Employee Remedies When Employers Misrepresent SSS Sickness Benefit Claims in the Philippines

I. Introduction

The Social Security System (SSS) sickness benefit is a critical social protection mechanism that provides employed members with daily cash allowance during periods of legitimate illness or injury that render them unable to work. Under Republic Act No. 11199 (Social Security Act of 2018), the benefit amounts to ninety percent (90%) of the member’s average daily salary credit, payable for a maximum of 120 days in one calendar year.

While the law imposes clear obligations on employers to facilitate the processing of sickness benefit claims, violations—particularly deliberate misrepresentation—remain distressingly common. Employers may falsely declare that the employee was not sick, was absent without official leave, was fit to work, or that the illness was due to misconduct or pre-existing conditions not disclosed. In extreme cases, employers forge medical certificates, alter dates of confinement, or simply refuse to transmit the sickness notification to SSS.

Such acts not only deprive employees of their rightful benefits but expose the employer to administrative, civil, labor, and criminal liability. This article exhaustively discusses the nature of the sickness benefit, the employer’s duties, what constitutes misrepresentation, and—most importantly—all available remedies for affected employees.

II. The SSS Sickness Benefit: Entitlement and Procedure

Eligibility requirements under Section 14-B of RA 11199:

• The member must have at least three (3) monthly contributions in the 12-month period immediately preceding the semester of sickness/injury.
• The member must have been confined for at least four (4) days (home or hospital confinement).
• The member must have used up all company sick leaves (if with pay) or must have been absent without pay due to sickness.
• The employer (or the member, if separated/self-employed/unemployed) must have notified the SSS of the sickness.

Notification procedure:

1. Employee notifies employer within five (5) calendar days from onset of illness (except in cases of force majeure or prolonged incapacity).
2. Employer must notify SSS within five (5) calendar days from receipt of the employee’s notification using SSS Form SNF (Sickness Notification Form) or through the employer’s My.SSS account.
3. If the employer paid the employee’s salary during the compensable period, SSS reimburses the employer. If no advance payment was made, SSS pays the employee directly.

Failure of the employer to notify SSS does not automatically forfeit the employee’s right to the benefit. SSS Circular No. 2019-008 and longstanding SSS policy allow the employee to file the claim directly when the employer refuses or fails to act.

III. What Constitutes Employer Misrepresentation

Misrepresentation occurs when the employer knowingly provides false or misleading information to SSS with the intent to prevent or reduce the payment of the sickness benefit. Common forms include:

1. Submitting a letter or accomplishment report stating that the employee was “fit to work,” “AWOL,” or “absent without leave” despite actual confinement.
2. Altering or refusing to acknowledge the dates of illness or medical certificates.
3. Declaring that the illness was due to employee’s fault, intoxication, notorious negligence, or pre-existing condition not disclosed (when in fact it was compensable).
4. Forging or causing the company physician to issue a false fit-to-work certificate.
5. Deliberately delaying transmittal of the sickness notification beyond the five-day period to cause denial on technical grounds.
6. Instructing HR personnel to reject or “lose” the employee’s submitted medical documents.

These acts are not mere administrative lapses; they are deliberate attempts to defeat a statutory benefit.

IV. Legal Consequences for Employers Who Misrepresent Claims

1. Administrative Liability before SSS (RA 11199, Section 28)

   • Penalty of not less than ₱5,000 nor more than ₱20,000 for each violation.
   • Additional 3% per month penalty on unremitted or delayed reimbursements.
   • SSS may file a separate collection case with prayer for preliminary attachment.

2. Criminal Liability

   • Violation of Section 29(a) of RA 11199 in relation to Article 172 (Falsification by Private Individual) and Article 171 (Falsification by Public Officer if the company physician is involved) of the Revised Penal Code: imprisonment of prisión correccional in its medium and maximum periods (2 years 4 months 1 day to 6 years) plus fine.
   • Estafa through falsification of private document (Article 315(3)(a) in relation to Article 172 RPC): reclusión temporal (12 years 1 day to 20 years) if the amount exceeds ₱22,000.
   • In numerous cases, the Supreme Court has sustained criminal convictions of HR officers and company presidents for falsifying sickness notifications (e.g., People v. Chua, G.R. No. 187052, September 13, 2017, involving falsified SSS forms).

3. Civil Liability

   • Payment of the sickness benefit in full, plus 12% legal interest per annum from date of denial until fully paid.
   • Moral damages (₱50,000–₱200,000 in decided cases), exemplary damages (₱50,000–₱100,000), and attorney’s fees (10–20% of the amount recovered).

