December 1, 2014

GSIS POLICY AND PROCEDURAL GUIDELINES NO. 274-14

 

I. Background/Rationale

Under Republic Act No. 8291, members are entitled to disability benefit claims due to loss or reduction in earning capacity caused by a loss or impairment of the normal functions of his or her physical and/or mental faculties as a result of an injury or disease.

GSIS grants benefits to member-claimants whose disability may be "permanent total," "permanent partial," or "temporary total."

Permanent partial disability (PPD) arises upon the irrevocable loss or impairment of certain portion/s of the physical faculties, despite which the member is still able to pursue a gainful occupation.

II. Objectives

This PPG aims to:

A. Guide the Medical Officers in determining and evaluating the illnesses or injuries that may qualify for PPD benefits under RA 8291;

B. Assist the claims processor in adjudicating the PPD claims under RA 8291; and

C. Establish the procedures in the processing and settlement of PPD benefits and identify the specific unit accountable and responsible for each stage of the process.

III. Definition of Terms

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 or her capacity to continue with his or her current gainful occupation or engage in any other gainful occupation;

B. Gainful Occupation — any productive activity that provides the member with income at least equal to the minimum compensation of government employees;

C. PermanentPartial Disability — arises upon the irreversible loss or impairment of certain physical faculties, despite which the member is still able to pursue a gainful occupation; EHaASD

D. Scheduled disability — any disability with a corresponding fixed or ranged rating of disabilities as listed under Section 17 (b) (1) of RA 8291. On the other hand, non-scheduled disabilities are those not listed under such provision.

E. Actual Loss of Income — refers to the number of days when a member went on leave of absence without pay (LWOP) reckoned immediately from the date of commencement of disability.

IV. Policies

A. Disabilities under PPD

1. The following disabilities shall be considered as Permanent and Partial Disability:

a. Complete and permanent loss of the use of or loss of: (physiologic and anatomic)

1) any finger;

2) any toe;

3) one arm;

4) one hand;

5) one foot;

6) one leg;

7) one or both ears;

8) hearing of one or both ears;

9) sight of one eye; or

b. Such other cases as may be determined by the GSIS.

2. The nature of the disability and the corresponding PPD benefits, shall depend on the usefulness of the body part to the performance of his or her job.

B. Conditions for Entitlement

1. The member shall be entitled to the PPD benefits, provided that the member satisfies the following conditions:

a. The member is in the service at the time of the disability; or

b. If separated from the service,

1) the member has paid at least thirty-six (36) monthly contributions within the five (5) year period immediately preceding his or her disability; or the member has paid a total of at least one hundred eighty (180) monthly contributions prior to the disability, provided that the following conditions shall be met:

a) He or she is gainfully employed prior to the commencement of disability resulting in loss of income as evidenced by any incontrovertible proof thereof;

b) He or she is not a registered member of any social insurance institution; and

c) He or she is not receiving any other pension either from GSIS or another local or foreign institution or organization.

C. Conditions for Non-Compensability EaSCAH

Any disability or injury shall not be compensable under any of the following conditions:

1. Any disability or injury as a result of, or due to grave misconduct, participation in riots, gross and inexcusable negligence, under the influence of drugs or alcohol or willful intention to injure or kill oneself or another;

2. Any Leave of Absence Without Pay (LWOP) incurred after the duration of entitlement to the benefit.

D. Computation of Benefits

1. Any member qualified to PPD benefit shall be entitled to a cash payment equivalent to the basic monthly pension (BMP) multiplied by the number of months indicated in the Scheduled Disabilities (Annex A) and Non-Scheduled Disabilities (Annex B).

2. The loss in earning capacity shall be determined not only on the basis of the member's actual loss of income from his or her current occupation but also on his or her capacity to continue engaging in any gainful occupation because of the impairment.

3. Only the LWOP period incurred during the period of entitlement, duly certified by the authorized officer of the agency where the member is employed, shall be compensable.

4. The PPD benefit to be granted shall be one time for every disability, if qualified.

5. If the member has two or more different contingencies during the same period of benefit entitlement, he or she shall be compensated only once for the overlapping periods.

 For claims with two or more injuries falling under the Scheduled or Non-Scheduled Disabilities, the claimant shall be paid with the higher benefit.

6. For the purpose of computing the corresponding benefit of inactive members for each kind of disability, the Basic Monthly Pension at the time of separation from GSIS shall be the basis.

