MEDICAL SERVICES, APPLIANCES AND SUPPLIES

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.

In the case of Corales vs. Employees Compensation Commission, G.R. No.

L-44063 February 27, 1979, the Supreme Court said that:

The Workmens’ Compensation Act reveals that it does not require that illness or
disability should result in wage-lose to entitle one to an award of medical or benefits.
That section clearly states that "immediately after an employee has suffered an injury or
contracted sickness and during the subsequent period of disability, the employer or
insurance carrier shall provide the employee with such services, appliances and
supplies as the nature of his disability and the process of his recovery may require; and
that which will promote his early restoration to the maximum level of his physical
capacity .

Scope of Medical Services

(Annex C, Amended Rules on Employees Compensation)

Medical Services cover the following:

a) Ward Services during confinement in an accredited hospital;
b) Subsequent domiciliary care by an accredited physician;
c) Medicines; and
d) Ambulatory services in an accredited hospital, in case of injury

A. Coverage of Ward Services

 They cover all of the services an in-patient would ordinarily receive in a hospital
such as:

1. Bed in a ward (6 beds in a room);

2. All meals, including special diets,
3. Regular nursing services;
4. Medicines furnished by the hospital;
5. Radiology service such as X-rays,
6. Medical supplies such as splints and casts,
7. Use of appliances and equipment furnished by the hospital such as wheelchair, crutches
and braces;
 8. Anesthetic services;
9. Operating room charges,
10. Surgery; and
11. Doctor's services

 Ward services do not include:

1. The extra charge for more comfortable accommodations such as private and semi-
private rooms;
2. Personal comfort or convenience such as charges for the use of a telephone, radio or
television;
3. Private duty nurses;

 If a patient receives services more expensive than ward services, payment by the
System shall be made only for the ward services. However, private or semi-private room
accommodations when medically necessary because the contagious disease or his
condition requires him to be isolated, or there is no available ward bed and the
emergency nature of the injury or disease requires him to be immediately
accommodated, shall be paid by the System after satisfying itself as to the
reasonableness thereof, and at no cost whatsoever to the patient. The continued
accommodation of the patient in a private or semi-private room when a ward bed is
available and the emergency or contagion no longer exists shall be paid by the System
as ward services.
 Only necessary and relevant services shall be paid by the System. Laboratory and/or
radiology services and medicines shall be kept to a level considered by the physician
reasonably necessary and relevant to the particular illness or injury

Meaning of Ward
(Sec. 3, Rule VIII, Amended Rules on Employees Compensation)
It refers to a hospital room that can accommodate six (6) or more patients.

Conditions for Entitlement

(Sec. 1, Rule VIII, Amended Rules on Employees Compensation)

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.
 U-BIX CORPORATION VS. RICHEL BANDIOLA
G.R. No. 157168
June 26, 2007
Facts:
Richel Bandiola was employed by U-BIX to install furniture for its customers. On
13 April 1997, Bandiola and two other U-BIX employees were involved in a vehicular
accident on their way to Baguio, where they were assigned by U-BIX to install furniture
for an exhibit. As a result of the accident, Bandiola sustained a fracture on his left leg.
Bandiola and his co-employees were initially brought to the Rosario District Hospital
then they were transferred to the Philippine Orthopedic Hospital (Orthopedic). U-BIX
paid for the medical expenses incurred in both hospitals. Bandiola claims that he asked
U-BIX for financial assistance but that the latter refused. As a consequence, he could no
longer afford to go back to the Orthopedic in Quezon City. Instead, he went to Medical
Center Parañaque (MCP) where he had his leg cast in fiberglass. He attached the
receipts, issued by MCP and Dr. Celestino Musngi, for medical expenses with a total
amount of ₱7,742.50. Bandiola added that he paid for other medical expenses for which
no receipts were issued. Bandiola maintains that before his leg was cast in fiberglass,
he asked Rey Reynes, U-BIX’s Assistant Manager for Project Management, for financial
assistance but was refused. After the medical procedure, he again went to Reynes and
presented a receipt for his medical expenses, but was told to pay for them in the
meantime. Bandiola filed a Complaint before the Labor Arbiter, where he alleged
underpayment of salary; non-payment of overtime pay; premium pay for work performed
on holidays and rest days; separation pay; service incentive leave pay; 13th month pay;
and the payment of actual, moral and exemplary damages.
Issue:
Whether or not Bandiola could claim Medical Benefits as provided under
Amended Rules on employees Compensation?
Held:
No. Contrary to the arguments put forward by U-BIX, it is liable to reimburse
Bandiola the amount of ₱7,742.50 for medical expenses because its failure to comply
with its duty to record and report Bandiola’s injury to the SSS precluded Bandiola from
making any claims. Moreover, U-BIX, by its own admission, reimbursed its other
employees who were involved in the same accident for their medical expenses. Clearly,
the reimbursement of medical expenses for injuries incurred in the course of
employment is part of the benefits enjoyed by U-BIX’s employees. The only justification
for its refusal to reimburse Bandiola was that he intended to defraud the company by
presenting spurious receipts amounting to ₱7,742.50 that were allegedly issued four
months before their presentation.
Period of Entitlement
(Sec. 2, Rule VIII, Amended Rules on Employees Compensation)

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 the periodic submission of a medical
report on his disability certified to his physicians.

