Labor Law: Book IV; Title II; Chapter V Medical Benefits (Arts. 191 - 196)

     Book IV

Health, Safety and Social Welfare

Title II

Employees’ Compensation and State Insurance Fund

Chapter V

Medical Benefits

Arts. 191 - 196

Q: Does the law fix a maximum amount of medical benefit claimable from the Fund?

Art. 191 [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. 192 [186]. Liability. 

The System shall have the authority to choose or order a change of physician, hospital or rehabilitation facility for the employee, and shall not be liable for compensation for any aggravation of the employee’s injury or sickness resulting from unauthorized changes by the employee of medical services, appliances, supplies, hospitals, rehabilitation facilities or physicians.

Art. 193 [187]. Attending physician. 

Any physician attending an injured or sick employee shall comply with all the regulations of the System and submit reports in prescribed forms at such time as may be required concerning his condition or treatment. All medical information relevant to the particular injury or sickness shall, on demand, be made available to the employee or the System. No information developed in connection with treatment or examination for which compensation is sought shall be considered as privileged communication.

Art. 194 [188]. Refusal of examination or treatment. 

If the employee unreasonably refuses to submit to medical examination or treatment, the System shall stop the payment of further compensation during such time as such refusal continues. What constitutes an unreasonable refusal shall be determined by the System which may, on its own initiative, determine the necessity, character and sufficiency of any medical services furnished or to be furnished.

Art. 195 [189]. Fees and other charges. 

All fees and other charges for hospital services, medical care and appliances, including professional fees, shall not be higher than those prevailing in wards of hospitals for similar services to injured or sick persons in general and shall be subject to the regulations of the Commission. Professional fees shall only be appreciably higher than those prescribed under Republic Act Numbered sixty-one hundred eleven, as amended, otherwise known as the Philippine Medical Care Act of 1969.

Art. 196 [190]. Rehabilitation services.

(a) The System shall, as soon as practicable, establish a continuing program, for the rehabilitation of injured and handicapped employees who shall be entitled to rehabilitation services, which shall consist of medical, surgical or hospital treatment, including appliances if they have been handicapped by the injury, to help them become physically independent.

 

(b) As soon as practicable, the System shall establish centers equipped and staffed to provide a balanced program of remedial treatment, vocational assessment and preparation designed to meet the individual needs of each handicapped employee to restore him to suitable employment, including assistance as may be within its resources, to help each rehabilitee to develop his mental, vocational or social potential.

Notes:

• Art. 191 [185] - Medical Services:
• The System provides medical services and appliances to employees immediately after sickness or injury.
• Services are based on the:
• nature of the illness or injury, and 
• progress of recovery
• Art. 192 [186] - Liability:
• The System has the authority to choose or change physicians, hospitals, or rehabilitation facilities for the employee.
• The System is not liable for complications due to unauthorized changes in medical services by the employee.
• Art. 193 [187] - Attending Physician:
• Physicians must comply with System regulations and provide timely reports on the employee's condition and treatment.
• Relevant medical information must be shared with the System or the employee upon request.
• No privilege on compensation-related information.
• Art. 194 [188] - Refusal of Examination or Treatment:
• System can stop compensation if the employee unreasonably refuses medical examination or treatment.
• The reasonableness of refusal and evaluates the necessity and sufficiency of medical services shall be determined by the System.
• Art. 195 [189] - Fees and Other Charges:
• Fees for medical services, including professional fees, shall not be higher than those prevailing in wards of hospitals for similar services.
• Professional fees must not significantly exceed those under the Philippine Medical Care Act of 1969.
• Art. 196 [190] - Rehabilitation Services:
• System establishes a rehabilitation program for injured/handicapped employees.
• Services include medical, surgical, and hospital treatment, along with appliances, to promote physical independence.
• Centers provide remedial treatment, vocational assessment, and preparation tailored to each employee's needs, aiming for suitable employment.

Notes:

• The. "compensation" extended to the employee (or to beneficiaries) are of three kinds: services, income benefit, and funeral benefit:
1. Services
• medical services, appliances and supplies (Art. 191 and Rule VIII of the ECC Rules) 
• rehabilitation services (Art. 196 and Rule IX of the ECC Rules)
2. Cash Income Benefit or Pension due to:
• temporary total disability (Art. 197 and Rule X of the ECC Rules) 
• permanent total disability (Art. 198 and Rule XI of the ECC Rules) 
• permanent partial disability (Art. 199 and Rule XII of the ECC Rules) 
• death (Art. 200 and Rule XIII of the ECC Rules) 
3. Funeral Benefit (Art. 200[d] and Rule XIV of the ECC Rules) 
• The medical services, appliances and supplies shall be provided to the afflicted employee beginning on the first day of injury or sickness, during the subsequent period of his disability, and as the progress of his recovery may require, subject to Section 5 of Rule IV, which requires submission of periodic medical report from the attending physician. 

