Presented By:

Ms. Lorelei B. SolidumMs. Lorelei B. SolidumBranch HeadBranch Head

Coverage: Medical Benefits

Topics

Unable to work due to sickness or injury;

Confined either in the hospital or at home for at least four (4) days ;

Paid at least three (3) monthly contributions within the 12-month period immediately before the semester of sickness or injury;

Has notified the employer or the SSS, if unemployed/SE/VM regarding his sickness or injury; and

Has used up all company sick leave with pay for the current year. [For employed members]

Failure to observe the rule on notification shall be a ground for the reduction or denial of the sickness claim application.

The daily cash allowance is equivalent to 90% of the member’s average daily salary credit.

120 days in one calendar year

Another 120 days for the succeeding year on account of the same illness

If the sickness persists he may be entitled to disability

Exclude the semester of contingency;

Select the six highest monthly salary credits (MSC) within the 12-month period immediately before the semester of contingency to arrive at the total monthly salary credit (TMSC);

Divide the TMSC by 180 to get the average daily salary credit (ADSC); and

Multiply the ADSC by 90 %, then multiply it by the approved number of days.

April-Sept: Semester

MONTHLY SALARY CREDIT

Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2012 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 0 0 0 0

2011 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000

Confinement Period July 1-30, 2012 30 days

Current Company Sick Leave with pay July 1-5, 2012 5 days

Sum of the 6 highest MSC from the 12 month period preceding the

semester of contingency

2011 Oct 15,0002011 Nov 15,0002011 Dec 15,0002012 Jan 15,0002012 Feb 15,000

2012 Mar 15,000Total Monthly Salary Credits 90,000Divided by 180Average Daily Salary Credit 500.00Multiplied by 90% 90%Daily Sickness Allowance 450.00Multiplied by approved number of days

25 30 days confinement less 5 days company sick leave w/ pay

Amount Of Sickness Benefit P 11,250.00

Sickness Benefit Reimbursement Application (SSS Form B-304)

Approved Sickness Notification (SN) – SSS Form CLD 9-N

Photocopy of member’s SS card or two (2) valid IDs duly certified by the member and authenticated by the authorized company signatory.

FOR HOME CONFINEMENT - Within one (1) year from the start of illness.

FOR HOSPITAL CONFINEMENT - Within one (1) year from the last day of confinement.

Where To File

Comparison of Processing Time Commitment

* OFFICE ORDER 37-P dated April 4, 2002** RA 9485 [Anti Red Act of 2007]

SSS Commitment

PROCESS

PROCESSING TIME (WORKING DAYS)

COS* ARTA**

Sickness Reimbursement

Regular 8 10

Unemployed/SE/VM 11 10

Process Workflow: Sickness

Process Workflow: Sickness

MEMBERS/ERs* SUBMIT CLAIM APPLICATIONS

TO SSS

SSS MAIN OFFICE/BRANCHES

* RECEIVES & PROCESSES CLAIM APPLICATIONS

CHECKS OR DENIAL LETTER

MEMBER/ERsRECEIVE PAYMENT

POST OFFICE* RECEIVES CHECKS/LETTER AND DELIVERS TO MEMBERS/ERs

MEMBERS/ERs

* SUBMIT BENEFIT CLAIMS TO SSS

SSS MAIN OFFICE/BRANCHES

* RECEIVES & PROCESSES CLAIMS

CHECKS, CREDITADVICE & REPORTS

* BANK RECEIVES CHECKS & REPORTS AND CREDITS AMOUNT TO ER ACCOUNT

Has given the required notification to her employer or if she is unemployed, voluntary or self-employed member to the SSS; and

Paid at least three (3) monthly contributions within the 12-month period immediately before the semester of member’s childbirth or miscarriage.

Maternity Notification

SSS Web Facility

SSS Web Facility

SSS Web Facility

SSS Web Facility

SSS Web Facility

SSS Single Sign On Maternity Notification Module

• 100% of Average Daily Salary Credit (ADSC) multiplied by 60 days for normal delivery or miscarriage and 78 days for caesarean cases.

