P30 per employee.
- Private sector contribution: 1% of monthly salary credit based on a wage schedule.
- Contribution obligation ceases on employee death or separation and suspends during disability without salary.
- Contributions begin January 1975; employers to remit monthly.
- Penalties for delinquency include employer liability for benefits, fines, imprisonment, and penalties on unpaid contributions.
Definitions Related to Earnings
- Quarter: 3 calendar months ending March, June, September, December.
- Semester: 2 consecutive quarters ending in contingency quarter.
- Monthly Salary Credit (MSC): actual wage basis with caps (P1,000 private, P3,000 public).
- Average Monthly Salary Credit: Computed using previous months' contributions with rules for recent coverage and disability.
- Average Daily Salary Credit: Determined by dividing sum of highest MSCs or actual wages adjusted for days worked.
- Replacement Ratio and Credited Years of Service established for benefit computations.
- Monthly Income Benefit formulas differ for SSS and GSIS but provide minimum guaranteed pensions.
Types of Benefits
- Benefits include medical services/appliances, rehabilitation, temporary total disability, permanent total/partial disability, death, and funeral benefit.
- Temporary total disability: inability to work up to 120 days, extendable to 240 days under certain conditions.
- Permanent total disability: inability to perform any gainful occupation beyond 120 days or specified conditions.
- Permanent partial disability: defined loss of use of body parts, with specific months of income benefits or pensions.
- Death benefit payable to primary or secondary beneficiaries with guaranteed minimums.
Medical Services and Supplies
- Entitlement requires employee registration, injury/sickness, and notice to System.
- Medical care includes ward services in accredited hospitals, domiciliary care, medicines, and ambulatory services for injuries.
- Ward services cover in-patient care necessary for treatment; excess charges for private accommodations are borne by employee.
- Payments capped at prevailing community rates or schedule limits.
Rehabilitation Services
- Voluntary coverage offering medical care, vocational training, and job placement aid.
- Entitled if permanently disabled and not placed in suitable employment.
- Rehabilitation period lasts until employment, self-termination, or suspension by center.
- System may subsidize wages during on-the-job training with descending wage participation.
- Rehabilitation centers and accredited facilities and personnel established.
- Suspension or termination may be appealed to the Governing Board.
- System's liability excludes injuries caused by intoxication, willful intent, or notorious negligence during rehabilitation.
Temporary Total Disability Benefits
- Employee qualifies if registered, injury/sickness causes temporary total disability, and Systems notified.
- Benefit starts on first day of disability up to 120 days (extendable to 240 days in some cases).
- Benefit equals 90% of average daily salary credit; minimum and maximum daily benefits apply.
- Monthly benefit suspended if medical reports not submitted timely.
Permanent Total Disability Benefits
- Entitlement requires registration, permanent disability due to injury/sickness, and System notification.
- Permanent total disabilities specifically listed (loss of limbs, sight, brain injury, etc.) and others approved by System.
- Benefit paid monthly, guaranteed for five years, and suspended for failure to submit medical reports or gainful employment.
- Dependent children receive 10% of monthly benefit each, up to five children.
- Adjustments apply for contingencies before or after specified dates.
Permanent Partial Disability Benefits
- Qualified employees receive monthly benefits for designated months depending on the loss type.
- Benefits can be lump sum or pension if exceeding 12 months.
- Losses proportionally compensated if partial; multiple losses combined but capped.
- Non-scheduled disabilities compensated based on percentage loss of work capacity.
Death Benefits
- Primary and secondary beneficiaries defined, with priority for primary beneficiaries.
- Benefits include monthly income and lump sum; minimum guaranteed amounts specified.
- Benefit calculations depend on whether employee was receiving disability benefits before death.
- Rules for valid marriage and dependent status apply.
Funeral Benefits
- Lump sum benefit of P3,000 payable to spouse, child who paid for funeral, or person with proof of expenses.
Beneficiaries
- Primary: spouse and dependent children under 21 or incapacitated.
- Secondary: dependent parents and unmarried children meeting certain conditions.
- Primary beneficiaries exclude secondary from death benefits.
- Absence of beneficiaries causes benefits to revert to Compensation Fund.
Employers’ Records and Notices
- Employees or representatives must notify employer of sickness/injury/death within 5 days.
- Employers maintain a logbook for recording such contingencies.
- Employers notify System within 5 days from logbook entry.
- Logbooks subject to System inspection.
- Failure to comply results in fines, imprisonment, and liability for benefits.
Accreditation of Medical and Rehabilitation Facilities
- Accreditation criteria for physicians, hospitals, and rehabilitation facilities defined.
- Conditions include licenses, facilities, staffing, records, and compliance with standards.
- Accredited entities agree to non-collection of fees for ward services and compliance with benefit limits.
- Utilization Review Committees oversee medical necessity of hospital care.
- Payment generally only for accredited providers; emergency care exceptions exist.
- Disaccreditation procedures and penalties established.
Settlement of Claims
- Medical benefit claims filed by accredited providers; income benefit claims by employees, dependents, or employers.
- Claims must be filed within three years or rights barred.
- The System adjudicates claims and may require additional evidence.
- Appeal to Commission possible within defined periods.
Judicial Review by Employees' Compensation Commission
- Commission decides appeals en banc within 30 working days.
- Minimum affirmative votes required for decision; no reconsideration allowed.
- Awards to be paid within 15 days.
- Employer payments enforceable as court decisions.
- Non-compliance punishable by contempt.
Penalties Under the Rules
- Employer failure to install safety devices may trigger penalties per Labor Code.
- Fraud or falsification related to benefits or documents punished with fines and imprisonment.
- Additional sanctions for recidivists, government employees, and professionals include disqualification and dismissal.
Implementing Provisions
- Amended rules took effect June 1, 1987.
- Authority and adoption signed by Commission members.
Annex A - Occupational Diseases
- Lists diseases compensable when contracted under specified work risks.
- Covers cancers, infections, radiation diseases, poisoning, pneumoconioses, cardiovascular diseases, and others.
- Conditions for compensability include work risk exposure, contracted disease during employment, and no employee negligence.
Annex B - Medical Examination Standards
- Requires periodic medical exams for employees exposed to occupational risks.
- Exam intervals vary based on exposure type.
- Exams focused on early detection of specific occupational diseases.
- Results reported and diseases disclosed to System.
Annex C - Medical Benefits Details
- Medical services cover ward services, domiciliary care, medicines, and emergency ambulatory services.
- Ward services include meals, nursing, medicines, labs, surgery, and doctor services.
- Excludes private room charges and personal convenience costs.
- Payments limited to ward rates and necessary services.
- Surgical benefits include surgeon and anesthesiologist fees within prescribed limits.
- Operating room fees compensated only for surgeries in accredited hospitals.