Guidelines for Permanent Total Disability (PTD) Claims under RA 8291

July 26, 2012

GSIS POLICY AND PROCEDURAL GUIDELINES NO. 216-12

 

I. Background/Rationale

This proposal is in response to the need for specific guidelines for Permanent Total Disability (PTD) claims under Republic Act No. 8291 or the GSIS Act of 1997.

Its adoption shall serve as a reference material to guide Medical Officers and other concerned personnel assigned under the Offices of the Senior Vice Presidents of Luzon, National Capital Region (NCR) and Visayas-Mindanao (VisMin) Groups relative to the processing and settlement of PTD claims.

II. Objectives

A. To guide the concerned Medical Officers in determining the illnesses or injuries that may qualify for PTD benefits under RA 8291.

B. To establish procedures in the processing and settlement of PTD claims and in identifying the specific Unit/Department/Personnel accountable and responsible for each stage of the process.

III. Definition of Terms

The following terms shall be defined as:

A. Disability — any loss or impairment of the normal functions of the physical and/or mental faculty of a member, which reduces or eliminates his/her capacity to continue with his/her current gainful occupation; and

B. Permanent Total Disability — accrues or arises due to injury or disease causing complete, irreversible and permanent incapacity that will permanently disable a member to work or engage in the same occupation resulting in loss of income.

IV. Policies

A. General Policies

1. The following disabilities shall be considered as permanent and total:

a. Complete loss of sight of both eyes;

b. Loss of two (2) limbs at or above the ankle or wrist;

c. Permanent complete paralysis of two (2) limbs, resulting in the full loss of voluntary movement of legs or arms;

d. Brain injury resulting in incurable imbecility, insanity, or physical incapacitation; and HcTDSA

e. Such other cases as may be determined by the GSIS Board of Trustees (BOT).

2. During the PTD evaluation process, the following conditions shall be satisfied:

a. Injury or illness is complete, irreversible and permanent;

b. No reasonable or foreseeable probability of recovery at the time of evaluation based on current medical literature;

c. State of irreversible changes (body organs and systemic functions) are already established and supported by medical evidence;

d. Associated symptoms are progressive and totally debilitating; and

e. Overall effect to the physical and/or mental faculties of the claimant prevents him/her from engaging in an occupation and/or earning the same level of income.

3. A claimant shall submit the following proof of inability to work, duly certified by his/her agency's Human Resources office:

a. Service Record;

b. Certificate of leaves (with or without pay) undertaken, including the leave balance; and

c. Daily Time Record (DTR) for the past three (3) months from the date of filing of claim.

4. No Medical Progress Report (MPR) shall be required for cases under Part IV.A.1 (a) to (d), unless specified in the approval.

B. Special or BOT-Determined PTD Cases

1. This shall cover special cases under Part IV.A.1 (e) or the BOT-determined PTD cases based on the symptoms or resultant effects of illnesses that may be similar or comparable to the effects of the illnesses under Part IV.A.1 (a) to (d), affecting the claimant's capacity to continue engaging in an occupation and/or earning the same level of income.

2. A claimant, entitled to disability benefits, shall submit annual MPR to determine if he/she has recovered or his/her condition still qualifies as PTD.

3. Unless the claimant has reached the minimum retirement age, the grant of disability benefits shall, after validation and due notice, be suspended by GSIS under any of the following conditions:

a. The claimant is reemployed but fails to inform GSIS of such reemployment;

b. The claimant is reemployed and is earning at least the same level of income before his/her entitlement to disability benefits;

c. The claimant recovers from disability as determined by the GSIS, whose decision shall be final and binding; or

d. The claimant fails to present his/her self for medical examination when required by the GSIS. However, he/she may request a home visitation in case he/she cannot present his/her self to GSIS for medical evaluation.

C. Evaluators of PTD Claims

An Office Order shall be issued identifying the Medical Evaluators and Medical Reviewers per area of jurisdiction. cDHCAE

D. Duties and Responsibilities 

1. The SVPs of Luzon, NCR and VisMin Groups shall:

a. Designate Medical Officers who shall act as Medical Evaluators and Medical Reviewers for their respective groups;

b. Approve or disapprove all PTD claims, within their jurisdiction, upon recommendation of the Medical Reviewer;

c. Submit approved and disapproved PTD claims for peer review of the two (2) other SVPs of the Operations Group within two (2) weeks upon approval. The review may not necessarily overturn the decision of the approving SVP, who shall still be accountable for the approval of the PTD claims.

d. Ensure the proper implementation of the PTD guidelines and resolve any queries and issues that may arise during its implementation;

e. Undertake necessary disciplinary action for negligence, connivance in committing fraudulent claims, and any deviations from the prescribed provisions; and

f. Submit a Year-End Report of all disability claims, including a listing of disability pensioners being monitored, to the President and General Manager not later than the second (2nd) week of January of the following year.

