State Insurance Fund Reviewer.docx

EMPLOYEES’ COMPENSATION AND STATE INSURANCE FUND FEATURE OF THE NEW COMPENSATION SHCEME  The employees’ compensation scheme under LC applies the social security principle in the handling of workmen’s compensation cases.  Employer does not intervene in compensation process and it has no control over payment of benefits.  All that is required of an employer is to give contribution to the State Insurance Fund from which the compensation payments are taken.  Employer’s duty is to only pay the regular monthly premiums to the scheme.  Employee no longer required to litigate his right to compensation. He simply files a claim with the Employee’s Compensation Commission which then determines WON the compensation should be paid.  No employer opposes the claim  Labor Code has abandoned the doctrine of presumptive compensability.  Under present law, illness is compensable only when it is classified as an occupational disease and the conditions that would render them compensable are met. Diseases not listed are compensable only if the claimant proves by substantial evidence that the risk of contracting the disease is increased by the conditions of employment. COMPENSATION BENEFITS available only in case work-connected disability or death arising from: 1.) INJURY 2. ILLNESS *It is not injury or illness which is compensated but the death or disability. GOING TO AND COMING FROM RULE – As a general Rule it is excluded from compensation if injury occured because it is not work related. EXCEPT; 1. GOING TO AND COMING FROM PLACE OF WORK DOCTRINE – Injury or death resulting from an accident while the employee is going to, or coming from, the workplace is NOT compensable AS GENERAL RULE EXCEPT if the ff. conditions are met: A. Act of the employee of going to, or coming from the workplace must have been a CONTINUING ACT. Not been diverted therefrom from any other activity and not departed from usual route. Or did not deviate from the usual route. Activity from his usual route. 2. PROXIMITY RULE – example Enter the Gate and was accidentaly hit by a car. Compensable 3. SPECIAL ERRAND RULE - Employee is Charged some duty. Ask for special assignment. Example Teacher was given project in the house and got accident or killed. It is COMPENSABLE if he can proved that it is work related and must have permission or official or mandate in the office. 4. EXTRA PREMISES RULE – Means of transport, or employer gave a transportation for employees and met an accident. COMPENSABLE. 5. SPECIAL ENGAGEMENT RULE – Injury during activity like company outing, pilgrims and other similar activities. This is compensable. Other exceptions: When it is INCIDENTAL TO EMPLOYMENT: 1. Acts done in a call of nature – acts personal to the comfort of employee 2. Performing an act benefit to the employer. 3. Done to further goodwill of employer 4. Acts in emergencies. 5. Acts to save the property of the employer. If the accident or injuries occured in the staff house provided by the employer. It is compensable provide that it is express, implied related to his duties. DUAL PURPOSE DOCTRINE – Compensable while oon the trip for the benefit of employer / personal purpose of employee.

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Acts of God and Force Majuere – Not compesable. It is only compensable if the employee is exposed to danger or injuriy as reasonable element that it is work related incident. Assualt is Compesable if victim but if it is the aggressor it is not compesable. THE TWENTY-FOUR-HOUR DUTY DOCTRINE 

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A soldier on active duty status is really on a 24-hour official duty status and is subject to military discipline and military law 24 hours a day. He is subject to call and to the orders of his superior officers at all times, 7 days a week, except when he is on VACATION LEAVE STATUS. Perceptible that on account of the nature of their work, policemen and limitary personnel have become “marked men” insofar as insurgents and other lawless elements are concerned and are therefore killed by insurgents at every opportunity. Moment a policeman or military personnel suffers a contingency, it is presumed that it arose from the nature of his work. To be entitled to compensation, the standard of work-connection must still be established by substantial evidence.

DEATH OR INJURY WHILE ON VACATION LEAVE 

Not compensable because an employee who is on leave does not perform his usual duties.

MILITARY MEN “ON PASS” OR ON REST AND RECREATION 

Disability or death arising from injury by a member of the military while “on pass” for a period not exceeding 72 hours is compensable. If the soldier was unable to report himself back for duty after 72-hour period, the disability or death is still compensable if such failure to report was due to legitimate and valid reasons such as fortuitous event or force majeure.

**Disability or death arising from injury by a member of the military while on rest and recreation, which is considered part of the soldier’s military activities, after having gone on actual combat duty, as certified to by the proper commanding officer, is compensable. COMPENSABILITY OF DEATH OR DISABILITY ARISING FROM ILLNESS DEATH OR DISABILITY ARISING FROM ILLNESS IS COMPENSABLE: a. Illness is classifies as an occupational disease b. If not classified, the risk of contracting the same is proven by substantial evidence to have been increased by the working conditions. COMPENSABILITY OF OCCUPATIONAL DISEASES a. b. c. d.