RULE VII – BENEFITS

SECTION 1. Types of benefits. 

The benefits under Employees Compensation are in the form of income or services, and consist of the following:

    (1) Medical services, appliances and supplies;

    (2) Rehabilitation services;

    (3) Temporary total disability benefit;

    (4) Permanent total disability benefit;

    (5) Permanent partial disability benefit;

    (6) Death benefit; and

    (7) Funeral benefit.

SECTION 2. Disability. 

(a) A total disability is temporary if as a result of the injury or sickness the employee is unable to perform any gainful occupation for a continuous period not exceeding 120 days, except as otherwise provided for in Rule X of these Rules.

(b) A disability is total and permanent if as a result of the injury or sickness the employee is unable to perform any gainful occupation for a continuous period exceeding 120 days, except as otherwise provided for in Rule X of these Rules.

(c) A disability is partial and permanent if as a result of the injury or sickness the employee suffers a permanent partial loss of the use of any part of his body.

SECTION 3. Income benefit. 

The disability or death resulting from the injury or sickness is compensable by cash payments, and not the injury or sickness itself, except in the case of permanent partial disability.

SECTION 3-A. Income benefit for permanent partial disability. -

In the case where the period covered for payment of income benefit for permanent partial disability does not exceed twelve months, the System may pay in lump sum or in monthly pension, otherwise income benefit shall be paid in monthly pension.

SECTION 4. Services.

The injury or sickness is compensable by medical services, appliances, supplies and rehabilitation services.

SECTION 5. Deprivation. 

No contract, regulation or device whatsoever shall operate to deprive the employee or his dependents of any part of the income benefits, and medical or related services, except as

provided under these Rules. Existing medical services being provided by the employer shall be maintained and continued to be enjoyed by his employees.

SECTION 6. Prescriptive period. - No claim for compensation shallbe given due course unless said claim is filed with the System within three years from the time the cause of action accrued. (ECC Resolution No. 2799, July 25, 1984).

RULE VIII - MEDICAL SERVICES, APPLIANCES AND SUPPLIES

SECTION 1. Condition to entitlement. 

Any employee shall be entitled to such medical services, appliances and supplies as the nature of his disability and the progress of his recovery may require, subject to the expense limitation as contained in Annex "C" hereof, if all of the following conditions are satisfied.

    (1) He has been duly reported to the System;

    (2) He sustains an injury or contracts sickness; and

    (3) The System has been duly notified of the injury or sickness.

SECTION 2. Period of Entitlement.

The medical services, appliances and supplies shall be provided to the afflicted employee beginning on the first day of the injury or sickness, during the subsequent period of his disability, and as the progress of his recovery may require, subject to Section 5 of Rule IV.

SECTION 3. Extent of Services.

(a) The employee is entitled to the benefits only for the ward services of an accredited hospital and accredited physician. However, if the employee chooses accommodations better than ward services the excess of the total amount of expenses incurred over the benefits provided under Annex "C" hereof, shall be borne by the employee. For this purpose, "ward" means a hospital room that can accommodate 6 or more patients.

(b) The hospital shall provide all the medicines, drugs or supplies necessary for the treatment of the employee. All reimbursements of medicines under P.D. 626, as amended, shall be in accordance with the amount that may be prescribed under Republic Act No. 9502 and its Implementing Rules and Regulations. (as provided under Board Resolution No. 09-09-134, September 25, 2009)

(c) Payments shall be made directly to the providers of such services in such amount as are prevailing in the community for similar services or provided under the schedule set forth in Annex "C" of these Rules, whichever is less.

RULE IX - REHABILITATION SERVICES

SECTION 1. Definition of terms. 

As used in this Rule unless otherwise indicated by the context, the following definition of terms are hereby adopted.

(a) Rehabilitation - The process by which there is provided a balanced program of remedial treatment, vocational assessment and preparation designed to meet the individual needs of each handicapped employee to restore him to suitable employment, including assistance as may be within its resources to help each rehabilitee to develop his mental, vocational or social potential.

(b) Rehabilitee - A disabled individual undergoing rehabilitation (student-rehabilitee or trainee) or who has finished a prescribed course in rehabilitation in which he is known as a graduate rehabilitee or trainee.

