Ortega vs. Social Security Commission

A claim for total permanent disability benefits under the Social Security Law requires proof that the claimant’s condition falls within the law’s specific enumeration or that a deteriorating related partial disability has reached a 100% additive rating; allegations of inability to perform one’s trade or profession, and supervening illnesses not raised in the administrative application, are legally insufficient.

Petitioner Ibarra P. Ortega, an SSS member with 41 posted contributions who had reached retirement age in 1998, earlier received partial permanent disability benefits for Generalized Arthritis and Partial Ankylosis totaling 23 monthly pensions. After the expiration of those benefits, he sought total permanent disability benefits, asserting additional diagnoses of trigger finger, bronchial asthma, hypertension, gastro-esophageal reflux disease, and rheumatoid arthritis. The SSS denied the claim on the basis that physical examination showed no progression of the original illness and that the claimant’s functional limitations did not warrant a total permanent disability rating. The case progressed through administrative and appellate review, culminating in the Supreme Court’s dismissal.

• Nature: Petitioner Ibarra P. Ortega, an SSS member, filed claims for partial permanent disability benefits due to Generalized Arthritis and Partial Ankylosis. The SSS granted these claims for a total monthly pension period of 23 months. After the benefits expired, petitioner sought total permanent disability benefits, asserting that his condition had worsened and was accompanied by additional ailments.

• The 2000 Claim: On April 26, 2000, petitioner filed with the SSS Malabon Branch Office a claim for total permanent disability benefits, docketed as BO-0000-1755. The claim was denied on the ground that he had already received disability benefits for the same illness and physical examination showed no progression. Dr. Juanillo Descalzo III, SSS Malabon Branch senior physician, noted only “slight limitation of grasping movement for both hands.”

• Petitioner’s Medical Evidence: Petitioner submitted a medical certificate from his attending physician, Dr. Rafael Recto, Jr., diagnosing “Trigger finger 4th (L) and thumb (L).” Another private practitioner, Dr. Flo dela Cruz, certified that petitioner also suffered from Bronchial Asthma, Hypertension, and Gastro-Esophageal Reflux Disease. Petitioner further claimed to be afflicted with rheumatoid arthritis of both hands affecting all fingers and both palms. He argued that the SSS physician’s brief examination could not prevail over the findings of his long-treating private physicians.

• SSS Review and Confirmatory Examinations: Upon referral by the SSC, the SSS Medical Program Department—through Dr. Carlota A. Cruz-Tutaan and Dr. Jesus S. Tan—examined petitioner and confirmed no progression of his illness. Their findings showed normal heart and lung functions, blood pressure of 140/80, and improved grasping with no abnormal limitation of movement on all fingers except a bent right small finger. The SSS Medical Program Department denied the claim with finality on November 22, 2000.

• SSC Proceedings and Further Examination: The SSC docketed the case as SSC Case No. 1-15115-2001. It directed the SSS to investigate the findings of petitioner’s attending physicians. Dr. dela Cruz’s records were reportedly destroyed by inundation. Dr. Recto’s July 10, 2001 letter-certification merely narrated recurring trigger finger, steroid injections, a surgical release on the left 4th trigger finger in 1998, and a later diagnosis of mallet finger (R, 5th) with advice for reconstructive surgery. The SSC, in resolving petitioner’s motion for reconsideration, ordered a domiciliary visit and physical examination. Dr. Rebecca Sison, SSS senior physician, examined petitioner on August 29, 2002 and found no neurological or sensory deficit, no loss of grasping power, full bending and raising capabilities, and normal extremities aside from a scar on the left 4th finger. Petitioner refused to undergo ECG and x-ray at the SSS office and refused to sign the medical field service form. Dr. Sison concluded there was “no sufficient basis that warrants the granting of Total Permanent disability.” Subsequent tests from hospitals of petitioner’s choice showed normal ECG, chest x-ray, and kidney/urinary bladder ultrasound.

• New Allegations on Appeal: After the case was submitted for decision before the Court of Appeals, petitioner manifested that he suffered a heart attack on February 25, 2004 and underwent coronary angiogram and angioplasty in 2005 at the Philippine Heart Center. These supervening heart-related conditions had not been raised in his original application before the SSS or in his petition before the SSC.

• Medical Opinion: Petitioner contended that the SSS physician’s interview of less than three minutes could not outweigh the diagnoses of his attending physicians, who had treated him over a long period and found multiple serious ailments.

• Fraudulent Findings: Petitioner charged the SSS medical officers with issuing fraudulent medical findings to justify the denial of his claim.

• Disability Standard: Petitioner invoked jurisprudence on work-connected disability claims, arguing that his inability to perform his trade and profession as a consultant, security consultant, security officer, and investigator entitled him to total permanent disability benefits.

• Supervening Illnesses: Petitioner sought consideration of his subsequent heart attack, coronary artery disease, ischemic heart disease, and severe hypertension, claiming these justified a finding of total permanent disability.

• Lack of Progression: The SSS maintained that four separate SSS physicians examined petitioner and consistently found no progression of his previously compensated partial disability; the slight limitation of grasping movement did not meet the threshold for total permanent disability.