Extent of Services
(Sec. 2, Rule VIII, Amended Rules on Employees Compensation)

 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 hereof, shall be borne by the employee.
 The hospital shall provide all the medicines, drugs or supplies necessary for the
treatment of the employee at a cost not exceeding the retail prices prevailing in local
drug stores.

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, appliance, supplies,
hospital, 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.

Duty of Attending Physician

The physician attending an injured or sick employee should comply with all the
regulations of the System and submit medical reports in prescribed forms.

Medical Information Not Privileged

Medical Information developed in connection with treatment or examination for which
compensation is sought is not considered as privileged communication.

Effects of Refusal to Submit to Medical Examination

 The System can stop the payment of compensation benefits if the employee
unreasonably refuses to submit to medical examination or treatment.

What constitutes “reasonable refusal” is determined by the System.

Fees and Other Charges

The following are the fees and charges:

a. Hospital Confinement
 The benefit for each day of confinement in an accredited hospital shall be only for
ward services.
 The benefit in case of injury shall not exceed the actual cost of ward services in
an accredited hospital.
 The benefit in case of sickness shall not exceed the actual cost of ward services
in an accredited hospital equipped with facilities necessary for the treatment of
the disease.
 Confinement shall be counted in units of a full day, with the day of admission
counted as a full day but not the day of discharge.

b. Domiciliary Care
 The benefit for the subsequent domiciliary care by an accredited physician shall not
exceed P60 for the first visit and P50 for each subsequent visits.
c. Ambulatory Care
 The benefit for ambulatory care in an accredited hospital, either by (1) a
physician in his hospital/clinic, or (2) training resident in emergency shall not
exceed P60 a day, exclusive of drugs and medicines.
 A patient who is treated for a specific minor surgical procedure or other treatment
that keeps him in the hospital only for a few hours (less than 24) shall be
considered an ambulatory patient regardless of the hour of admission, whether or
not he used a bed, or whether or not he remained in the hospital past midnight.

d. Surgical Expense Benefit

 A qualified employee who has undergone a surgical procedure in an accredited
hospital shall be entitled to a surgical expense benefit, which shall consist of:

i. A surgeon's fee according to the ECC Relative Value Study

ii. An anesthesiologist's fee ordinarily not exceeding twenty five percent (25%)
of the surgeon's fee.

 The surgeon's fee shall be paid to the surgeon who performed the operation, and
the anesthesiologist's fee to the anesthesiologist, subject to the following
conditions:
i. Only one surgeon shall be paid for each operation;
ii. Only one anesthesiologist, if any shall be paid for each operation; and
 iii. Local anesthesia, other than regional nerve block anesthesia, shall not be
compensable.
 The operating room fee shall be paid by the System only for surgical procedure
done in the operating-diagnostic therapy room complex of the accredited
hospital.

Rehabilitation Services

Definition of Terms (Sec. 1, Rule IX, Amended Rules on Employees Compensation)

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.

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.

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

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

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 associations and organizations on
rehabilitation as may be needed.

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.

Suitable Employment
Remunerative occupation giving the rehabilitee earnings at least equal to the statutory minimum
wage.

Nature of Coverage (Sec. 2, Rule IX, Amended Rules on Employees Compensation)

a. Coverage of handicapped employees in the rehabilitation services program is voluntary
in nature,
b. Coverage under this Rule shall take effect upon completion of registration

Conditions for Entitlement (Sec. 3, Rule IX, Amended Rules on Employees Compensation)
Any employee shall be entitled to rehabilitation services, if all the following conditions are
satisfied:
a) He has been reported to the System;
b) He sustains a permanent disability as a result of a compensable injury or sickness as
defined in these Rules;
c) He has not been placed in suitable employment

Period of Entitlement (Sec. 4, Rule IX, Amended Rules on Employees Compensation)

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.

Extent of Services (Sec. 5, Rule IX, Amended Rules on Employees Compensation)

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

Rehabilitation Centers (Sec. 6, Rule IX, Amended Rules on Employees Compensation)

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.

Liability Limitations (Sec. 8, Rule IX, Amended Rules on Employees Compensation)

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.

Participation of the System (Sec. 9, Rule IX, Amended Rules on Employees Compensation)
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-the-job training;
3. 10% of the wages for the fifth and sixth weeks of the on-the-job training;
4. 0% of the wages for the rest of the period of the on-the-job training.