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Book IV, Labor Code State Insurance Code PD626

1. Governing Law and Amendments 2. Membership Qualifications / Eligibility



RA10606 RA7875 RA9241 Mandatory Coverage. All citizens of the Philippines shall be covered by the National Health Insurance Program. In accordance with the principles of universality and compulsory coverage enunciated in Section 2(b) and 2(l) hereof, implementation of the Program shall ensure sustainability of coverage and continuous enhancement of the quality of service: Provided, That the Program shall be compulsory in all provinces, cities and municipalities nationwide, notwithstanding the existence of LGU-based health insurance programs: Provided, further, That the Corporation, Department of Health (DOH), local government units (LGUs), and other agencies including nongovernmental organizations (NGOs) and other national government agencies (NGAs) shall ensure that members in such localities shall have access to quality and costeffective health care services.

RA9679 PD1752 RA7742 Membership in the Fund shall be for a period of twenty (20) years, except when earlier terminated by reason of retirement, disability, insanity, death, departure from the country or other causes as may be provided for by the Board of Trustees: Provided, That those who become members of the Fund after the effectivity of this Act may withdraw the total accumulated value of their contributions to the Fund after the tenth or the fifteenth year of continuous membership: Provided, further, That said members have no outstanding housing loans with the Fund: provided, finally, That this option may be exercised only once and shall not prejudice the members continuing membership in the Fund. *Membership to the Fund shall be mandatory for the

Compulsory for all employees receiving compensation who have not reached the compulsory retirement age.

1. Compulsory upon all employees not over sixty (60) years of age and their employers. 2. Spouses who devote full time to managing the household and family affairs, unless they are also engaged in other vocation or employment which is subject to mandatory coverage, may be covered by the SSS on a voluntary basis. 3. Filipinos recruited by foreignbased employers for employment abroad may be covered by the SSS on a voluntary basis. 4. All selfemployed professionals 5. Partners and single proprietors of

Coverage in the State Insurance Fund shall be compulsory upon all employers and their employees not over sixty years of age; Provided, That an employee who is over sixty years of age and paying contributions to qualify for the retirement or life insurance benefit administered by the System shall be subject to compulsory coverage.

businesses 6. Actors and actresses, directors, scriptwriters and news correspondents who do not fall within the definition of the term "employee"; in Sec. 8 (d) of this Act 7. Professional athletes, coaches, trainers and jockeys 8. Individual farmers and fishermen

following: a. All employees, workers, professionals, officers and companies who are compulsorily covered by the SSS and GSIS b. Uniformed members of the Armed Forces of the Philippines, the Bureau of Fire Protection, the Bureau of Jail Management and Penology, and the Philippine National Police; c. Overseas Filipino Workers (OFWs) d. Filipinos employed by foreign-based employers, whether deployed locally or abroad. Membership to the Fund is also open to the following: a. Non-working spouses of Pag-IBIG members; b. Filipino employees of foreign government or international organization, or their wholly-owned instrumentality based in the Philippines, in the absence of an administrative agreement with the Fund; c. Employees of an employer who is granted a waiver or suspension of coverage by the Fund under RA 9679;

3. Contributions / Fees

Mandatory for the member and the employer to pay the monthly contributions.

1. Employee's Contribution Beginning as of the last day of the calendar month when an employee's compulsory coverage takes effect and every month thereafter during his employment, the employer shall deduct and withhold from such employee's monthly salary, wage, compensation or earnings, the employee's contribution in an amount

All members who can afford to pay shall contribute to the Fund, in accordance with a reasonable, equitable and progressive contribution schedule to be determined by the Corporation on the basis of applicable actuarial studies and in accordance with the following guidelines: (a) Members in the formal economy and their employers shall continue paying the same monthly contributions as provided for by law until such time that the Corporation shall have determined a new contribution schedule: Provided, That their monthly contributions shall not exceed five percent (5%) of their respective monthly salaries.

d. Leaders and members of religious groups; e. A member separated from employment, local or abroad, or ceased to be selfemployed but would like to continue paying his/her personal contribution; f. Public officials or employees who are not covered by the GSIS such as barangay officials; and g. Filipinos naturalized in other countries. Coverage of the Fund and/or the payment of monthly contribution to the same may be rules and resolutions of the Board of Trustees be waived or suspended by reasons of nature of employment, condition of business, ability to make contributions and other reasonable considerations.