• Statutory Enumeration: The SSC and SSS argued that petitioner’s condition did not fall within the specific list of permanent total disabilities under Section 13-A(d) of the Social Security Law, nor did it reach a 100% additive rating for related deteriorating partial disabilities.

• Substantial Evidence: Respondents asserted that the uniform findings of multiple government physicians constituted substantial evidence sufficient to support the denial, and that the certifications of petitioner’s private physicians were either unverified, based on unavailable records, or merely described conditions already accounted for.

• Procedural Impropriety: The SSC defended the appellate court’s refusal to consider new ailments raised for the first time on appeal, as these were outside the issues framed in the administrative proceedings.

• Procedural Remedy: Whether the petition, filed simultaneously under Rule 45 and Rule 65 of the Rules of Court, was proper.

• Scope of Review: Whether the Supreme Court could review questions of fact in a petition for review on certiorari under Rule 45, particularly the medical determination that petitioner was not totally and permanently disabled.

• Entitlement to Total Permanent Disability Benefits: Whether petitioner’s medical condition qualified him for total permanent disability benefits under Section 13-A of the Social Security Law.

• Applicability of Labor Code Standards: Whether the standard for total permanent disability under the Labor Code (inability to perform any gainful occupation) applied to claims under the Social Security Law.

• Supervening Illnesses: Whether new medical conditions (heart disease, diabetes) raised for the first time before the Court of Appeals could be considered in determining entitlement to benefits.

• Procedural Remedy: The petition was treated as one filed under Rule 45. The remedies of appeal and certiorari are mutually exclusive and not alternative or successive. The assailed Decision and Resolution of the appellate court were final judgments disposing of the case, making Rule 45 the appropriate remedy. The petition could not be simultaneously subsumed under Rule 65, and petitioner’s attempt to rectify the caption as a mere “clerical error” confirmed his decision to pursue certiorari under Rule 65, which was improper.

• Scope of Review: The petition raised questions of fact, not questions of law. The Supreme Court is not a trier of facts and accords great weight, and even finality, to factual findings of administrative agencies and quasi-judicial bodies—especially those affirmed by the Court of Appeals. The SSC, which acquired expertise in disability determinations, had its findings supported by substantial evidence. The Court would not re-weigh the evidence.

• Entitlement to Total Permanent Disability Benefits: Substantial evidence supported the conclusion that petitioner was not entitled to total permanent disability benefits. Four SSS physicians examined petitioner and found no progression of his original illness and no condition falling under the law’s enumeration of permanent total disabilities (complete loss of sight of both eyes, loss of two limbs, permanent complete paralysis of two limbs, brain injury resulting in incurable imbecility or insanity, and such cases as determined and approved by the SSS). Petitioner’s condition did not meet any enumerated category. Furthermore, the proviso on additive percentage degree of disability for deteriorating and related permanent partial disabilities did not apply because there was a dearth of evidence that his array of illnesses was related to the previously compensated Generalized Arthritis and Partial Ankylosis. The SSC did not ignore private physicians’ certifications; it investigated them and found the records partly unavailable and the diagnoses insufficient to alter the conclusion.

• Applicability of Labor Code Standards: The Labor Code standard for total permanent disability (inability to perform any gainful occupation for a continuous period exceeding 120 days, regardless of loss of body parts) does not govern claims under the Social Security Law. The two systems differ in nature and purpose: Labor Code provisions cover compensability of work-connected or work-aggravated disabilities resulting in loss of income, while Social Security Law benefits provide insurance against the hazards of disability, sickness, old age, or death irrespective of employment connection. Petitioner’s reliance on Labor Code jurisprudence was therefore misplaced.

• Supervening Illnesses: The Court of Appeals correctly refused to consider petitioner’s newly alleged heart conditions. Factual questions may not be raised for the first time on appeal, and documents not forming part of the administrative record cannot be considered. The issues in a case are limited to those presented in the pleadings. A change of theory on appeal is not allowed. The SSS must be afforded the opportunity to properly meet new allegations, particularly given the practice that only qualified government physicians are competent to issue medical certificates for official purposes. The dismissal was without prejudice to the filing of a new application for the supervening illnesses (Coronary Artery Disease 1VD and Diabetes Mellitus Type 2), which were found dissimilar from the subject matter of the present action.

• Mutual Exclusivity of Appeal and Certiorari — The remedies of appeal and certiorari are mutually exclusive and not alternative or successive. A party may not join a petition for review under Rule 45 and a special civil action for certiorari under Rule 65 in a single pleading, nor delegate upon the court the task of determining under which rule the petition should fall.

• Substantial Evidence in Administrative Proceedings — The quantum of proof required in cases before administrative or quasi-judicial bodies is substantial evidence—that amount of relevant evidence a reasonable mind might accept as adequate to justify a conclusion. Findings of fact of administrative agencies, which have acquired expertise because their jurisdiction is confined to specific matters, are generally accorded not only respect but finality when affirmed by the Court of Appeals.