(c) Rehabilitation Center - An organized service of varied rehabilitation measures usually located in one site for the rehabilitation of disabled individuals. (Example: the WRCC-the Center).

(d) Rehabilitation Facility - An organized service offering one or more types of service for the rehabilitation of the handicapped individual.

(e) Governing Board - For this purpose, the Workers Rehabilitation Center Complex shall receive policy guidance from and shall be under the general management of, the Employees' Compensation Commission, which is hereby constituted as its Governing Board.

Whenever necessary, the Governing Board may create an Advisory Council that shall act as a Consultative and Advisory Body, to be composed of representatives from the National Commission on Rehabilitation, the Ministry of Health, the Institute of Public Health of the University of the Philippines, and such other specialized association and organizations on rehabilitation as may be needed.

(f) Placement Officer - A person practicing the allied medical profession or discipline specialized in psychology of the handicapped and whose responsibility is to personally advise and guide the disabled individual to acceptance into a job.

(g) Suitable Employment - Remunerative occupation giving the rehabilitee earning at least equal to the statutory minimum wage.

SECTION 2. Nature and effectivity of coverage.

    (a) Coverage under this Rule shall be voluntary.

    (b) Coverage under this Rule shall take effect upon completion of registration.

SECTION 3. Condition to entitlement. 

Any employee shall be entitled to rehabilitation services, if all of the following conditions are satisfied:

    (1) He has been reported to the System;

    (2) He sustains a permanent disability as a result of a compensable injury or sickness as a defined in these Rules. Provided, that all employees who sustained temporary

disability as a result of a work-connected contingency shall also be entitled to rehabilitation services. (as amended by Board Resolution No. 11-04-11, April 28, 2011)

    (3) He has not been placed in suitable employment.

SECTION 4. Period of entitlement. 

Rehabilitation services shall be provided during the period of the disability unless such services are suspended or terminated under any of the following conditions:

    (1) Upon suitable employment;

    (2) Upon suspension or termination of such services by the Rehabilitation Center;

    (3) By self-termination.

SECTION 5. Extent of services.

Rehabilitation services shall consist of medical-surgical management, hospitalization, necessary appliances and supplies, vocational training and assistance for placement. (Transportation allowances* between place of residence and the rehabilitation facility, lunch, and dormitory allowances in appropriate cases may be included in the extent of services).

*Meal and Transportation allowance was increased from One Thousand Eight Hundred pesos (P1,800.00) to Two Thousand Five Hundred pesos (P2,500.00). (As provided under Board Resolution No. 10-10-158, October 20, 2010).

SECTION 6. Rehabilitation Centers. 

There shall be established a Workers Rehabilitation Center Complex, and such other rehabilitation centers or services as the needs of occupationally disabled employees, whether from private or public sector, may require.

SECTION 7. Accreditation of Rehabilitation Facilities. 

Hospitals accredited under Rule XVII of these Rules; rehabilitation facilities, vocational and training centers and their personnel participating in the work of rehabilitation accredited by the Philippine Academy of Rehabilitation Medicine (PARM) may apply for accreditation.

SECTION 8. Liability limitations.

The System shall not be legally responsible when the injury, sickness, disability or death during the rehabilitation is occasioned by any of the following:

    (1) His intoxication,

    (2) His willful intention to injure or kill himself or another;

    (3) His notorious negligence.

SECTION 9. Suspension, termination and appeal.

    (a) Grounds - For adequate and duly proven causes and upon recommendation of the rehabilitation counselor, the student-rehabilitee may be suspended or terminated by the Center.

    (b) Appeal - The decision of the Center may be appealed within 15 days from notice thereof to the Governing Board whose decision shall be final and executory.

SECTION 10. Placement. 

Arrangement for placement of the rehabilitee shall be an integral part of the rehabilitation program.

SECTION 11. Participation of the System. 

As incentive to the participating employers in the on-the-job training and possible employment of the rehabilitee, the System may enter into agreement with the employer to participate in the payment of wages of the placed rehabilitee as follows:

    (1) 50% of the wages for the first two weeks after the start of the on-the-job training;

    (2) 25% of the wages for the third and fourth weeks of the on-thejob training;

    (3) 10% of the wages for the fifth and sixth weeks of the on-thejob training;

    (4) 0% of the wages for the rest of the period of the on-the-job training.

SECTION 12. Reports. 

Reports to the Governing Board on the progress of activities of rehabilitation program shall be submitted by the Center once every 3 months as often as necessary.