Employer's contributions. (a) Under such regulations as the System may prescribe, beginning as of the last day of the month when an employee's compulsory coverage takes effect and every month thereafter during his employment, his employer shall prepare to remit to the System a contribution equivalent to one percent of his monthly salary credit. (b) The rate of contribution shall be reviewed periodically and, subject to the limitations herein provided, may be revised as the experience in risk, cost of administration, and actual or anticipated as well as unexpected losses, may require.

corresponding to his salary, wage, compensation or earnings during the month. 2. Employer's Contributions Beginning as of the last day of the month when an employee's compulsory coverage takes effect and every month thereafter during his employment, his employer shall pay, with respect to such covered employee, the employer's contribution in accordance with the schedule indicated in Section Eighteen of this Act. Notwithstanding any contract to the contrary, an employer shall not deduct, directly or indirectly, from the compensation of his employees covered by the SSS or otherwise recover from them the employer's contributions with respect to such

It shall be mandatory for all government agencies to include the payment of premium contribution in their respective annual appropriations: Provided, further, That any increase in the premium contribution of the national government as employer shall only become effective upon inclusion of said amount in the annual General Appropriations Act. (b) Contributions from members in the informal economy shall be based primarily on household earnings and assets. Those from the lowest income segment who do not qualify for full subsidy under the means test rule of the DSWD shall be entirely subsidized by the LGUs or through cost sharing mechanisms between/among LGUs and/or legislative sponsors and/or other sponsors and/or the member, including the national government: Provided, That the identification of beneficiaries who shall receive subsidy from LGUs shall be based on a list to be provided by the DSWD through the same means test rule or any other appropriate statistical method that may be adopted for said purpose. (c) Contributions made in

(c) Contributions under this Title shall be paid in their entirety by the employer and any contract or device for the deduction of any portion thereof from the wages or salaries of the employees shall be null and void. (d) When a covered employee dies, becomes disabled or is separated from employment, his employer's obligation to pay the monthly contribution arising from that employment shall cease at the end of the month of contingency and during such months that he is not receiving wages or salary.

employees. 3. The contributions to the SSS of the self-employed member shall be determined in accordance with Section Eighteen of this Act.

4. All Benefits and Rules on Entitlement

1. Separation Benefits payable upon reaching 60 years of age or upon separation, whichever comes later: Provided, That the member resigns or separates from the service after he has rendered at least 3 years of service but less than 15 years. 2. Unemployment benefits - paid to a permanent employee who is involuntarily separated from the service due to the abolition of his office or position usually resulting from reorganization: Provided, That he

1. Retirement Benefits. (a) A member who has paid at least 120 monthly contributions prior to the semester of retirement and who (1) has reached the age of 60 years and is already separated from employment or has ceased to be selfemployed or (2) has reached the age of 65 years, shall be entitled for as long as he lives to the monthly pension: Provided, That he shall have the option to receive his first 18 monthly pensions in lump sum discounted at a preferential rate of interest to be

behalf of indigent members shall not exceed the minimum contributions for employed members. (d) The required number of monthly premium contributions to qualify as a lifetime member may be increased by the Corporation to sustain the financial viability of the Program: Provided, That the increase shall be based on actuarial estimate and study. A member whose premium contributions for at least three (3) months have been paid within six (6) months prior to the first day of availment, including those of the dependents, shall be entitled to the benefits of the Program:Provided, That such member can show that contributions have been made with sufficient regularity: Provided, further, That the member is not currently subject to legal penalties as provided for in Section 44 of this Act. The following need not pay the monthly contributions to be entitled to the Programs benefits: (a) Retirees and pensioners of the SSS and GSIS prior to the effectivity of this Act; and (b) Lifetime members.

