Denied SSS Sickness Benefit Claims: Employer Obligations and Remedies in the Philippines

This comprehensive guide covers how the Social Security System (SSS) sickness benefit works, why claims get denied, what employers are legally required to do, and the remedies available to employees and employers—complete with timelines, checklists, and appeal templates. Philippine context, private-sector employees.

1) Quick Primer: What the SSS sickness benefit is (and isn’t)

Purpose. The SSS sickness benefit is a daily cash allowance paid for work-interfering incapacity due to an illness or injury not caused by work (work-related contingencies fall under the Employees’ Compensation (EC) program).

Who can claim.

Employed members: Benefit is advanced by the employer and later reimbursed by SSS.
Self-employed/voluntary/OFW members: File directly with SSS.
Separated/unemployed members: File directly with SSS for contingencies that arise after separation, subject to rules on contributions and notice.

Core qualifying conditions (typical).

Incapacity to work of at least 3 calendar days (out-patient or in-patient).
Sufficient contributions (commonly, at least 4 monthly contributions within the 12 months immediately before the semester of sickness).
Timely notice of sickness and timely filing of the claim.
Within compensable limits (generally up to 120 days per calendar year; extended rules may apply to certain long-term conditions like TB subject to updated SSS issuances).
Sickness is substantiated by medical evidence acceptable to SSS.

Amount. The Daily Sickness Allowance (DSA) is typically 90% of the member’s Average Daily Salary Credit (ADSC), multiplied by approved days, subject to SSS caps and rules.

2) Employer obligations, at a glance (employed members)

A. Before sickness occurs (standing duties)

Register and keep SSS compliance current. Timely remittance of contributions is critical; missing contributions can sink eligibility.
Maintain accurate payroll and leave records.
Orient employees: how to notify sickness, documents needed, and filing timelines.

B. When an employee gets sick

Receive the employee’s notice of sickness or confinement (employees usually must notify within 5 calendar days from the start of sickness for out-patient cases; hospital confinement typically has longer or different notice treatment).
Evaluate eligibility (minimum 3 days incapacity, contributions, etc.).
Advance the benefit equal to the DSA × approved days, if eligible.
File for reimbursement with SSS—using the correct employer reimbursement form—within the prescriptive period (commonly 1 year from the end of each period of confinement/illness or from accrual as SSS rules specify).
Cooperate with SSS on medical/records verification.

C. What employers must never do

Refuse to accept an employee’s claim documents or sit on the notice.
Condition advancement on “SSS approval first.” The statutory design is advance now, reimburse later (for eligible cases).
Misclassify an illness as “leave only” to avoid advancing the benefit.
Alter records to affect ADSC or contribution history.

D. Payroll coordination

SSS sickness benefit is separate from statutory Service Incentive Leave (SIL) under the Labor Code. Company sick leave plans may supplement but cannot supplant the SSS benefit.

3) Why SSS sickness claims get denied

A. Contribution-related

Fewer than required contributions in the 12 months before the semester of sickness.
Gaps due to late postings or unremitted contributions by the employer.

B. Timeliness defects

Late notice of sickness (employee to employer or to SSS) beyond allowable periods.
Late filing of employer reimbursement (or member claim) beyond the 1-year prescriptive window.

C. Substantiation defects

Medical certificate does not establish incapacity (e.g., “fit to work”).
Missing discharge summaries, operative reports, diagnostic results, or physician’s license details.
Inconsistent dates (sickness period vs. medical documents vs. leave records).

D. Non-compensable periods

Less than 3 days incapacity.
Exceeding 120 days in the calendar year (unless a specific extension rule applies under updated SSS guidelines).
Work-related illness wrongly claimed as SSS sickness instead of EC.

E. Red flags

Fraud indicators (backdated medicals, altered forms, forged signatures).
Double-claiming with other programs where offsetting applies.

4) What employers should do when SSS denies a reimbursement

Identify the denial ground in writing. Get the SSS notice and read the exact basis (timeliness, contributions, medical, etc.).
Rectify what’s curable:
- Contribution posting issues: Submit proof of remittance; work with SSS to post missing payments.
- Document gaps: Secure a more detailed medical certificate, attach diagnostics, physician PRC details, hospital abstracts.
- Date conflicts: Reconcile HR attendance logs, leave forms, and doctor’s orders.
Re-file / request reconsideration within allowable periods, attaching a Position Letter (see template below).
If truly ineligible (e.g., contributions lacking), inform the employee in writing, explain why, and explore alternatives (company sick leave, salary loan options, EC if work-related).