E. Evaluation of Claim

1. The Medical Officers shall evaluate the compensability of the claim based on the medical condition of the member.

2. All medically approved PPD claims shall be reviewed by the Claims Unit to determine eligibility of member to the PPD benefits.

F. Exclusiveness of Benefits

Whenever other laws provide similar benefits for the same contingencies covered by RA 8291, the member who qualifies for the benefit shall have the option to choose which benefits will be paid to him. However, if the benefits provided by the law chosen by the member are less than the benefits provided under RA 8291, the GSIS shall pay only the difference.

G. List of Illnesses or Injuries

The Schedule of Disabilities (Annex A) and Non-Scheduled Disabilities (Annex B) may be used as guides but shall not automatically entitle a claimant to PPD benefits without a determination of the aforementioned conditions.

H. Appeals for Disapproved PPD Claims

1. First Appeal — Committee on Claims (COC)

 Request for reconsideration of disapproved PPD claim shall be in writing, addressed to the Chairperson of the COC, and shall be filed within 30 days from receipt of disapproval. A written notice about COC's decision shall be sent to the claimant, copy furnished the Manager, Vice President and Senior Vice President concerned. cHCaIE

2. Second Appeal — Board of Trustees

 Further appeal to the COC's decision shall be filed with the Board of Trustees within 30 days from receipt of COC decision affirming the disapproval of his or her claim.

 Only the Board of Trustees can decide with finality the outcome of an appeal from the Committee on Claims (COC).

I. Duties and Responsibilities

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

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

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

c. Recommend the inclusion of additional diseases or injuries to the list, subject to the approval of the GSIS Board of Trustees;

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

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

2. The Medical Reviewers shall:

a. Ensure the uniform implementation of PPD evaluation in accordance with the prescribed guidelines;

b. Review and validate the documents submitted by the Medical Evaluator;

c. Endorse to the concerned SVP the Medical Evaluation Report (MER), forwarded by the Medical Evaluator, signifying his or her concurrence on the recommendation;

d. Maintain and regularly update the monitoring tool for PPD claims for documentation and monitoring purposes;

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

f. Review and update the Schedule of Disabilities (Annex A) and Non-Scheduled Disabilities (Annex B) every two (2) years or as often as necessary.

3. The Medical Evaluator shall:

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

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

c. Evaluate the claim and recommend approval or disapproval whether the injury or illness of the claimant is qualified under PPD; and

d. Forward the MER to the Medical Evaluator detailing the basis or justification of his or her recommendation, for confirmation.

4. The Claims Unit shall:

a. Determine the actual loss of income incurred by the PPD applicant; AHacIS

b. Review all medically approved PPD claims to ensure the completeness of non-medical requirements;

c. Inform the PPD claimant of the result of the evaluation of his or her claim accordingly within three (3) working days upon receipt of the documents from the Medical Evaluator. All disapproved claims together with their documents shall be retained in case the claimant decides to appeal the decision.

5. The Corporate Communications Office shall prepare the necessary information materials to disseminate the implementation of this PPG.

V. Procedures

The Manual of Operations shall conform to the following procedures:

1. Disability Determination Process

	Activity	Responsible Unit
1.	Accomplish and submit application	Claimant or Authorized
	for disability benefit together with	Representative
	other supporting documents.
2.	Receive application form and verify	Frontline Services Division of the
	non-medical eligibility requirements	Central Office or Branch Office
	(e.g., application form, and service
	records indicating LWOP).
	2.1	If complete, log to TMS and
		proceed to Activity 3.
	2.2	If incomplete, return the
		documents to claimant or
		authorized representative and
		issue Deficiency Slip.
3.	Forward TMS and transmit the
	application together with the
	supporting documents to the
	concerned Medical Officer
	(Evaluator) for medical evaluation.
4.	Receive and validate submitted	Medical Officer (Evaluator)
	documents. Require the claimant to
	submit additional documents if
	medical evidence is unavailable or
	insufficient or conduct physical
	examination, as necessary.
5.	Evaluate the claim and initially
	determine whether the claimant
	is eligible for PPD benefits or not.
	Prepare the Medical Evaluation
	Report (MER) and recommend
	Approval or Disapproval of the
	claim.
6.	Forward MER and TMS to the
	designated Medical Officer
	(Reviewer)
7.	Thoroughly review the preliminary	Medical Officer (Reviewer)
	evaluation in accordance with the
	guidelines and concur with the
	recommended approval or denial of
	the claim.
8.	Submit MER to the SVP concerned.
9.	Approve or confirm the disapproval	SVP concerned
	of the claim. Return signed MER to
	Medical Officer (Evaluator).
10.	Receive signed MER from the SVP	Medical Officer (Evaluator)
	and log approved or disapproved
	claim in the monitoring tool.
	Forward approved or disapproved
	PPD claim and TMS to Claims Unit.
11.	Determine instruction of the SVP.	Claims Unit
	11.1	If approved, process payment
		of PPD claim.
	11.2	If disapproved, inform claimant
		in writing.