Provident (savings) benefits claim: Pag-IBIG Fund guarantees the refund of member's total accumulated savings (TAV), which consists of the member's accumulated contributions, the employer counterpart contributions, if any, and the dividend earnings credited to the member's account upon occurrence of any of the following grounds for withdrawal: 1. Membership maturity. The member must have remitted at least 240 monthly membership contributions with the Fund. For Pag-IBIG Overseas Program (POP) members, membership with the Fund shall be at the end of five (5), ten (10), fifteen (15), or twenty (20) years depending on the option of the

ART. 185. Medical services. Immediately after an employee contracts sickness or sustains an injury, he shall be provided by the System during the subsequent period of his disability with such medical services and appliances as the nature of his sickness or injury and progress of his recovery may require, subject to the expense limitation prescribed by the Commission. ART. 191. Temporary total disability. (a) Under such regulations as the Commission may approve, any employee under this Title who sustains an injury or contracts sickness resulting in temporary total disability shall for each day of such a disability or fraction thereof be paid by the System an income benefit equivalent to ninety percent of his average daily salary credit, subject to the following conditions: The daily

has been paying integrated contributions for at least one (1) year prior to separation. 3. Retirement Benefits (1) Such member has rendered at least 15 years of service; (2) he is at least 60 years of age at the time of retirement; and (3) he is not receiving a monthly pension benefit from permanent total disability. 4. Permanent Disability Benefits A member who suffers permanent disability for reasons not due to his grave misconduct, notorious negligence, habitual intoxication, or willful intention to kill himself or another. 5. Survivorship Benefits (1) basic survivorship pension is 50% of the basic monthly pension (2) dependent

determined by the SSS. 2. Death Benefits Upon the death of a member who has paid at least 36 monthly contributions prior to the semester of death, his primary beneficiaries shall be entitled to the monthly pension: Provided, That if he has no primary beneficiaries, his secondary beneficiaries shall be entitled to a lump sum benefit equivalent to 36 times the monthly pension. 3. Permanent Disability Benefits Upon the permanent total disability of a member who has paid at least 36 monthly contributions prior to the semester of disability, he shall be entitled to the monthly pension: Provided, That if he has not paid the required 36 monthly contributions, he

member upon membership registration. 2. Retirement. The member shall be compulsorily retired upon reaching age 65. He may however, opt to retire upon the occurrence of any of the following: a. Actual retirement from the SSS, the GSIS or a separate employer provident/retirement plan, provided the member has at least reached age 45. b. Upon reaching age 60. 3. Permanent and Total Disability or Insanity. The following disabilities shall be deemed total and permanent: a. Temporary total disability lasting continuously for more than 120 days; b. Complete loss of sight of both eyes; c. Loss of two limbs at or over the ankle or wrist; d. Permanent complete paralysis of two limbs; e. Brain injury resulting in incurable imbecility or insanity; and f. Such other cases which are adjudged to be total and permanent disability by a duly licensed physician and approved by the Board of Trustees. 4. Separation from the service due to health reason

income benefit shall not be less than Ten Pesos nor more than Ninety Pesos, nor paid for a continuous period longer than one hundred twenty days, except as otherwise provided for in the Rules, and the System shall be notified of the injury or sickness. ART. 192. Permanent total disability. (a) Under such regulations as the Commission may approve, any employee under this Title who contracts sickness or sustains an injury resulting in his permanent total disability shall, for each month until his death, be paid by the System during such a disability, an amount equivalent to the monthly income benefit, plus ten percent thereof for each dependent child, but not exceeding five, beginning with youngest and without substitution: Provided, That the monthly income benefit shall be the new amount of the monthly benefit for all covered pensioners, effective upon approval of this Decree. ART. 193. Permanent partial disability. (a) Under such regulation as the Commission may approve, any employee under this Title who