• The ADSC is obtained by dividing the sum of the six (6) highest monthly salary credits (MSC) in the 12-month period immediately before the semester of contingency by 180 .

Payment will be made only for the 1st four deliveries or miscarriages.

Abortion and miscarriage included (effective May 24, 1997)

Payment of maternity benefit will be a bar to the recovery of sickness benefit for the same period for which daily maternity benefits have been received.

•Claim application shall be filed within ten (10) years from the date of delivery or miscarriage.

Exclude the semester of delivery/miscarriage;

Select the six highest monthly salary credits within the 12-month period immediately before the semester of contingency to arrive at the total monthly salary credit (TMSC);

Divide the TMSC by 180 to get the average daily salary credit (ADSC). This is the daily maternity allowance; and

Multiply the daily maternity allowance by 60 or 78 days as the case may be to get the total amount of maternity benefit.

MONTHLY SALARY CREDIT

Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2012 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 0 0 0 0

2011 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000 15,000

TYPE OF DELIVERY DELIVERY DATE NO. OF DAYS

Normal July 1, 2012 60 days

Caesarean July 1, 2012 78 days

Sum of the 6 highest MSC from the 12 month period before the semester of contingency

2011 Oct 15,0002011 Nov 15,0002011 Dec 15,0002012 Jan 15,0002012 Feb 15,000

2012 Mar 15,000

Total Monthly Salary Credits 90,000Divided by 180Average Daily Salary Credit 500Multiplied by 100% 100%Daily Maternity Allowance 500.00Multiplied by number of days Normal delivery 60 Caesarean delivery 78

Amount of Maternity BenefitNormal delivery P 30,000.00Caesarean delivery P 39,000.00

Maternity Reimbursement Form;

Maternity notification (MN) stamped received by SSS prior to delivery;

Photocopy of the member’s SS card or two (2) valid IDs duly certified by the member and authenticated by the authorized company signatory;

Note: MN is not required if the member has been confined in the hospital duly licensed by the Department of Health.

OTHER DOCUMENTS:A NORMAL DELIVERY - Original or certified true

copy of the child’s birth or fetal death certificate (if child died or stillborn) duly registered with the Local Civil Registrar (LCR)

B CAESAREAN DELIVERY – Original or certified true copy of child’s birth or

fetal death certificate (if child died or stillborn) duly registered with the LCR; and

Certified true copy of Operating Room Record (ORR) or Surgical memorandum.

OTHER DOCUMENTS:C MISCARRIAGE –

Pregnancy test before & after miscarriage or Ultrasound Report & medical certificate (if complete miscarriage); or D & C report & histopath report duly certified by the authorized hospital representative (if incomplete miscarriage)

Obstetrical History indicating the number of pregnancy/ies including hydatidiform mole duly certified by the attending physician with his/her license number, printed name and signature;

Other documents that may be required by the Medical Evaluation Section.

Maternity Reimbursement Form;

Maternity notification (MN) stamped received by SSS prior delivery;

SS card or two (2) valid IDs both with signatures and at least one with photo.

Note: MN is not required if the member has been confined in the hospital duly licensed by the Department of Health.

OTHER DOCUMENTS:A NORMAL DELIVERY - Original or certified true

copy of the child’s birth or fetal death certificate (if child died or stillborn) duly registered with the Local Civil Registrar (LCR)

B CAESAREAN DELIVERY – Original or certified true copy of child’s birth or

fetal death certificate (if child died or stillborn) duly registered with the LCR; and

Certified true copy of Operating Room Record (ORR) or Surgical memorandum.

OTHER DOCUMENTS:C MISCARRIAGE –

Pregnancy test before & after miscarriage or Ultrasound Report & medical certificate (if complete miscarriage); or D & C report & histopath report duly certified by the authorized hospital representative (if incomplete miscarriage)

Obstetrical History indicating the number of pregnancy/ies including hydatidiform mole duly certified by the attending physician with his/her license number, printed name and signature;

Other documents that may be required by the Medical Evaluation Section.