Employee’s work must involve the described risk Disease was contracted as a result of the employee’s exposure to the described risks Disease was contracted within a period of exposure and under such factors necessary to contract it Was no notorious negligence on the part of the employee

THE “INCREASED RISK” DOCTRINE 

Diseases which are not classified as “occupational disease” are compensable only if the claimant can prove that the risk of contracting the disease was increased by the working conditions.

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There is increased risk if the illness is caused by or precipitated by factors inherent in the employees’ nature of work and working conditions. It does not include aggravation of pre-existing illness. Not require that there should be a direct causal connection between the disease and the employment. All that is required is reasonable work-connection, which could be established by mere substantial evidence. It is essential for the claimant to show that the development of the disease was brought largely by the conditions present in the nature of the job. Law does not require that the employment should be the sole factor in the growth, development and acceleration of the illness to entitle him to compensation benefits. It is enough that his employment had contributed, even in a small degree to the development of the disease. Test of evidence: Probability not certainty.

PROGRESSION/ DETERIORATION OF ILLNESS/INJURY 

When the primary illness or injury is shown to have arisen in the course of the employment, every natural consequence that flows from the illness or injury shall be deemed employment-related, hence, compensable.

COVERAGE AND LIABILITY ART. 168: COMPULSORY COVERAGE 

Coverage in the State Insurance Fund shall be compulsory upon all employers and their employees not over sixty (60) years of age: Provided, That an employee who is over (60) 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.

COVERED EMPLOYEES      

All employers, whether belonging to the public or private sector are covered Public sector employers are those covered by the Government Service Insurance System (GSIS) including GOCC, Phil. Tuberculosis Society, National Red Cross and the Phil. Veterans Bank. Private sector employersare covered by Social Security System (SSS) Employees not over 60 years old whether public or private sectors are covered. Employees over 60 years old are covered if they have been paying contributions to SSS or GSIS prior to the age of 60 and have not been compulsorily retired. Employees coverable by both the SSS and GSIS shall be coverable by both systems.

ART. 170: EFFECTIVE DATE OF COVERAGE  

Coverage om employers shall take effect on the 1st day of operation but nor earlier than January 1, 1975 Coverage of employees shall take effect on the first day of employment

WHEN AN EMPLOYEE IS DEEMED REPORTED 

If the SSS or GSIS has received a report or written communication about him from his employer and Employees’ Compensation contribution paid in his name before a compensable contingency occurs.

EFFECT OF FAILURE TO REPORT (1) In case of failure or refusal to register employees, the employer or responsible official who committed the violation shall be punished with a fine of not less than P1,000 nor more than P10,000 and/or imprisonment for the duration of the violation or non-compliance or until such time that rectification of the violation has been made, at the discretion of the Court. (2) In case a compensable contingency occurs after thirty (30) days from employment and before the System receives any report for coverage about the employee or EC contribution on his behalf, his employer shall be liable to the System for the lump sum equivalent of the benefits to which he or his dependents may be entitled.

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ART. 172: LIMITATION OF LIABILITY 

The State Insurance Fund shall be liable for compensation to the employee or his dependents, except when the disability or death was occasioned by the employee’s intoxication, willful intention to injure or kill himself or another, notorious negligence, or otherwise provided under this Title.

FACTORS THAT BAR COMPENSABILITY 1. Intoxication 2. Wilful intention to injure or kill himself or another 3. Notorious negligence INTOXICATION – Refers to a person’s condition in being under influence of liquor or prohibited drugs to the extent that his acts, words or conduct is impaired visibly, as to prevent him from physically and mentally engaging in the duties of his employment 

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To constitute a ground for denial of compensation, the degree of intoxication must be such that it rendered the employee incapable of doing work. The accident or injury must be shown that it arose out of his drunken condition and not because of work. Intoxication which does not incapacitate the employee from following his occupation is not sufficient to defeat the recovery of compensation, although intoxication may be a contributory cause to his injury.

WILLFUL INTENTION TO INJURE/KILL HIMSELF OR ANOTHER  

Contemplates a deliberate intent on the part of the employee to inflict injuries to himself or another. The resulting injury, disability or death was not caused by the employment but by the employee’s own voluntary act.

NOTORIOUS NEGLIGENCE   

Something more than mere or simple negligence or contributory negligence. It signifies a deliberate act of the employee to disregard his own personal safety. More than mere carelessness or lack of foresight and is tantamount to gross negligence. To constitute ground for denial of compensation: must be shown by clear and convincing proof that it was the cause of the injury. Disobedience to rules, orders, and/or prohibition does not per se constitute notorious negligence, if no intention can be attributed to the injured to end his life.

THE LABOR CODE VIS-À-VIS THE CIVIL CODE Can the injured employee (or his heir in case of death), avail of the compensation benefits under LC and sue the employer for damages under Civil Code. NO.

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