children's pension not exceeding 50% of the basic monthly pension. 6. Funeral Benefit The amount of funeral benefit shall be P12,000 P18,000. 7. Life Insurance Benefits

shall be entitled to a lump sum benefit equivalent to the monthly pension times the number of monthly contributions paid to the SSS or 12 times the monthly pension, whichever is higher. 4. Funeral Benefit A funeral grant equivalent to Twelve thousand pesos (P12,000.00) shall be paid, in cash or in kind, to help defray the cost of funeral expenses upon the death of a member, including permanently totally disabled member or retiree. 5. Sickness benefit. (a) A member who has paid at least 3 monthly contributions in the twelvemonth period immediately preceding the semester of sickness or injury and is confined therefor for more than 3 days in a hospital or elsewhere with the approval of the SSS,

5. Permanent departure from the country 6. Death. In case of death, the Fund benefits shall be divided among the member's legal heirs in accordance with the New Civil Code as amended by the New Family Code.

contracts sickness or sustains an injury resulting in permanent partial disability shall for each month not exceeding the period designated herein be paid by the System during such a disability an income benefit equivalent to the income benefit for permanent total disability. ART. 194. Death. (a) Under such regulations as the Commission may approve, the System shall pay to the primary beneficiaries upon the death of the covered employee under this Title an amount equivalent to his monthly income benefit, plus ten percent thereof for each dependent child, but not exceeding five, beginning with the youngest and without substitution, except as provided for in paragraph (j) of Article 167 hereof: Provided, However, That the monthly income benefit shall be guaranteed for five years: Provided, Further, That if he has no primary beneficiary, the System shall pay to his secondary beneficiaries the monthly income benefit but not to exceed sixty months: Provided, Finally, That the minimum death benefit shall not be less than P15,000.

5. Procedures of Availment

Claims for benefits under this Act except for life and retirement shall prescribe after 4 years from the date of

shall, for each day of compensable confinement or fraction thereof, be paid by his employer, or the SSS, if such person is unemployed or self employed, a daily sickness benefit equivalent to 90% of his average daily salary credit. 6. Maternity Leave Benefit A female member who has paid at least 3 monthly contributions in the twelvemonth period immediately preceding the semester of her childbirth or miscarriage shall be paid a daily maternity benefit equivalent to 100% of her average daily salary credit for 60 days or 78 days in case of caesarean delivery. Compulsory coverage of the employer shall take effect on the first day of his operation and that of the employee on the

SEC. 25. Reimbursement and Period to File Claims. All claims for reimbursement or payment for services rendered shall be filed within a period of sixty (60) calendar days from the date of discharge of the

The Fund shall be private in character, owned wholly by the members, administered in trust and applied exclusively for their benefit. All the personal and employer contributions shall

No claim for compensation shall be given due course unless said claim is filed with the System within three years from the time the cause of action accrued. ART. 201. Prescriptive period. -


first day of his employment: Provided, That the compulsory coverage of the self employed person shall take effect upon his registration with the SSS.

patient from the health care provider. The period to file the claim may be extended for such reasonable causes determined by the Corporation.

be fully credited to each member, accounted for individually and transferable in case of change of employment. They shall earn dividends as may be provided for in the implementing rules. The said amounts shall constitute the provident fund of each member, to be paid to him, his estate or beneficiaries upon termination of membership, or from which peripheral benefits for the member may be drawn.

No claim for compensation shall be given due course unless said claim is filed with the System within three years from the time the cause of action accrued. ART. 292. Money claims. - All money claims arising from employer-employee relations accruing during the effectivity of this Code shall be filed within three (3) years from the time the cause of action accrued; otherwise, they shall be forever barred. All money claims accruing prior to the effectivity of this Code shall be filed with the appropriate entities established under this Code within one year from the date of such effectivity, and shall be processed or determined in accordance with the implementing rules and regulations of the Code; otherwise, they shall be forever barred. Workmens compensation claims accruing prior to the effectivity of this Code and during the period from November 1, 1974 up to December 31, 1974, shall be filed with the appropriate regional offices of the Department of Labor not later than March 31, 1975; otherwise, they shall be forever barred.

