G.R. No. 196102, November 26, 2014
GOVERNMENT SERVICE INSURANCE SYSTEM, Petitioner, v. AURELIA Y. CALUMPIANO, Respondent.
D E C I S I O N
DEL CASTILLO, J.:
x x x Aurelia Y. Calumpiano5 was employed as Court Stenographer at the then Court of First Instance of Samar from January 5, 1972 until her retirement on March 30, 2002.
On March 7, 2002, shortly before her retirement, [respondent] filed before the Supreme Court, an application for disability retirement on account of her ailmentfs], Hypertensive Cardiovascular Disease [and] Acute Angle Closure Glaucoma. To bolster her claim, [respondent] submitted the medical certificates issued by her attending physicians, Dr. Alfred I. Lim and Dr. Elmer Montes, both of whom are Ophthalmologists [at] Eastern Samar Provincial Hospital. She submitted them together with the results of her perimetry test, [a certificate of] which x x x was issued by Dr. Lim. On September 30, 2002, the Supreme Court approved [respondent's] application for disability retirement, under Republic Act No. 8291 (New GSIS Act of 1997).
[Respondent's] disability claim was forwarded to GSIS,6 but the latter denied her claim for the reason that hypertension and glaucoma, which were her illnesses, were not work[-]related. Her motion for reconsideration was likewise denied by the GSIS.
Petitioner filed an appeal [with] the ECC, which rendered the assailed Decision,7 the dispositive portion of which stated:chanRoblesvirtualLawlibraryWHEREFORE, in view of the foregoing, the decision appealed from is hereby AFFIRMED and the instant appeal dismissed for want of merit.
"Glaucoma is characterized by an intraocular pressure sufficiently elevated to produce intraocular damage. The three major categories of glaucoma are: (1) angle-closure glaucoma, (2) open-angle glaucoma, and (3) congenital and juvenile glaucoma. Eyes that develop primary angle glaucoma are anatomically predisposed to the condition. In primary open-angle glaucoma, [the] angle appears open [and] does not seem to function properly. The exact nature of obstruction has not yet been elucidated. Congenital glaucoma and juvenile glaucoma are thought to be hereditary in most cases, although infectious causes are possible (rubella).["] (Pathologic Basis of Disease by Corran, 6th edition, pages 1374-1375)
"Hypertension is an increase in the blood pressure within the normal of less than 120/80 mm Hg as defined by the Joint National Committee VII. Primary risk factor for developing hypertension is smoking. Other important risk factors are excess body weight, high salt intake, nutritional factors, high alcohol consumption, physical inactivity and psychological factors, including stress." (Principles of Internal Medicine)
To warrant compensability of ailment and its resulting sickness, disability or death under P.D. 626, as amended, Rule III, Section l(b) thereof, specifically provides that the ailment must be listed by the Commission as an occupational disease with the conditions set forth therein satisfied, otherwise, the conditions imposed under the Increased Risk Theory must be complied with.
Appellant9 worked as a Court Stenographer III of the Supreme Court for thirty (30) years. Her duties were no doubt stressful and the same may have caused her to develop her ailment, hypertension. However, to make the same compensable, it is necessary that there must be impairment of function of her body organs like kidneys, heart, eyes and brain resulting in her permanent disability. An examination of the appellant's records would show that she was not suffering from end[-]organ damage. This was shown in the x x x report [of the ECG] that was taken on the appellant on January 21, 2002. Thus, the same cannot be considered compensable and work-connected.
Likewise, her other ailment, Glaucoma[,] cannot also be considered work-connected. Medical science has explained that it is characterized by an intraocular pressure sufficiently elevated to produce intraocular glaucoma. Here, there was nothing in her duties that would cause or increase her risk of contracting the said ailment.10
WHEREFORE, the petition is GRANTED. Accordingly, the assailed Decision is SET ASIDE. Let this case be REMANDED to the Employees' Compensation Commission for the payment of the disability benefits due the Petitioner.
