List of Sickness Covered by SSS – How to File Claim?

Are you a Social Security System (SSS) pensioner in the Philippines? Are you aware of the sicknesses and medical conditions covered by your Social Security benefits? Knowing which sicknesses are covered by your SSS pension can help ensure that self-employed members, voluntary members, Overseas Filipino Workers (OFWs), non-working spouses (NWS), and employees facing unemployment get the financial assistance and medical care they need when dealing with illness or injury.

In this article, we’ll look at the list of sicknesses that are covered by SSS in the Philippines. For these member categories, SSS provides a daily cash allowance paid for the number of days an employee facing unemployment is unable to work due to sickness or injury.

SSS Sickness Benefit Qualification

To qualify for sickness benefits from the Philippines’ Social Security System (SSS), a member must satisfy the following criteria:

1. Incapacity to work due to sickness or injury for a minimum of 4 days, requiring confinement in a hospital or at home
2. Payment of at least 3 months’ worth of contributions to SSS within the 12 months preceding the semester of sickness/injury
3. Proper notification to SSS regarding the sickness or injury using the Sickness notification form

The sickness benefit aims to provide temporary financial aid to SSS members who are unable to earn due to illness or injury. By meeting the qualification conditions laid out above, members can avail of this crucial protection during difficult periods.

What Sicknesses Covered By The SSS?

The Social Security System in the Philippines provides health insurance coverage for a number of medical conditions. These include:

Chronic Illnesses

Certain long-term illnesses such as diabetes, cancer, hypertension, and arthritis are also covered by the SSS pension. You may be eligible for regular payments depending on the severity of your condition and any other factors.

SSS provides coverage for a wide range of chronic diseases that require prolonged medical care. These include both non-communicable illnesses like heart disease, chronic respiratory conditions, gastrointestinal disorders, neurological diseases, mental health disorders, and diabetes. Communicable chronic diseases like HIV/AIDS are also covered.

Some common chronic illnesses covered by SSS sickness benefits include:

• Cardiovascular diseases like hypertension, coronary artery disease, heart failure, stroke
• Respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), emphysema
• Gastrointestinal problems like irritable bowel syndrome, gastroesophageal reflux disease
• Kidney diseases including chronic kidney failure, nephrolithiasis, glomerulonephritis
• Neurological disorders like epilepsy, Parkinson’s disease, Alzheimer’s disease
• Mental health conditions such as clinical depression, bipolar disorder, schizophrenia
• Diabetes mellitus types 1 and 2
• Cancers like breast, lung, colon, prostate, leukemia, lymphoma
• Rheumatic diseases such as rheumatoid arthritis, systemic lupus erythematosus
• Inherited blood disorders like thalassemia, hemophilia

The expenses incurred for diagnosis, treatment, and long-term care of these chronic medical conditions are covered by SSS sickness benefits, subject to eligibility requirements. This provides much-needed financial assistance to members with prolonged illnesses.

Maternity Benefits

Pregnant women who are members of the SSS may be eligible for maternity benefits if they meet certain requirements.

These include having been employed for at least three months before becoming pregnant and being enrolled in either PhilHealth or HMO plans.

Disability Benefits

If you become disabled due to an illness or injury, you may be eligible to receive a monthly disability allowance from the SSS.

This allowance is based on your monthly salary prior to becoming disabled and is intended to provide financial assistance while you recover from your disability or adjust to retirement with it.

Death Benefits

If you pass away due to an illness or injury that was covered by your SSS membership, your beneficiaries may be eligible to receive death benefits from the Social Security System.

The amount of these benefits will depend on how long you were employed before passing away, as well as other factors such as whether or not you had children at the time of death.

What Is Not Covered By The SSS?

While there are many medical conditions and illnesses that are covered by your SSS, there are certain things that will not be included in its coverage. These include:

Pre-Existing Conditions

Generally speaking, pre-existing conditions are not covered by most health insurance plans including those provided through Social Security System memberships in the Philippines.

This means that if you have a condition prior to joining the program then it likely won’t be covered under any circumstances.

Cosmetic Procedures

Procedures such as plastic surgery, non-emergency dental care, and vision correction surgeries are generally not included in social security system plans either.

This is because they are considered elective rather than medically necessary treatments or procedures.

How is the SSS Sickness Benefit Amount Calculated?

The SSS sickness benefit provides income replacement for members unable to work due to illness or injury. The benefit amount is determined based on the member’s average daily salary credit (ADSC) over a 12-month period.

Importantly, the member’s daily sickness benefit allowance is set at 90% of their ADSC. This allows for substantial income replacement while out of work.

To calculate the benefit amount:

1. Identify the Semester of Contingency to exclude from the calculation. This is the 2 consecutive quarters ending in the quarter of sickness.
2. Look back 12 months from the month before the Semester of Contingency to establish the 12-month calculation period.
3. Identify the member’s 6 highest Monthly Salary Credits in this period and total them. The Monthly Salary Credit is based on total taxable monthly earnings.
4. Divide the total Monthly Salary Credits by 180 to determine the ADSC.
5. Multiply the ADSC by 90% to arrive at the daily sickness benefit allowance.
6. Finally, multiply the daily allowance by the approved number of sickness days to get the total lump sum benefit amount payable.

The daily cash allowance you can receive is equivalent to 90% of your average daily salary credit. There is a maximum limit of 750 pesos per day.

Duration of SSS Sickness Benefits

The duration of sickness benefits you can receive will depend on your SSS contributions as follows:

• For members with less than 3 monthly contributions: you can receive up to 20 days of leave.
• For members with 3 to 11 monthly contributions: you can receive up to 120 days of sickness benefits.
• For members with at least 12 monthly contributions: you can receive up to 240 days of sickness benefits per year.

How do I File an SSS Sickness Benefit Claim?

Follow these steps to claim your sickness benefits:

1. Notify SSS within 5 days of your hospital or home confinement. This can be done online through My.SSS or in person at a branch.
2. Download and fill up the Sickness Benefit Reimbursement Application Form (SS Form B1-3) from the SSS website.
3. Submit the application form together with supporting documents like medical certificates, clinical records, hospital receipts, and prescriptions.
4. If approved, you can claim your sickness benefits through a bank deposit, issuance of a check, or cash card.

Conclusion

The Social Security System in the Philippines provides financial assistance for its members who are unable to work due to an illness or injury through its Sickness Benefit program.

Having a clear understanding of what is and isn’t included in an SSS plan can help ensure that you get all of the coverage and financial assistance available when dealing with an illness or injury both now and later down the line.

If you have any questions regarding what is or isn’t covered by your plan then contact your local branch today for more information!