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WHEREAS, Section 15 of RA. No. 8291 states that a member who suffers permanent disability for reasons not due to his grave misconduct, notorious negligence, habitual intoxication, or willful intention to kill himself/herself or another, shall be entitled to the benefits under Permanent Total Disability (PTD) subject to conditions provided under Section 16;

WHEREAS, pursuant to Section 16 (d) (1) to (4) of RA. No. 8291, certain illnesses or diseases have been identified as qualifying a member for benefits under PTD;

WHEREAS, Section 16 (d) (5) also allowed GSIS to determine other cases that would qualify a member for coverage under PTD;

WHEREAS, there is a need to adopt guidelines in determining cases under Section 16 (d) (5), considering the symptoms or resultant effects of illnesses that may be similar or comparable to the effects of the illnesses under Section 16 (d) (1) to (4), affecting the claimant’s capacity to continue engaging in an occupation and/or earning the same level of income;

RESOLVED, to APPROVE and CONFIRM the Policy and Procedural Guidelines (PPG) on Permanent Total Disability Claims under R.A. No. 8291 as proposed by the Senior Vice President, Corporate Services Group and Corporate Planning Office, in her Memorandum dated 4 July 2012;

RESOLVED FINALLY, that Board Resolution No. 11 dated 26 January 2012, the interim policy for PTD claims under Section 16 (d) (5) of R.A. No. 8291 is hereby SUPERSEDED upon the implementation of the PPG on PTD Claims.

A copy of the draft PPG on PTD Claims is made an integral part of this Resolution.

Attachment:

Policy and Procedural Guidelines No. 216-12

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

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

1. To guide the concerned Medical Officers in determining the illnesses or injuries that may qualify for PTD benefits under RA 8291.
   
   
2. 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:

1. 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
   
   
2. 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.
   
   
1. Complete loss of sight of both eyes;
2. Loss of two (2) limbs at or above the ankle or wrist;
3. Permanent complete paralysis of two (2) limbs, resulting in the full loss of voluntary movement of legs or arms;
4. Brain injury resulting in incurable imbecility, insanity, or physical incapacitation; and
5. 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:
   
   
1. Injury or illness is complete, irreversible and permanent;
2. No reasonable or foreseeable probability of recovery at the time of evaluation based on current medical literature;
3. State of irreversible changes (body organs and systemic functions) are already established and supported by medical evidence;
4. Associated symptoms are progressive and totally debilitating; and
5. 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:
   
   
1. Service Record;
2. Certificate of leaves (with and without pay) undertaken, including the leave balance; and
3. 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:
   
   
   1. The claimant is reemployed but fails to inform GSIS of such reemployment;
   2. The claimant is reemployed and is earning at least the same level of income before his/her entitlement to disability benefits;
   3. The claimant recovers from disability as determined by the GSIS, whose decision shall be final and binding; or
   4. 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.

D. DUTIES AND RESPONSIBILITIES

1. The SVPs of Luzon, NCR and VisMin Groups shall:
   
   
   1. Designate Medical Officers who shall act as Medical Evaluators and Medical Reviewers for their respective groups;
   2. Approve or disapprove all PTD claims, within their jurisdiction, upon recommendation of the Medical Reviewer;
   3. 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.
   4. Ensure the proper implementation of the PTD guidelines and resolve any queries and issues that may arise during its implementation;
   5. Undertake necessary disciplinary action for negligence, connivance in committing fraudulent claims, and any deviations from the prescribed provisions; and
   6. 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:
   
   
   1. Supervise Medical Evaluators and monitor the evaluation process and ensure its uniform implementation in accordance with the prescribed guidelines;
   2. 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;
   3. Maintain and regularly update the monitoring tool for disability claims for documentation and monitoring purposes;
   4. Validate supporting documents submitted by the Medical Evaluators; and
   5. Submit the required reports to the concerned SVP within the prescribed period.
      
      
3. The Medical Evaluator shall:
   
   
   1. Gather medical evidence by obtaining claimant’s medical and/or surgical history and other medical documents;
   2. Require submission of claimant’s proof of inability to work;
   3. Conduct physical examination (PE) and other necessary procedures in the GSIS Office or during home visitation for verification purposes, whenever necessary; and
   4. Conduct preliminary review to determine if the injury or illness of the claimant qualifies under PTD.

E. ADDITIONAL RESPONSIBILITIES ON SPECIAL OR BOT-DETERMINED PTD 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:
   1. Monitor the timely submission of MPRs and ensure that these are verified and validated; and
   2. Send letter to 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 Vis-Min 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 (BOT) 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.

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 together with the supporting documents.	Claimant or Authorized Representative
2. Receive application or MPR and log to TMS, and verify non-medical eligibility requirements (e.g., endorsement from operating units, application forms, service records), if applicable. 2.1 If complete, proceed to Activity 3. 2.2 If incomplete, return documents to claimant	Frontline Services Division of the Central Office or Branch Office
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
4. Receive and validate submitted documents. Require 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.	Medical Evaluators
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 in accordance with guidelines and recommend the approval or denial of the claim.	Medical Reviewer
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 concerned with comments.	Other SVPs
12. Decide whether to maintain approval or disapproval of the PTD claim, considering the inputs by other SVPs. Transmit documents to Medical Reviewer.	SVP Concerned
13. Log approved or disapproved claim in the monitoring tool. Forward approved or disapproved PTD claim or MPR and TMS to Claims Unit.	Medical Reviewer
14. Determine instruction of the SVP. 14.1 If approved, process payment of PTD claim. 14.2 If disapproved, inform claimant in writing.	Claims Unit
15. Forward supporting documents to Records Management Department (RMD) for storage.
End Process

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

Activity	Responsible Unit/Person
1. Identify PTD pensioners due to submit MPRs from the monitoring tool.	Medical Reviewer
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 and submit to Medical Reviewer	Medical Evaluator
5. Prepare list of PTD pensioners with no MPR and CIUR. Forward to Membership.	Medical Reviewer
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 indicating salary, such as ITR, certificate of employment, copy of company ID, or payslip	FSD
   2. Log in TMS.
   3. Forward documents and TMS to Claims Unit.
   4. Determine source of information. 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	Claims Unit
   5. Review report 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.	Division Chief, FSD
   6. Compare current salary with previous salary. 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.	Claims Unit
   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 to Claims Unit.	Membership Department
   End of Process

This PPG shall take effect immediately.

(SGD.) ROBERT G. VERGARA
President and General Manager

 

^[*] Text available at the Office of the National Administrative Register, U.P. Law Complex, Diliman, Quezon City.