Important: An employer’s failure to advance the benefit when the employee was eligible may expose the employer to labor money claims (for the unpaid advances), SSS administrative penalties, and potential criminal liability for violations of the Social Security Act and implementing rules (separate from civil liability to the employee).

5) Remedies for employees after a denial

A. Internal SSS remedies

Motion for Reconsideration / Request for Re-evaluation at the branch or processing unit, addressing the specific ground for denial and submitting additional evidence.
Appeal to the Social Security Commission (SSC)—generally within 60 days from receipt of the adverse SSS decision.
Petition for Review to the Court of Appeals (Rule 43) from an SSC decision—generally within 15 days from receipt.
Appeal to the Supreme Court (Rule 45 on questions of law) thereafter.

B. Labor standards / enforcement avenues

DOLE or Single-Entry Approach (SEnA) for assisted settlement where the dispute centers on an employer not advancing a presumptively eligible benefit or refusing to process.
NLRC money claims if the issue is the employer’s failure to advance or reimburse the employee.
Criminal/administrative complaints with SSS for employer violations (e.g., non-remittance).

C. If illness is work-related

File under Employees’ Compensation (EC) (usually through SSS but under the EC program). EC and SSS sickness are distinct; the work-related path is EC (with its own forms, evidence standards, and medical schedule).

6) Timelines & prescription (typical)

Employee’s notice to employer (out-patient): Within 5 calendar days from start of sickness.
Employer’s filing for reimbursement: Generally within 1 year from end of each period of confinement/illness (or from accrual per SSS form instructions).
Appeal to SSC: 60 days from receipt of the adverse SSS decision.
Rule 43 to CA: 15 days from receipt of SSC decision.

Tip: Even if notice/filing became late, submit justifying affidavits (e.g., hospital confinement, force majeure, lack of branch access) and any proof that the delay was reasonable; SSS may consider equitable factors depending on its latest circulars.

7) Documentation checklist

From the employee

Duly accomplished Sickness Benefit Application (or part of the employer reimbursement packet).
Medical certificate stating diagnosis, period of incapacity, attending physician’s PRC number, contact details, and advice on rest/work resumption.
Hospital records: admission/discharge, operative reports, diagnostics.
Proof of confinement or treatment (if out-patient, doctor’s orders and clinic logs).
Company records: leave forms, DTR/timekeeping extracts.

From the employer

Reimbursement application (current SSS form for employer reimbursement).
ER certification of the employee’s ADSC computation and approved days.
Payroll proof of the cash advance paid to the employee.
Contribution history (as posted) and any posting correction requests.
Transmittal sheet and authorization if filed by a representative.

8) ADSC / DSA computation (illustrative)

Determine the Average Daily Salary Credit (ADSC) from the member’s Average Monthly Salary Credit (AMSC) schedule and divisor.
Compute Daily Sickness Allowance (DSA) = 90% × ADSC.
Multiply by approved number of days (subject to caps like 120 days/year, and per-sickness rules).
Deduct any overlaps (e.g., if company plan pays full wages and is designed to integrate with SSS).

Employers should document the math in an internal worksheet and attach to the claim. Transparent computation helps prevent denials over “inconsistent amounts.”

9) Employer risk controls to prevent denials

SOP within HR:
- Day 0–1: acknowledge receipt of employee notice; give checklist.
- Day 1–3: verify contributions and ADSC; pre-compute benefit; release advance aligned with payroll.
- Day 3–7: assemble reimbursement packet; calendar the 1-year prescriptive end date.
Medical panel: maintain a roster of partner clinics to obtain complete certifications.
SSS e-services: use online facilities (if available) to check posting/claim status.
Quarterly audits of contribution postings.
Train leaders to avoid delays in endorsing medicals and leave approvals.

10) Decision tree: denied claim—what now?

