In conflicting medical reports on workers’ disability claims, 3rd opinion is ‘mandatory’

Published August 2, 2022, 3:35 PM

by Rey Panaligan 

Supreme Court (SC)

On claims for disability benefits, both the employee and the employer must “observe strictly the mandatory procedure” of referring to a third physician the conflicting medical opinions between the company designated physician and the employee’s chosen physician.

The Supreme Court (SC) said that “it is only this compulsory procedure that assessment of the disability of the seafarer can be resolved with finality.”

“If either of the parties disregards the good faith compliance of the other, the legal consequences shall be borne by the erring party,” the SC stressed in the decision written by Chief Justice Alexander G. Gesmundo.

The decision made public last July 21 denied the petition filed by Benhur Shipping Corporation (BSC)/Sun Marine Shipping S.A. (SMS) as it affirmed with modification the rulings handed down by the Court of Appeals (CA) in 2016 and 2017 in favor of seafarer Alex Pefiaredonda Riego.

A summary of the decision issued by the SC’s public information office (PIO) stated that on Oct. 8, 2013, BSC employed Riego a chief cook on board the vessel MV Hikari I, an ocean-going vessel of its foreign principal, SMS.

On the first week of December 2013, Riego suffered from abdominal and lower back pain while on board the vessel. After he was examined by a doctor in Thailand and given medications, he was recommended for repatriation for further medical evaluation.

Riego returned to the Philippines on Dec. 15, 2013 and was endorsed by BSC to Marine Medical Services where he was attended to by the company-designated physician, for further medical care and treatment.

On Dec. 16, 2013, the company-designated physician issued the first Medical Report stating that Riego was referred to a gastro-enterologist and orthopedic surgeon.

The specialist recommended that Riego undergo laboratory examination, gastroscopy, ultrasound of the whole abdomen and magnetic resonance imaging, or MRI, of the lumbosacral spine, and was asked to return for re-evaluation.

Subsequently, the company-designated physician issued four more Medical Reports with the final report on May 26, 2014, stating that on follow-up check-up, Riego still complained of lower back pain radiating to the left lower extremity with no significant improvement with physical therapy, and there was still sensory deficit on his left leg.

The company-designated physician stated that if Riego is entitled to disability benefits, his final disability grading under the POEA (Philippine Overseas Employment Administration) schedule of disabilities remains at Grade 11 – 1/3 loss of lifting power.

On May 30, 2014 a certification was issued that Riego “has under medical/surgical evaluation treatment from Dec. 16, 2013 to present due to Hiatal Hernia; L4-L5, L5-S1 Disc Bulge.”

Riego consulted a physician of his choice for a second medical opinion. On June 5, 2014, his physician of choice issued a Medical Report stating that he was permanently disabled and permanently unfit to work in any capacity.

Subsequently, Riego twice sent letter-request to BSC and SMS for referral to a third physician. His requests were ignored. He then filed a case before the National Labor Relations Commission (NLRC) for disability benefits,

The labor arbiter granted partially Riego’s claims for disability benefits at $7,465 with 10 percent attorney’s fees.

On July 16, 2015, the NLRC affirmed the ruling of the labor arbiter. It ruled that Riego’s claim for permanent and total disability benefits was without basis at all.

On appeal, the CA reversed the NLRC as it ordered BSC and SMS to pay $60,000 as Riego’s permanent disability benefits with 10 per cent attorney’s fees.

The CA ruled that “if the treatment of 120 days is extended to 240 days, but still no medical assessment is given, the finding of permanent and total disability becomes conclusive.”

It pointed out that Riego “should be granted total and permanent disability benefits since no assessment was issued for a disability grade before the lapse of the 120-day period.”

The case reached the SC on the petition filed by BSC and SMC.

In denying the firm’s petition, the SC said.

“Indeed, when the employer fails to act on the seafarer’s valid request for referral to a third doctor, the tribunals and courts are empowered to conduct its own assessment to resolve the conflicting medical opinions of the company-designated physician and the seafarer’s chosen physician based on the totality of evidence.

“The employer simply cannot invoke the conclusiveness of the company-designated physician’s medical opinion vis-a-vis the seafarer’s chosen physician’s medical opinion when it is because the employer’s own inaction and neglect that the medical assessment was not referred to a third doctor.

“In this case, the May 26, 2014 Final Medical Report of the company-designated physician, and both the June 5, 2014 and July 2, 2014 Medical Reports of the seafarer’s chosen physician, consistently held that respondent (Riego) indeed suffered a disability. These reports merely differ on the extent of the disability suffered by respondent.

“Indeed, with respondent’s disability, he cannot anymore return to his occupation as a seafarer. He will be unable to perform the tasks required of him as a seafarer. More, the records do not show that respondent was indeed able to return to work as a seafarer.

“The Court emphasizes anew that in disability compensation, it is not the injury which is compensated, but rather, the incapacity to work resulting in the impairment of one’s earning capacity.

“Considering respondent’s condition, it is highly improbable for him to perform his usual tasks as seafarer on any vessel which effectively disables him from earning wages in the same kind of work or that of a similar nature for which he was trained.

“Verily, the occupation that sustains his livelihood is now a thing of the past due to the disability he suffered while employed by petitioners. Respondent’s disability resulted to his loss of earning capacity and, therefore, entitles him to permanent and total disability benefits.

“WHEREFORE, the petition is DENIED. The September 30, 2016 Decision and January 6, 2017 Resolution of the Court of Appeals in CA-G.R. SP No. 142911 are AFFIRMED with MODIFICATION. Petitioners are hereby ORDERED to PAY respondent Alex Pefiaredonda Riego total and permanent disability benefits in the amount of US$60,000 at the prevailing rate of exchange at the time of payment, as well as attorney’s fees equivalent to ten percent (10%) of the total monetary award.

“Finally, all monetary awards shall earn legal interest at the rate of six percent (6%) per annum from finality of this Decision until full payment. SO ORDERED.”