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No. 11 dated 26 January 2012, the interim policy for PTD claims under Section 16 (d) (5) of R.A. No. 8291 is hereby SUPERSEDED upon the implementation of the PPG on PTD Claims.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
III. DEFINITION OF TERMS
The following terms shall be defined as:
IV. POLICIES
A. GENERAL POLICIES
B. SPECIAL OR BOT-DETERMINED PTD CASES
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
E. ADDITIONAL RESPONSIBILITIES ON SPECIAL OR BOT-DETERMINED PTD CASES
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
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:
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 Reviewer14. 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
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
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.