Requirements to Claim SSS Sickness Benefits in the Philippines

Overview

The Social Security System (SSS) Sickness Benefit is a daily cash allowance paid to a member who is unable to work due to sickness or injury and is confined for at least four (4) days, either in a hospital or at home. It is intended to partially replace lost income during periods of temporary incapacity.

Who May Claim

  • Employed members (private sector), including kasambahay.
  • Self-Employed (SE) members (e.g., sole proprietors, freelancers, professionals).
  • Voluntary Members (VM) and Overseas Filipino Workers (OFWs).
  • Unemployed but still active members (those with prior contributions) may also qualify if other conditions are met.

Note: Government workers covered by GSIS claim under a different system.

Core Qualifying Conditions

To be entitled, all of the following must be satisfied:

  1. Incapacity & Confinement

    • You were unable to work due to sickness or injury.
    • There was confinement of at least 4 days (continuous or cumulative/intermittent for the same illness, as certified by a licensed physician).

  2. Contribution Requirement

    • You have paid at least three (3) monthly SSS contributions within the 12-month period immediately preceding the semester of sickness.

    “Semester of sickness” means the two consecutive quarters ending in the quarter when the sickness began. Contributions within that semester do not count toward the “3 out of 12” rule; SSS looks at the 12 months immediately before that semester.

  3. Notification/Timeliness

    • You (or your employer) complied with SSS notification deadlines (see “Notification Rules & Who Files” below).

  4. Sick Leave With Pay (for employed members)

    • You have exhausted company sick leave with pay for the current year. If you still have paid sick leave, that period is not compensable by SSS.

Notification Rules & Who Files

If You Are Employed

  • Your duty:

    • Home confinement: Notify your employer within 5 calendar days from the start of incapacity.
    • Hospital confinement: Notify your employer within 5 calendar days from discharge.

  • Employer’s duty:

    • File the Sickness Benefit Reimbursement with SSS within 5 calendar days from receipt of your notice (home confinement) or from your discharge (hospital confinement).
    • Advance the benefit to you (pay you the daily allowance in your payroll) and later seek reimbursement from SSS.
    • Certify that you have no more sick leave with pay for the year for the days claimed.

Tip: Many employers file online via My.SSS. Keep copies of your medical documents and employer’s acknowledgment of your notice.

If You Are Self-Employed, Voluntary, OFW, or Separated/Unemployed

  • You file directly with SSS (online via My.SSS is typical).
  • Home confinement: File/notify within 5 calendar days from the start of incapacity.
  • Hospital confinement: File/notify within 5 calendar days from discharge.

Practical leeway exists for special cases (e.g., severe illness where timely filing was impossible), but you must provide a written explanation and supporting proof. Late filings can result in denial for the affected days.

Documentary Requirements (Typical)

Always prepare clear, legible copies; bring/show originals if asked.

  1. Sickness Benefit Application (online or the latest SSS form).

  2. Medical Certificate accomplished by a licensed physician, stating:

    • Diagnosis, dates of confinement/incapacity, treatment, and fitness-to-work date (if known).

  3. Supporting Medical Records, as applicable:

    • Hospital: Admission record, discharge summary, operative record, laboratory tests, imaging results.
    • Home: Clinic records, prescriptions, test results; for intermittent treatment (e.g., dialysis/chemo), schedule and proof of sessions.

  4. Proof of Identity (valid ID) and SSS number.

  5. For Employed Members:

    • Employer’s Certification that sick leave with pay has been exhausted (for the period claimed).
    • SSS Sickness Reimbursement filing via employer’s My.SSS, with company ID number and bank details for reimbursement.

  6. For SE/VM/OFW/Unemployed:

    • Disbursement Account Enrollment (PESONet bank/e-wallet/remittance partner) set up in DAEM under My.SSS.

  7. Additional proofs if applicable (police report for injuries, quarantine orders for infectious diseases, etc.).

Keep all original prescriptions and receipts; while not always required, they help validate treatment dates and severity.

How the Benefit Is Computed

  1. Find the Average Daily Salary Credit (ADSC)

    • SSS determines your Average Monthly Salary Credit (AMSC) from the best 6 of the last 12 months posted before the semester of sickness, then converts to a daily equivalent.
    • The Daily Sickness Allowance (DSA) is 90% of the ADSC.

  2. Count the Compensable Days

    • Exclude: Rest days only if you are not normally scheduled to work on those days and your physician did not medically certify incapacity for them; otherwise, certified days in the incapacity period are compensable up to the caps below.
    • Offset: Any days with company sick leave with pay (employed members) are not payable by SSS.

  3. Apply the Caps

    • Maximum of 120 days per calendar year (across all illnesses).
    • For the same illness, SSS may pay up to 240 days in total across multiple years; beyond that, the case may be evaluated for disability benefits rather than sickness.

You cannot receive SSS sickness benefit for the same period already paid under SSS maternity benefit. Overlaps are disallowed.

Types of Confinement & Special Cases

  • Hospital Confinement: Any in-patient admission; documentation centers on admission and discharge records.