- WHETHER THE COURT OF APPEALS ERRED IN FINDING THAT RESPONDENT'S DISEASES (HYPERTENSION AND GLAUCOMA) ARE COMPENSABLE UNDER THE INCREASED RISK THEORY; AND
- WHETHER THE COURT OF APPEALS ERRED IN REVERSING TFIE FINDINGS OF FACTS OF THE ECC.16
Cerebro-vascular accident and essential hypertension are considered as occupational diseases under Nos. 19 and 29, respectively, of Annex "A" of the Implementing Rules of P.D. No. 626, as amended. Thus, it is not necessary that there be proof of causal relation between the work and the illness which resulted in the respondent's disability. The open-ended Table of Occupational Diseases requires no proof of causation. In general, a covered claimant suffering from an occupational disease is automatically paid benefits.
However, although cerebro-vascular accident and essential hypertension are listed occupational diseases, their compensability requires compliance with all the conditions set forth in the Rules. In short, both are qualified occupational diseases. For cerebro-vascular accident, the claimant must prove the following: (1) there must be a history, which should be proved, of trauma at work (to the head specifically) due to unusual and extraordinary physical or mental strain or event, or undue exposure to noxious gases in industry; (2) there must be a direct connection between the trauma or exertion in the course of the employment and the cerebro-vascular attack; and (3) the trauma or exertion then and there caused a brain hemorrhage. On the other hand, essential hypertension is compensable only if it causes impairment of function of body organs like kidneys, heart, eyes and brain, resulting in permanent disability, provided that, the following documents substantiate it: (a) chest X-ray report; (b) ECG report; (c) blood chemistry report; (d) funduscopy report; and (e) C-T scan.
The degree of proof required to validate the concurrence of the above-mentioned conditions under P.D. No. 626 is merely substantial evidence, that is, such relevant evidence as a reasonable mind might accept as adequate to support a conclusion. What the law requires is a reasonable work-connection and not direct causal relation. It is enough that the hypothesis on which the workmen's claim is based is probable. As correctly pointed out by the CA, probability, not the ultimate degree of certainty, is the test of proof in compensation proceedings. For, in interpreting and carrying out the provisions of the Labor Code and its implementing Rules and Regulations, the primordial and paramount consideration is the employee's welfare. To safeguard the worker's rights, any doubt as to the proper interpretation and application must be resolved in [his] favor.
In the instant case, medical reports and drug prescriptions of respondent's attending physicians sufficiently support her claim for disability benefits. Neither the GSIS nor the ECC convincingly deny their genuineness and due execution. The reports are made part of the record and there is no showing that they are false or erroneous, or resorted to [for the purpose] of deceiving the Court, hence, are entitled to due probative weight. The failure of respondent to submit to a full medical examination, as required by the rules, to substantiate her essential hypertension, is of no moment. The law is that laboratory reports such as X-ray and ECG are not indispensable prerequisites to compensability, the reason being that the strict rules of evidence need not be observed in claims for compensation. Medical findings of the attending physician may be received in evidence and used as proof[s] of the fact in dispute. The doctor's certification as to the nature of claimant's disability may be given credence as he or she normally would not make untruthful certification. Indeed, no physician in his right mind and who is aware of the far[-]reaching and serious effect that his or her statements would cause on a money claim against a government agency would vouch indiscriminately without regarding his own interests and protection.
Significantly, even medical authorities have established that the exact etiology of essential hypertension cannot be accurately traced:The term essential hypertension has been employed to indicate those cases of hypertension for which a specific endocrine or renal basis cannot be found, and in which the neural element may be only a mediator of other influences. Since even this latter relationship is not entirely clear, it is more properly listed for the moment in the category of unknown etiology. The term essential hypertension defines simply by failing to define; hence, it is of limited use except as an expression of our inability to understand adequately the forces at work.25It bears stressing, however, that medical experiments tracing the etiology of essential hypertension show that there is a relationship between the sickness and the nature and conditions of work, hi this jurisdiction, we have already ruled in a number of cases the strenuous office of a public schoolteacher. The case of Makabali v. Employees' Compensation Commission, which we have re-affirmed in the subsequent cases of De Vera v. Employees' Compensation Commission, Antiporda v. Workmen's Compensation Commission, and De la Torre v. Employees' Compensation Commission, amply summarized, thus:chanroblesvirtuallawlibrary
x x x x
The fact that the essential hypertension of respondent worsened and resulted in a CVA at the time she was already out of service is inconsequential. The main consideration for its compensability is that her illness was contracted during and by reason of her employment, and any non-work related factor that contributed to its aggravation is immaterial.