 

 End of Process

All PPGs, Office Orders, and Circulars policies and procedures previously adopted which are inconsistent with the provisions above are hereby deemed superseded or modified accordingly.

This PPG shall take effect immediately.

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

ANNEX A

Schedule of Disabilities

A. Scheduled Disability

The Musculo-Skeletal System

This system is made up of the bones, muscles, and other structures attached to them and are divided into: (1) the upper extremity; (2) the lower extremity, and (3) the back or the spine.

Each division is considered a unit of the whole man. The major joints refer to the hip, knee, ankle, shoulder, elbow, wrist and hand. Wrist and hand are considered together as one major joint.

Adequate History	This includes the date of injury or trauma, detailed
	description of character, location, and radiation of
	pain, effect or response to prescribed treatment.
	From the date of injury, waiting period must be
	observed before giving permanent disability
	benefits. Established waiting period for injury of
	small bone is 3 months and for long bones is 6 to
	12 months.
Physical Examination	The specific findings must be stated. Detailed
	description of orthopedic and neurologic findings
	such as description of gait, limitation of movement,
	motor and sensory abnormalities, muscle spasm,
	deep tendon reflexes and circulatory deficits should
	be included.
	In atrophy, there should be circumferential
	measurements of both thighs and lower legs; or
	upper and lower arms at a stated point above and
	below the knee or elbow. In hand muscle atrophy;
	measurement should also include strength of grip.
	When surgery has been performed, documentation
	should include operative notes and pathologic
	report. If there is no significant range in PE or
	X-Ray findings for any six (6) months period after
	surgery, evaluation should be made on the basis of
	demonstrable residuals.
Roentgenography	This includes evidences of fracture, malunion or
	non-union of fractures, calcifications, ankylosis,
	osteoporosis, herniated nucleus pulposus, spinal
	stenosis, arthritis, and vertebral deformities.
Loss of function	The loss of function results from the amputation,
	the deformity, or the loss of the use of the body
	part in relation to the performance of his/her job.

 

Special considerations in the evaluation of Permanent Partial Disabilities of the Musculo-Skeletal System

Impairment Category	Special Considerations
Amputations due to	In establishing values of amputation and
trauma/injury or	deformities, consideration should be given to both
amputation of	loss of motor function and loss of sensation. In
anatomical deformity	amputation, disability is evaluated according to
due loss of function	functional loss, which is done according to the
brought about by	level of the amputation and given on the date of
degenerative changes.	surgery was done. When there is concomitant
	ankylosis of joints of small bones, the date of
	evaluation of the disability is 3 months after the
	injury.
Ankylosis and other	The limitation of normal range of motion of a joint
limitation of movements	should be determined whether partial or complete.
resulting from fractures,	Complete ankylosis is more disabling and has a
osteoarthritis, disorders	higher value of impairment. Ankylosis of the knee
of the spine, herniated	and elbows are less disabling than that of the hip
nucleus pulposus,	and shoulder joints.
spinal stenosis
Atrophy, shortening
deformities
When there is non-union	In fractures of long bones with resulting ankylosis,
of fractures as seen on	disability is determined after termination of
X-Ray, surgical	treatment which is usually 6 months after injury or
management is directed	6 months after maximum benefit from surgical
towards restoration of	therapy. Clinical findings such as coordination of
functional use. Such	movements and strength of the affected bone and
function is not restored	not X-Ray result should be used as guides in
within 6 to 12 months	demonstrating residuals.
Anesthesia,	In paralysis of upper extremities due to injuries of
Paresthesia, Paresis	peripheral nerves, hereby resulting to the loss of
and Paralysis resulting	the use of that body part, a six (6) months waiting
from direct injury to	period must be observed in order to allow
bones, nerves and	regeneration of the nerves before evaluating for
muscles.	permanent disability.