6. Administratio n

The GSIS shall formulate, adopt, amend and/or rescind such rules and regulations as may be necessary to carry out the provisions and purposes of this Act, as well as the effective exercise of the powers and functions, and the discharge of duties and responsibilities of the GSIS, its officers and employees.

The SSS shall submit annually not later than April 30, a public report to the President of the Philippines and to the Congress of the Philippines covering its activities in the administration and enforcement of this Act during the preceding year including information and recommendations on broad policies for the development and perfection of the program of the SSS.

The Corporation shall have the following powers and functions: a) to administer the National Health Insurance Program; b) to formulate and promulgate policies for the sound administration of the Program; c) to set standards, rules, and regulations necessary to ensure quality of care, appropriate utilization of services, fund viability, member satisfaction, and overall accomplishment of Program objectives; d) to formulate and implement guidelines on contributions and benefits; portability of benefits, cost containment and quality assurance; and health care provider arrangements, payment, methods, and referral systems; xxx

Section 13. Rule-Making Power. The Board of Trustees is hereby authorized to make and change needful rules and regulations, which shall be published in accordance with law or at least once in a newspaper of general circulation in the Philippines, to provide for, but not limited to the following matters: (a) The effective administration, custody, development, utilization and disposition of the Fund or parts thereof, including payment of amounts credited to members or to their beneficiaries or estates; (b) Extension of Fund coverage to other working groups, and waiver or suspension of coverage or its enforcement for reasons herein stated; (c) Grounds for and effects of termination of membership other than by completion of term; (d) Fund earnings and their distribution, investment and/or plowing back for the exclusive benefit of the members;

ART. 176. Employees' Compensation Commission. (a) To initiate, rationalize and coordinate the policies of the employees' compensation program, the Employees' Compensation Commission is hereby created to be composed of five ex-officio members, namely: the Secretary of Labor and Employment as Chairman, the GSIS General Manager, the SSS Administrator, the Chairman of the Philippine Medical Care Commission, and the Executive Director of the ECC Secretariat, and two appointive members, one of whom shall represent the employees and the other, the employers, to be appointed by the President of the Philippines for a term of six years. The appointive member shall have at least five years experience in workmen's compensation or social security programs. All vacancies shall be filled for the unexpired term only. (As amended by Sec. 19(c), E.O. 126). (b) The Vice Chairman of the Commission shall be alternated each year between the GSIS General Manager and the SSS Administrator. The presence of four Members shall constitute a quorum. Each Member shall receive a per diem of two hundred pesos for every

(e) Interim disbursements of accumulated values to members of ameliorative and similar purposes; (f) Housing and other loan assistance programs for members; (g) Adjudication and settlement of claims and disputes and the procedures for the same on any matters involving the interests of members in the Fund; (h) Optimize the effectiveness of the initial coverage drive through phased implementation based on reasonable classifications of employers and/or employee groups; and (i) Other matters that, by express or implied provisions of this Act, shall require implementation by appropriate policies, rules and regulations.

meeting that is actually attended by him, exclusive of actual, ordinary and necessary travel and representation expenses. In his absence, any Member may designate an official of the institution he serves on full-time basis as his representative to act in his behalf. (As amended by Sec. 2, P.D. 1368). (c) The general conduct of the operations and management functions of the GSIS or SSS under this Title shall be vested in its respective chief executive officer, who shall be immediately responsible for carrying out the policies of the Commission. (d) The Commission shall have the status and category of a government corporation, and it is hereby deemed attached to the Department of Labor for policy coordination and guidance.