ADDITIONAL REQUIRED DOCUMENTS FOR UNEMPLOYED MEMBER –

Certification of separation from employer (with effective date of separation); or

Notice of strike duly acknowledged by the Department of Labor and Employment (DOLE); or

Certification from DOLE, if with pending labor case; or

Affidavit of separation duly notarized, if company ceased operation, subject to further verification by SSS.

Comparison of Processing Time Commitment

* OFFICE ORDER 37-P dated April 4, 2002** RA 9485 [Anti Red Act of 2007]

SSS Commitment

PROCESS

PROCESSING TIME (WORKING DAYS)

COS* ARTA**

Maternity Reimbursement

Normal/Caesarean 8 10

Miscarriage 11 10

MEMBERS/ERs* SUBMIT CLAIM APPLICATIONS

TO SSS

SSS MAIN OFFICE/BRANCHES

* RECEIVES & PROCESSES CLAIMS

CHECKS OR DENIAL LETTER

MEMBER/ERsRECEIVE PAYMENT

POST OFFICE* RECEIVES CHECKS /LETTERS AND DELIVERS TO MEMBERS/ERs

MEMBERS/ERs

* SUBMIT CLAIM APPLICATIONS TO SSS

SSS MAIN OFFICE/BRANCHES

* RECEIVES & PROCESSES CLAIMS

CHECKS, CREDITADVICE & REPORTS

* BANK RECEIVES CHECKS & REPORTS AND CREDITS AMOUNT TO ER ACCOUNT

EC PROGRAMEC PROGRAM

Medical Services, Appliances and Supplies

Rehabilitation Services

Income Cash Benefit for:

• Temporary total disability/sickness

• Permanent total disability

• Permanent partial disability

• Death

An income cash benefit equivalent to 90% of the average daily salary credit with a minimum of P10.00 and a maximum of P200.00 per day..

Sickness or injury is work- connected;

Employee has been duly reported to SSS;

SSS has been notified of such sickness or injury; and

The employee has the required monthly contributions paid for him by his employer.

It occurred while employee was performing his official function, at the place where his work required him to be, & if elsewhere, the employee must have been executing an order for the employer.

It occurred while the employee was performing an act within the time & space limits of his employment to minister to personal comfort such as satisfaction of thirst, hunger or other physical demands, or to protect himself from excessive cold;

It occurred while the employee was engaged in a company sponsored activities, such as, field trips, picnics, intramurals, etc.;

It occurred while the employee is on board a shuttle bus or any vehicle provided by the company.

* Any sickness is compensable provided that it is listed by the ECC as an occupational disease. Otherwise, proof must be shown that the risk of contracting the disease is increased by the working condition.

Intoxication / drunkenness

Willful intention to injure or kill himself or another

Notorious negligence

Three (3) years prescriptive period from date of contingency.

• 240 days in one calendar year.

Note: If qualified under the double recovery scheme, employer must submit another sickness reimbursement under SS Sickness.

EC claims should be filed within 3 years from date of work-related accident or illness

IF EC SICKNESS IS FOR MEMBERS WITH MORE THAN 12 MONTHS COVERAGE

MONTHLY SALARY CREDIT

YEAR Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2012 9,000

8,500

8,500

7,500

2011 10,000

8,000

11,000

10,000

8,000

8,500

7,000

9,000

8,000

9,000

9,000

10,000

2010 5,000

9,000

8,000

10,000

5,000

-

8,000

6,000

7,500

7,500

8,000

8,000

Sum of the 6 highest MSC from the 12 month period preceding the semester of contingency

YEAR MONTH EC SS2010 Apr 10,000 10,0002010 Jul 8,000 8,0002010 Nov 8,000 8,0002010 Dec 8,000 8,0002011 Jan 10,000 10,000