  • Home Confinement: Allowed if medically justified; requires robust medical certification covering the entire incapacity period.

  • Intermittent/Recurring Treatment:

    • Some conditions (e.g., dialysis, chemotherapy, TB treatment) produce non-continuous incapacity. You may file per treatment cycle or grouped sessions as certified by your physician. Keep session logs.

  • Occupational/Work-Related Injuries:

    • These may also be compensable under the Employees’ Compensation (EC) program (administered by SSS). EC has separate rules and benefits; you may pursue EC in addition to SSS sickness where allowed, subject to program rules and non-duplication for the same contingencies.

Prescription (Deadlines) & Late Filing

  • General rule: Observe the 5-day notice windows above.
  • Reimbursement filing (employers) and member applications should generally be filed within one (1) year from the end of each confinement period.
  • Late notice can cause non-compensability of days prior to notice; SSS may accept late filings with valid, documented reasons, but days lost to delay may no longer be payable.

Disqualifications & Non-Compensable Situations

  • No posted contributions satisfying the “3 out of 12 before the semester” rule.
  • Failure to notify within required periods without valid justification.
  • Days covered by paid company sick leave (for employed).
  • Periods paid under SSS maternity benefit (no double payment).
  • Self-inflicted injury or willful intention to injure oneself (as determined by SSS).
  • Fraudulent or tampered medical certifications/records.
  • Detention or conviction (incapacity unrelated to sickness) may disqualify.

Payment & Crediting

  • Employed: Employer advances the DSA and later seeks reimbursement from SSS. You receive the cash via payroll.
  • SE/VM/OFW/Unemployed: Paid direct to your enrolled disbursement account (PESONet bank/e-wallet/remittance partner) after SSS approval.

Ensure your DAEM account in My.SSS is active, verified, and matches your name to avoid delays.

Taxes, Contributions & Effects

  • The sickness benefit is a social insurance benefit, not regular wages; it is not subject to SSS contributions and generally not subject to withholding tax. Company practice on payroll reporting may vary—check with HR/payroll for the payslip treatment.

Practical Filing Roadmap (Member’s Checklist)

  1. Confirm contribution history: Ensure you meet the 3/12 rule (check your My.SSS).

  2. See a licensed physician: Obtain a clear medical certificate with diagnosis and incapacity dates.

  3. Notify on time:

    • Employed: Tell HR within 5 days (or 5 days after discharge if hospitalized).
    • Others: File directly with SSS within the same timeframes.

  4. Prepare documents: Medical cert, supporting records, ID, and (if employed) employer certification on sick leave with pay.

  5. File through the correct channel:

    • Employed: Employer files reimbursement; you track with HR.
    • SE/VM/OFW/Unemployed: File online via My.SSS; ensure DAEM enrollment.

  6. Track approval: Monitor My.SSS for status; respond promptly to any SSS request for additional documents.

Frequently Asked Questions

1) Can I claim if I was sick only 3 days? No. The benefit requires at least 4 days of incapacity.

2) I’m employed and still have 2 days of paid sick leave. Can SSS pay those days? No. SSS pays only after paid sick leave is exhausted for the year, and only for the certified incapacity days.

3) Can the benefit be split if my doctor says I’m intermittently unfit for work (e.g., chemo every week)? Yes. File per certified treatment cycle or grouped sessions. Keep medical proofs for each incapacity block.

4) What if I filed late? SSS may accept with justification, but days prior to notice may be forfeited.

5) How much will I get per day? 90% of your ADSC (Average Daily Salary Credit), subject to the 120-day/year and 240-day/same-illness limits.

6) Can I claim SSS sickness while on maternity leave? No. Overlapping periods with maternity benefit are not payable under sickness.

7) Is doctor’s note alone enough for home confinement? It must clearly certify incapacity, with dates, diagnosis, and treatment; attach supporting records (tests, prescriptions). SSS may require additional proofs.

8) I had a work accident. SSS or EC? Potentially both, but EC is a separate program for work-related contingencies. Ask HR/SSS about filing an EC claim alongside SSS sickness where applicable.

Employer Compliance Highlights

  • Record employee notice dates (home/hospital) and file with SSS within 5 days of notice/discharge.
  • Advance the benefit (90% of ADSC per compensable day) through payroll.
  • Certify no more sick leave with pay for the period claimed.
  • File for reimbursement within the prescriptive period (generally within 1 year from end of confinement).
  • Maintain supporting medical documents for audit.

Key Takeaways

  • Meet the 3-of-12 contributions rule (before the semester of sickness).
  • Notify on time (5-day rule) and keep solid medical proofs.
  • 120 days/year cap overall; 240 days for the same illness over time (then consider disability).
  • 90% of ADSC per compensable day; employed members must exhaust sick leave with pay first.

This article provides a comprehensive, practice-oriented guide to the SSS Sickness Benefit. For edge cases (e.g., prolonged therapies, overlapping benefits, or late notices due to force majeure), prepare detailed medical/legal explanations and consult your nearest SSS branch or your HR for procedural specifics.

Disclaimer: This content is not legal advice and may involve AI assistance. Information may be inaccurate.

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