 

Amputations/Disarticulations

A loss of a wrist shall be considered a loss of a hand, and a loss of an elbow considered loss of the arm, a loss of an ankle shall be considered a loss of a foot, and a loss of knee shall be considered a loss of the leg, a loss of more than one joint shall be considered a loss of the whole finger or toe. Such cases shall be considered Scheduled Disabilities.

An injury, lesion, or mutilation resulting to a complete and permanent loss of use of a hand, an arm, a foot, a leg, a thumb, any finger or toe or a joint shall be considered equivalent to loss of hand, arm, foot, leg, thumb, finger, toe or joint. Such cases shall also be considered Scheduled Disabilities.

Upper Extremity
	Average Rating
One Arm	12 months
One Hand	10 months
One Thumb	3 months
One Index Finger	2 months
One Middle Finger	1 month
One Ring Finger	1 month
One Little Finger	1 month
Lower Extremity
	Average Rating
One Leg	12 months
One Foot	8 months
One Big Toe	2 months
Any other Toe	1 month

Loss of Use of Organs of Special Senses

Average Rating for Loss of One Eye and/or Loss of Vision, One eye

Evaluation of these cases depends upon the resulting permanent visual acuity. Resulting negative vision and vision limited to light perception on counting fingers of less than five (5) feet should be rated as 100% loss of function of the eye. The underlying cause for 100% loss of vision may either be due to injury, disease or abnormalities of the affected eye. Such case shall be considered a Scheduled Disability.

Complete loss of vision, one eye  12 months

Average Rating for loss of one or both Ears and loss of Hearing, One or both Ears

Evaluation of hearing impairment shall depend on the Audiometric findings, where a severe hearing loss shall be rated as complete loss of the use of the affected Ear(s).

Complete loss of hearing, one ear or loss of one ear 5 months

Complete loss of hearing, both ears or loss of both ears 10 months

Severe and Profound Hearing Loss are considered complete hearing loss.

Basis:

• Normal hearing for adult has 0-25 dBHL

• Severe hearing loss 70-90 dBHL — Cannot hear a conversation unless a speaker speaks loudly near the ear.

• Profound Hearing Loss 90+ dBHL — Cannot understand speech even if the speaker shouts. Can only hear very loud sounds such as motorcycle engine. DHITcS

ANNEX B

Schedule of Disabilities

			Schedule of Disabilities
B.	Non-Scheduled Disabilities
Dreaded Illnesses
Cancer
	Carcinoma of any functional system/body part	12 months
Benign Brain Tumors	12 months
Pulmonary System
	Chronic Obstructive Pulmonary Disease (COPD)	12 months
	Moderately Advanced Pulmonary Tuberculosis	9 months
	S/P Laryngectomy	12 months
Cardio Vascular System
	Aneurysm, S/P ruptured	12 months
	Cor Pulmonale	12 months
	Myocardial Infarction (if disallowed under PD 626)	12 months
	Rheumatic Heart Disease/Congestive Heart Failure	12 months
Cerebro Vascular Disease (stroke)	12 months
Gastrointestinal
	Liver Cirrhosis, compensated	3 months
Urinary System
	End Stage Renal Disease	12 months
Hemic and Lymphatic System
	Aplastic Anemia	12 months
	Hodgkin's Disease	12 months
	Leukemia	12 months
	Lymphomas	12 months
	Paroxysmal Nocturnal Hemoglobinuria	10 months
Nervous System
	Guillain-Barre Syndrome	12 months
	Traumatic Injuries to Brain	12 months
	Parkinson's Disease	12 months
	Spinal Cord Compression	12 months
Musculo-Skeletal System
	Osteomyelitis	12 months
	Non-Union/Malunion of Fractured Long Bone/s	12 months
	Charcot Foot	12 months
Osteoarthritis
	Hip		2 months
	Spine	2 months
Gouty Arthritis
	Digits	1 month
	Elbows	1 month
	Knees	2 months
Rheumatoid arthritis
	Hip		3 months
	Spine	3 months
Psoriatic arthritis
	Hip		3 months
	Spine	3 months
Osteoporosis
Arthritis
	Must satisfy all the conditions stated below:
	(1)	Irreversible loss or impairment of normal functions which reduces, but
		not totally disable the member;
	(2)	Positive X-Ray findings of degenerative arthritis/joint damage/bone
		demineralization;
	(3)	There is limitation of motion;
	(4)	There is external arthritic deformity/bone deformity
Auto-Immune
	Systemic Lupus Erythematosus	10 months

 

Published in The Philippine Star on February 21, 2015.