V. Remedies Available to Employees

A. Administrative Remedies Before the SSS

1. Direct Filing of Sickness Benefit Claim

   • Employee may file directly with SSS even without employer’s notification.
   • Submit: SSS Form CLD-9A (Sickness Benefit Application), medical certificates, SNF accomplished by employee, proof of notification to employer (text messages, emails, registered mail, barangay certification of service, or affidavit of co-employees).
   • SSS is required to process the claim and, if approved, pay the employee directly.

2. Filing of Complaint Against Employer for Violation of RA 11199

   • File a letter-complaint with the SSS Member Services Department or through the SSS Hotline 1455.
   • SSS will summon the employer and impose the appropriate penalty.
   • SSS may also require the employer to pay the benefit directly to the employee if misrepresentation is established.

B. Labor Remedies Before DOLE/NLRC

The sickness benefit, while an SSS benefit, becomes a labor claim when the denial or non-payment is due to the employer’s fault or bad faith.

1. Money Claims for Sickness Benefit Equivalent (Single Entry Approach – SENA)

   • File at the DOLE Regional Office via SENA within three (3) years from accrual of the cause of action.
   • Jurisdiction: If the claim does not exceed ₱5,000 per claimant, DOLE Regional Director has original jurisdiction. Above ₱5,000, compulsory arbitration before the NLRC Labor Arbiter.
   • The NLRC has consistently ruled that employers are solidarily liable with SSS for the payment of sickness benefits when denial is attributable to the employer’s misrepresentation or non-remittance of contributions (see Lepanto Consolidated Mining Co. v. Dumapis, G.R. No. 163210, August 13, 2008, and subsequent cases applying the same principle to sickness benefits).

2. Illegal Dismissal with Claim for Sickness Benefit (if termination was linked to the illness)

   • If the employer terminated the employee for alleged AWOL when the employee was actually sick and the employer misrepresented the facts to SSS, the termination is illegal (King of Kings Transport v. Mamac, G.R. No. 166208, June 29, 2007).
   • Awards: full backwages, separation pay (if reinstatement not feasible), sickness benefit equivalent, moral and exemplary damages, 10% attorney’s fees.

C. Civil Action for Damages

File a separate civil action for damages based on Article 19, 20, 21, and 2176 of the Civil Code (abuse of right, violation of law, acts contra bonus mores, quasi-delict).

Venue: Regional Trial Court of the employee’s residence or place of work.

Recoverable amounts in actual cases:

• Sickness benefit (₱15,000–₱150,000 depending on salary credit)
• Moral damages (₱100,000–₱300,000 when bad faith is flagrant)
• Exemplary damages (₱100,000–₱200,000)
• Attorney’s fees and litigation expenses

D. Criminal Complaint

File directly with the Office of the City/Provincial Prosecutor for:

• Falsification of private document (Article 172 RPC)
• Estafa through falsification
• Violation of Section 29 RA 11199

Supporting evidence: original vs. falsified documents, medical records from hospital, attending physician’s affidavit, co-employee affidavits, text/email trail showing employer’s instructions to falsify.

The criminal case may be used as basis for preliminary attachment of employer’s properties to secure payment of the civil liability.

VI. Practical Steps for Employees (Step-by-Step Guide)

1. Immediately notify the employer in writing (email with read receipt, text message with screenshot, or registered mail). Keep proof.
2. If employer refuses to process within five days, file the claim directly with SSS online via My.SSS or at the nearest branch.
3. Simultaneously file a complaint against the employer with SSS for violation of RA 11199.
4. Within 30 days from SSS denial (if any), file a request for reconsideration or appeal to the Social Security Commission.
5. File SENA at DOLE within three years for money claims.
6. Consult a labor lawyer immediately—most reputable labor law firms handle SSS misrepresentation cases on contingency basis (no win, no fee).

VII. Preventive Measures Employees Should Take

• Always notify the employer in writing and keep proof.
• Submit medical certificates to both HR and SSS directly (via My.SSS).
• Monitor claim status online using My.SSS account.
• Join or form a labor union—unionized workplaces have significantly lower incidence of SSS misrepresentation.

VIII. Conclusion

Employer misrepresentation of SSS sickness benefit claims is not a mere administrative oversight; it is a serious violation of law that carries heavy administrative, civil, labor, and criminal consequences. Employees are not helpless. The combined force of RA 11199, the Labor Code, the Revised Penal Code, and settled jurisprudence provides multiple, overlapping remedies that, when pursued simultaneously and competently, almost always result in full recovery of the benefit plus substantial damages.

No employer should be allowed to profit from denying a sick worker the modest daily allowance that the law guarantees. Employees who have been victimized must assert their rights promptly and vigorously—through SSS direct filing, DOLE/NLRC money claims, civil suits for damages, and criminal prosecution. The law is unequivocally on the side of the worker.