2. The Medical Reviewers shall:

a. Supervise Medical Evaluators and monitor the evaluation process and ensure its uniform implementation in accordance with the prescribed guidelines;

b. Endorse to the concerned SVP his/her recommendation on PTD claims and the Disability Evaluation Sheet (DES) detailing the basis/justification of his/her recommendation;

c. Maintain and regularly update the monitoring tool for disability claims for documentation and monitoring purposes;

d. Validate supporting documents submitted by the Medical Evaluators; and

e. Submit the required reports to the concerned SVP within the prescribed period.

3. The Medical Evaluator shall:

a. Gather medical evidence by obtaining claimant's medical and/or surgical history and other medical documents;

b. Require submission of claimant's proof of inability to work;

c. Conduct physical examination (PE) and other necessary procedures in the GSIS Office or during home visitation for verification purposes, whenever necessary; and

d. Conduct preliminary review to determine if the injury or illness of the claimant qualifies under PTD. aCATSI

E. Additional Responsibilities on Special or BOT-Determined PTC Cases

1. The SVPs of Luzon, NCR and VisMin Groups shall submit to the BOT quarterly report of all disability claims granted under special or BOT-determined PTD cases

2. The Medical Reviewers shall:

a. Monitor the timely submission of MPRs and ensure that these are verified and validated; and

b. Send letter to the concerned claimant at least two (2) months prior to the scheduled submission of MPRs.

F. List of Illnesses or Injuries

The List of Illnesses/injuries (Annex A) and the Physical and Duration/Prognosis Classifications (Annex B) may be used as guides and shall not automatically entitle a claimant to PTD benefits, without a determination as to claimant's inability to work or engage in an occupation and/or earn the same level of income.

This List shall be reviewed and updated by the Medical Reviewers every two (2) years or as often as necessary. The SVPs of Luzon, NCR and VisMin Groups may recommend the inclusion of any additional disease or injury to the list of illnesses or injuries, subject to approval of the BOT.

G. Processing Period

The processing time for PTD claims shall be sixty (60) days from submission of complete requirements by the claimant.

H. Appeals

A claim disapproved or suspended by the SVP may be appealed to the Committee on Claims (COC). This must be filed within sixty (60) days from receipt of the notice of disapproval or suspension.

The COC's decision may be appealed to the Board of Trustees within sixty (60) days from receipt of the COC's resolution.

I. Administrative Sanction

Non-compliance with the aforementioned rules and regulations shall subject the erring officer and/or employee to disciplinary action in accordance with Section 46 (b), Subtitle A, Title I, Book V of the Administrative Code of 1987, as amended and/or Section 38 of Presidential Decree No. 1146 dated 31 May 1977 and the Revised Rules on Administrative Cases in the Civil Service (RRACCS) promulgated on 18 November 2011.

J. System Requirement

1. The Operations Groups shall provide the business requirements to the Information Technology Services Group (ITSG) to serve as basis for the development or enhancement of computerized systems.

2. ITSG shall provide the necessary computer services support and automation enhancements that will efficiently and effectively implement this PPG.

3. The Operations Groups, the Information Security Office (ISO) and the Internal Audit Services Office (IASO) shall conduct User Acceptance Testing (UAT) to facilitate the implementation of the program.

4. The Controller Group shall provide the necessary accounting entries and the accounting reports required to properly reflect the transactions in the books of accounts.

5. The IASO shall conduct a review of the procedures and computerized system to ensure compliance with this PPG. AHTICD

K. Manual of Operations

The Functional Group (FG) concerned shall ensure that all necessary changes in procedures are reflected in the pertinent sections of the Manual of Operations to conform to this PPG.

L. Information Drive

The Corporate Communications Office (CCO) shall be responsible for the information dissemination of this PPG.