Read denial reason → Contribution? Timeliness? Medical? Non-compensable?
If contribution → Submit remittance proofs; request posting; re-evaluate semester-of-contingency.
If timeliness → Prepare justification (affidavits, proof of hospital confinement/force majeure).
If medical → Ask physician for detailed findings and incapacity dates; attach diagnostics.
If non-compensable → Check EC route (work-related) or company benefits.
If still denied → File reconsideration → SSC appeal (60 days) → CA Rule 43 (15 days).

11) Model letters

A) Employer Position Letter (Reconsideration)

Subject: Request for Reconsideration – Denied Sickness Reimbursement of [Employee Name], SS No. [____] To: SSS [Branch/Office]

We respectfully request reconsideration of the denial dated [date] citing [ground].

Factual background. [Summarize illness, incapacity dates, notice received, advance paid.]

Grounds for reconsideration.

Contributions: Attached are proof of remittances and posting corrections.

Medical sufficiency: Attached updated medical certificate with PRC details, diagnostics, and discharge summary covering [dates].

Timeliness: Any delay was due to [reason]; see attached affidavit and hospital proof.

We submit that the member meets eligibility and that the employer properly advanced the benefit. We pray for approval of reimbursement in the amount of ₱[amount].

Attachments: [list]

Respectfully, [Name/Title/Company]

B) Employee Appeal to SSC (Outline)

Caption & parties
Statement of facts (illness, incapacity, notices, filings)
Issues (e.g., whether SSS erred in finding insufficient contributions)
Arguments (cite law, implementing rules, equity)
Prayer (reversal, approval of benefit)
Annexes (SSS decision, medicals, payroll records, remittances)

12) Special situations

Hospital confinement first, out-patient rest after. Ensure dates are contiguous and medically justified; submit both hospital and clinic documents.
Multiple episodes in a year. Track the 120-day annual cap carefully across episodes.
Separated employees whose sickness began after separation. Check if contributions/semester rules still allow a claim; these are filed directly with SSS.
Pregnancy-related conditions. Sickness vs. maternity benefits must be distinguished; do not double-claim for the same period.
Telework/partial capacity. If the member performed remunerative work during claimed days, SSS may deny those days; secure a fit-to-resume date to mark the return.

13) Compliance and penalties (employer side)

Failure to advance eligible sickness benefits, failure to remit/post contributions, or obstruction of claims can lead to:
- Administrative assessments and disallowances of reimbursement;
- Money claims by employees (with damages/attorney’s fees in appropriate cases);
- Criminal liability and fines under the Social Security Act and issuances (separate from Labor Code sanctions).
Corporate officers directly responsible may be personally liable under statutory provisions.

14) Practical FAQs

Q: Can we wait for SSS to approve before paying the employee? A: No. For employed members, the structure is advance by employer, then seek reimbursement.
Q: The employee notified us late. Are we automatically barred? A: Not necessarily. Submit explanations and proofs (hospitalization, emergency) and ask SSS to consider; however, late notice can limit or forfeit reimbursement depending on the rule invoked.
Q: We found missing contributions. What now? A: Pay/post immediately and submit proofs; if the semester test still fails, consider company goodwill assistance and ensure no repeat.
Q: The illness is clearly work-related. A: File under EC, not SSS sickness. EC has its own medical schedule and proof rules; coordination still typically runs through SSS windows.

15) Action plan template for HR

Adopt a written SSS sickness SOP (notice channels, forms, cut-offs).
Create a calendar tickler per claim: notice date, confinement period, 1-year reimbursement deadline, appeal deadlines.
Standardize the medical packet requirements (PRC details, diagnostics, incapacity dates, fit-to-work).
Quarterly reconciliation of posted contributions vs. payroll.
Train supervisors to route sickness notices within 24 hours to HR/Payroll.
Maintain appeal templates and a “denial-ground playbook.”

16) Key takeaways

Most denials arise from late actions, missing contributions, and thin medical proof.
Employers have a statutory duty to advance the sickness benefit for eligible employed members and to seek reimbursement on time.
Both employers and employees have clear remedies: reconsideration, SSC appeal (60 days), and Rule 43 to the Court of Appeals (15 days).
A tight HR compliance loop—notice intake, documentation, timely filing—prevents denials and disputes.

Disclaimer

This article provides general information on SSS sickness benefits in the Philippines and typical practices/requirements. Always check the latest SSS forms, circulars, and implementing rules, and consider obtaining professional advice for specific cases or litigation strategy.