7. DesputeResolution

1. The GSIS shall have original and exclusive jurisdiction to settle any dispute arising under this

1. Dispute arising with respect to coverage, benefits, contributions and penalties shall be heard by the

Grievance and Appeal Procedures. A member, a dependent, or a health care provider may file a complaint for grievance based on any of the above grounds, in

The Fund shall have original and exclusive jurisdiction over all claims and disputes on any other matter relative to the implementation of the provisions of RA 9679

ART. 180. Settlement of claims. The System shall have original and exclusive jurisdiction to settle any dispute arising from this Title with respect to coverage, entitlement to

Act and any other laws administered by the GSIS. 2. Appeals from any decision or award of the Board shall be governed by Rules 43 and 45 of the 1997 Rules of Civil Procedure.

Commission. 2. The decision of the Commission upon any disputed matter may be reviewed both upon the law and the facts by the Court of Appeals.

accordance with the following procedures: (a) A complaint for grievance must be filed with the Corporation which shall refer such complaint to the Grievance and Appeal Review Committee. The Grievance and Appeal Review Committee shall rule on the complaint through a notice of resolution within sixty (60) calendar days from receipt thereof. (b) Appeals from the decision of the Grievance and Appeal Review Committee must be filed with the Board within thirty (30) calendar days from receipt of the notice of resolution.

and these Rules affecting the rights and interest of the members. The decision of the Chief Executive Officer of the Fund shall final and executory, unless appealed to the Board, after the lapse of 30 days from receipt by the aggrieved party of such decision. The decision of the Board shall, unless appealed to a competent court, become final and executory after 15 days from receipt of such decision.

benefits, collection and payment of contributions and penalties thereon, or any other matter related thereto, subject to appeal to the Commission, which shall decide appealed cases within twenty working days from the submission of the evidence. ART. 181. Review. - Decisions, orders or resolutions of the Commission may be reviewed on certiorari by the Supreme Court on questions of law upon petition of an aggrieved party within ten days from notice thereof. ART. 182. Enforcement of decisions. (a) Any decision, order or resolution of the Commission shall become final and executory if no appeal is taken therefrom within ten days from notice thereof. All awards granted by the Commission in cases appealed from decisions of the System shall be effected within fifteen days from receipt of notice. (b) In all other cases, decisions, orders and resolutions of the Commission which have become final and executory shall be enforced and executed in the same manner as decisions of the Court of First Instance, and the

Commission shall have the power to issue to the city or provincial sheriff or to the sheriff whom it may appoint such writs of execution as may be necessary for the enforcement of such decisions, orders or resolutions, and any person who shall fail or refuse to comply therewith shall, upon application by the Commission, be punished by the proper court for contempt. 8. Strengths The lack of a PhilHealth identification card will not be a reason to deny medical service to anyone. Its actuarial life is only estimated to last until 2036. It must include the legitimate surviving spouse of the GSIS member or pensioner as a dependent together with a legally-adopted child, illegitimate child, and natural or adoptive parents as beneficiaries. The commission must be lenient in approving the claims of the members who have proven to have contributions. There are lots of complaints about the implementation this program. Voluntary, not compulsory, membership would give leeway to OFW families to choose between getting a housing loan or simply building their own home at a lower cost.

9. Weaknesses

10. Recommenda tions for Improvement (Proposed Amendment)

B. Question A, a female, married government employee is also teaching in a private university. She delivered a baby by Caesarean section. She was later diagnose with cancer of the ovary and had to undergo an ovorectomy. She is a solo parent but is named as dependent of her 21-year old son working in a big firm. 1. What are the benefits that she is entitle to?

2. Is she entitled to claim benefits from (a) GSIS law? Yes. A is a government employee. (b) SSS law? No. A is not qualified as dependent of his 21-year old son working in a big firm. (c) PhilHealth law? (d) Labor Code Book 4? (e) Other laws? A is entitled to claim Maternity leave benefits.