• Non-Delegability of Fact-Finding by the Supreme Court — The Supreme Court is not a trier of facts and accords great weight to the factual findings of lower courts or agencies whose function is to resolve factual matters. It will not weigh evidence all over again in a petition for review under Rule 45.

• Distinction Between Labor Code Disability and SSS Disability — A disability is total and permanent under the Labor Code if, as a result of work-connected injury or sickness, the employee is unable to perform any gainful occupation for a continuous period exceeding 120 days, regardless of loss of body parts. Under the Social Security Law, total permanent disability is determined by specific statutory enumeration and an additive rating system for deteriorating related partial disabilities; it does not depend on loss of earning capacity or employment connection.

• Change of Theory on Appeal Prohibited — Issues are limited to those presented in the pleadings below. A factual question may not be raised for the first time on appeal, and documents forming no part of the proofs before the appellate court will not be considered. A change of theory on appeal is not allowed, as fair play requires the opposing party to have had the opportunity to properly meet the issue.

• “The remedies of appeal and certiorari are mutually exclusive and not alternative or successive.”

• “It is settled that the Court is not a trier of facts and accords great weight to the factual findings of lower courts or agencies whose function is to resolve factual matters. It is not for the Court to weigh evidence all over again.”

• “Claims under the Labor Code for compensation and under the Social Security Law for benefits are not the same as to their nature and purpose. On the one hand, the pertinent provisions of the Labor Code govern compensability of work-related disabilities or when there is loss of income due to work-connected or work-aggravated injury or illness. On the other hand, the benefits under the Social Security Law are intended to provide insurance or protection against the hazards or risks of disability, sickness, old age or death, inter alia, irrespective of whether they arose from or in the course of the employment.”

• “A change of theory on appeal is not allowed. In this case, the matter of petitioner’s serious heart condition was not raised in his application before the SSS or in his June 19, 2000 petition before the SSC. Fair play dictates that the SSS be afforded the opportunity to properly meet the issue with respect to the new ailments besetting petitioner.”

• Lazaro v. Social Security Commission, 479 Phil. 384 (2004) — Followed; reiterated the rule that the Supreme Court accords great weight to factual findings of lower courts or administrative agencies.

• Vicente v. Employees’ Compensation Commission, G.R. No. 85024, January 23, 1991, 193 SCRA 190 — Distinguished; petitioner’s reliance on this and similar cases involving work-connected disability was held misplaced because the standards under the Labor Code differ from those under the Social Security Law.

• Nagkahiusang Mamumuo sa PICOP Resources, Inc.- Southern Philippines Federation of Labor v. Court of Appeals, G.R. No. 148839-40, November 2, 2006, 506 SCRA 542 — Applied; the Court ruled that a party should not join both petitions in one pleading, as a petition cannot be subsumed simultaneously under Rule 45 and Rule 65.

• Ybañez v. Court of Appeals, 323 Phil. 643 (1996) — Applied; affirmed that a petition cannot be simultaneously under Rule 45 and Rule 65.

• Mackay v. Judge Angeles, 458 Phil. 1031 (2003) — Cited; distinguished certiorari as a mode of appeal under Rule 45 from certiorari as an original action under Rule 65.

• F.F. Marine Corporation v. National Labor Relations Commission, Second Division, G.R. No. 152039, April 8, 2005, 455 SCRA 154 — Cited; supported the rule that a factual question may not be raised for the first time on appeal.

• Drilon v. CA, 336 Phil. 949 (1997) — Cited; stated that a change of theory on appeal is not allowed.

• Section 13-A(d), (f), (g), Republic Act No. 1161 (Social Security Law), as amended — The provisions enumerating permanent total disabilities (complete loss of sight of both eyes, loss of two limbs at or above the ankle or wrists, permanent complete paralysis of two limbs, brain injury resulting in incurable imbecility or insanity, and such cases as determined and approved by the SSS), the schedule of compensability for permanent partial disabilities, and the additive rule for deteriorating and related permanent partial disabilities up to a maximum of 100%. The Court applied these provisions to determine that petitioner’s condition did not fall within the enumeration and that no related deterioration of the previously compensated partial disability was established.

• Rule 45 and Rule 65, Rules of Court — The Court distinguished the two remedies: Rule 45 is the proper mode of appeal from a final judgment, order, or resolution, limited to questions of law; Rule 65 is an original action for certiorari available only when there is no appeal or other plain, speedy, and adequate remedy. The Court applied these distinctions to treat the improperly combined petition as one under Rule 45 and to deny it.

• Rule 133, Section 5, Rules of Court — Defines the quantum of evidence in administrative proceedings as substantial evidence. The Court applied this standard to uphold the SSC’s findings.

• Articles 173 and 192, Labor Code; Rule VII, Section 2(b), Amended Rules on Employees’ Compensation — Cited to distinguish the Labor Code’s definition of total permanent disability (inability to perform any gainful occupation for over 120 days) from the Social Security Law’s definition, emphasizing the distinct nature and purpose of the two systems.

Leonardo A. Quisumbing (Chairperson), Dante O. Tinga, Presbitero J. Velasco, Jr., and Teresita J. Leonardo-De Castro (additional member per Raffle in lieu of Justice Arturo D. Brion who inhibited).