M. Procedural Guidelines

The detailed procedures to be included in the Manual of Operations of the operating units concerned (OUC) shall adhere to the following general guidelines:

1. Processing of PTD Claim (or MPR for Special Claimants)

	Activity	Responsible Unit/
			Person
1.	Accomplish and submit PTD application or MPR	Claimant or
	together with the supporting documents.	Authorized
			Representative
2.	Receive application or MPR and log on to TMS,	Frontline Services
	and verify non-medical eligibility requirements	Division of the
	(e.g., endorsement from operating units, application	Central Office or
	forms, service records), if applicable.	Branch Office
	2.1	If complete, proceed to Activity 3.
	2.2	If incomplete, return documents to claimant.
3.	Forward TMS and transmit the application or MPR,
	together with the supporting documents, to the
	concerned Medical Evaluator for review or initial
	medical evaluation.    DcaCSE
4.	Receive and validate submitted documents. Require	Medical Evaluators
	the claimant to submit additional documents if
	medical evidence is unavailable or insufficient to
	support the claimant's medical/surgical history or
	conduct another PE and/or medical procedures, if
	necessary.
5.	Evaluate the claim or MPR and initially determine
	whether the claimant is eligible for PTD benefits or
	not. Prepare DES.
6.	Forward DES and TMS to the designated Medical
	Reviewer.
7.	Thoroughly review the preliminary evaluation	Medical Reviewer
	in accordance with guidelines and recommend
	the approval or denial of the claim.
8.	Submit DES to SVP concerned, including medical
	history, laboratory results, and PE findings.
9.	Approve or disapprove PTD claim or MPR.	SVP Concerned
10.	Forward documents to the two (2) other
	SVPs for peer review.
11.	Assess PTD claim and return to SVP	Other SVPs
	concerned with comments.
12.	Decide whether to maintain approval or	SVP Concerned
	disapproval of the PTD claim, considering
	the inputs by other SVPs. Transmit documents
	to Medical Reviewer.
13.	Log approved or disapproved claim in the	Medical Reviewer
	monitoring tool. Forward approved or
	disapproved PTD claim or MPR and TMS to
	Claims Unit.
14.	Determine instruction of the SVP.	Claims Unit
	14.1	If approved, process payment of PTD
		claim.
	14.2	If disapproved, inform claimant in
		writing.
15.	Forward supporting documents to Records
	Management Department (RMD) for storage.

 

 End of Process

2. Monitoring of MPR Submission (interim procedure pending system enhancement)

	Activity	Responsible Unit/Person
1.	Identify PTD pensioners due to submit MPRs	Medical Reviewer
	from the monitoring tool.
2.	Send letters to PTD pensioners at least two (2)
	months prior to scheduled submission.
3.	Forward list to Medical Evaluator.
4.	Indicate whether MPR was submitted or not	Medical Evaluator
	and submit to Medical Reviewer.
5.	Prepare list of PTD pensioners with no MPR and	Medical Reviewer
	CIUR. Forward to Membership.
6.	Tag pension record as suspended.	Membership Department

 

 End of Process

3. Suspension of Pension in Case of Reemployment

	Activity	Responsible Unit/Person
1.	Receive information and proof of employment	FSD
	indicating salary, such as ITR certificate of
	employment, copy of company ID, or payslip.
2.	Log in TMS.
3.	Forward documents and TMS to Claims Unit
4.	Determine source of information.	Claims Unit
	4.1	If source is pensioner or authorized
		representative, proceed to Activity 5.
	4.2	If source is not the pensioner or authorized
		representative, confirm the information, if
		necessary, and submit report and TMS to
		Manager.
5.	Review report.	Division Chief, FSD
	5.1	If information is legitimate, indicate in the
		remarks portion of the TMS. Return TMS to
		Claims Unit and proceed to Activity 6.
	5.2	If information is not legitimate, indicate in
		the remarks portion of TMS and close the
		same.
6.	Compare current salary with previous salary.	Claims Unit
	6.1	If current salary is equal or more than the
		previous salary, indicate in the remarks
		portion of the TMS. Proceed to Activity 7.
	6.2	If current salary is less than the previous
		salary, indicate in the remarks portion of the
		TMS and close the same.
7.	Prepare and forward CIUR, together with TMS, to
	Membership Department.
8.	Prepare letter informing pensioner that his/her
	pension will be suspended and forward the same
	to RMD for mailing.
9.	Mail letter.	RMD
10.	Suspend pension and forward TMS Claims Unit.	Membership Department

 

 End of Process

The PPG shall take effect immediately.

(SGD.) ROBERT G. VERGARAPresident and General ManagerGovernment Service Insurance System

Published in the Official Gazette, Vol. 111, No. 3, Page 427 on January 19, 2015.