2011 Mar 11,000 11,000Total Monthly Salary Credits (TMSC) 55,000 55,000Divided by 180 180Average Daily Salary Credit (ADSC) 305.56 305.56Multiplied by 90% 90% 90%Daily Sickness Allowance (DSA) 275.00 275.00Maximum Daily Salary Allowance (DSA) 200.00 275.00Multiplied by number of days 30 30Amount of Benefit P 6,000.00 P 8,250.00

IF EC SICKNESS IS FOR MEMBERS WITH LESS THAN 12 MONTHS COVERAGE

MONTHLY SALARY CREDIT

YEAR Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011 0 0 0 0 5,000

6,000

3,000

5,000 6,000 0 0 0

2010 0 0 0 0 0 0 0 0 0 0 0 0

Sum of the MSC from month of coverage to month prior

the contingency

YEAR MONTH EC

2011 May 5,0002011 Jun 6,0002011 Jul 3,000

2011 Aug 5,000Total Sum 19,000Divided by number of months 4Average 4,750Multiplied by 6 months (constant) 6Total Monthly Salary Credit (TMSC) 28,500Divided by 180Average Daily Salary Credit (ADSC) 158.33Multiplied by 90% 90%Daily Sickness Allowance (DSA) 142.50Multiplied by number of days 15Amount of EC Sickness Benefit P 2,137.50

MONTHLY SALARY CREDIT

YEAR Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2011 0 0 0 0 5,000

6,000

3,000

5,000

6,000 0 0 0

2010 0 0 0 0 0 0 0 0 0 0 0 0

IF EC SICKNESS IS WITHIN THE MONTH OF COVERAGE

IF EC SICKNESS IS WITHIN THE MONTH OF COVERAGE

Earnings per day P 390.00Multiply by # of days worked - July 1 - 15, 2012 15Total Earnings P 5,850.00 Convert to Salary Credit 6,000 Multiply by Constant factor 6Total Monthly Salary Credit (TMSC) 36,000 Divided by 180 180Average Daily Salary Credit (ADSC) 200.00Multiply by 90% 90%Daily Sickness Allowance 180.00Number of days approved - July 16 - 31, 2012 16Amount of Benefit P 2,880.00

SUPERSEDES Circular 8-P dated September 2002

1. Sickness & Maternity benefit reimbursements of employers is directly credited to their respective bank accounts.

2. The program utilizes a multi-bank remittances network, or avails the services of the participating banks under the SMEC Payment thru the Bank Program.

3. Enrollment to the program is needed. Savings or current account accepted for enrollment.

4. Signatory in the enrollment form shall be the authorized bank account signatory as designated by the employer/company’s Board of Directors.

6. SSS notifies employer through a Payment Advice every time payment is made to their bank account.

5. Designated bank shall confirm the correctness of the bank account information.

I. ENROLLMENT PROCESS

• Mails notices to employers

(Follow usual procedure in the receipt of claims up to the (Follow usual procedure in the receipt of claims up to the generation of checks) generation of checks)

Delivers the following:-Cheques-Credit Advice -Bank Branch Remittance Summary-Bank Branch Abstract of Remittances-Magnetic tape/cartridge

Mails Payment Advice to employers.

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1. Asia United Bank2. Bank of Carmona, Inc.3. Bank of Commerce4. Bank of the Philippine Island5. Rural Bank of Trece Martirez6. Century Savings Bank7. China Bank8. City State Savings Bank9. Country Rural Bank Taguig10. Eastwest Bank11. Maybank12. Metrobank

13. PB Com14. Phil. Business Bank15. Phil. National Bank16. Phil. Postal Savings Bank17.Phil. Savings Bank18.Phil Veterans Bank19.RCBC20.RCBC Savings Bank21.Real Bank22.Rural Bank of Pililla, Inc.23.Standard Chartered Bank24.Union Bank of the Phils.