Indeed, an employee's disability may not manifest fully at one precise moment in time but rather over a period of time. It is possible that an injury which at first was considered to be temporary may later on become permanent or one who suffers a partial disability becomes totally and permanently disabled from the same cause. The right to compensation extends to disability due to disease supervening upon and proximately and naturally resulting from a compensable injury. Where the primary injury is shown to have arisen in the course of employment, every natural consequence that flows from the injury likewise arises out of the employment, unless it is the result of an independent intervening cause attributable to claimant's own negligence or misconduct. Simply stated, all medical consequences that flow from the primary injury are compensable.
P.D. No. 626, as amended, is said to have abandoned the presumption of compensability and the theory of aggravation prevalent under the Workmen's Compensation Act. Nonetheless, we ruled in Employees' Compensation Commission v. Court of Appeals, that:Despite the abandonment of the presumption of compensability established by the old law, the present law has not ceased to be an employees'1 compensation law or a social legislation; hence, the liberality of the law in favor of the working man and woman still prevails, and the official agency charged by law to implement the constitutional guarantee of social justice should adopt a liberal attitude in favor of the employee in deciding claims for compensability, especially in light of the compassionate policy towards labor which the 1987 Constitution vivifies and enhances. Elsewise stated, a humanitarian impulse, dictated by no less than the Constitution itself under the social justice policy, calls for a liberal and sympathetic approach to legitimate appeals of disabled public servants; or that all doubts to the right to compensation must be resolved in favor of the employee or laborer. Verily, the policy is to extend the applicability of the law on employees' compensation to as many employees who can avail of the benefits thereunder.26 (Emphasis supplied)
Other than the given facts, another undisputed aspect of the case is the status of the ailments that precipitated De Castro's separation from the military service - CAD and hypertensive cardiovascular disease. These are occupational diseases. No less than the ECC itself confirmed the status of these ailments when it declared that "Contrary to the ruling of the System CAD is a form of cardiovascular disease which is included in the list of Occupational Diseases." Essential hypertension is also listed under Item 29 in Annex "A" of the Amended ECC Rules as an occupational disease.
Despite the compensable character of his ailments, both the GSIS and the ECC found De Castro's CAD to be non-work related and, therefore, non-compensable. To use the wording of the ECC decision, it denied De Castro's claim "due to the presence of factors which are not work-related, such as smoking and alcohol consumption." De Castro's own military records triggered this conclusion as his Admitting Notes, made when he entered the V. Luna General Hospital due to chest pains and hypertension, were that he was a smoker and a drinker.
As the CA did, we cannot accept the validity of this conclusion at face value because it considers only one side - the purely medical side - of De Castro's case and even then may not be completely correct. The ECC itself, in its decision, recites that CAD is caused, among others, by atherosclerosis of the coronary arteries that in turn, and lists the following major causes: increasing age; male gender; cigarette smoking; lipid disorder due to accumulation of too much fats in the body: hypertension or high blood pressure; insulin resistance due to diabetes; family history of CAD. The minor factors are: obesity; physical inactivity; stress; menopausal estrogen deficiency; high carbohydrate intake; and alcohol.
We find it strange that both the ECC and the GS1S singled out the presence of smoking and drinking as the factors that rendered De Castro's ailments, otherwise listed as occupational, to be non-compensable. To be sure, the causes of CAD and hypertension that the ECC listed and explained in its decision cannot be denied; smoking and drinking are undeniably among these causes. Flowever, they are not the sole causes of CAD and hypertension and, at least, not under the circumstances of the present case. For this reason, we fear for the implication of the ECC ailing if it will prevail and be read as definitive on the effects of smoking and drinking on compensability issues, even on diseases that are listed as occupational in character. The ruling raises the possible reading that smoking and drinking, by themselves, are factors that can bar compensability.
We ask the question of whether these factors can be sole determinants of compensability as the ECC has apparently failed to consider other factors such as age and gender from among those that the ECC itself listed as major and minor causes of atherosclerosis and, ultimately, of CAD. While age and gender are characteristics inherent in the person (and thereby may be considered non-work related factors), they also do affect a worker's job performance and may in this sense, together with stresses of the job, significantly contribute to illnesses such as CAD and hypertension. To cite an example, some workplace activities are appropriate only for the young (such as the lifting of heavy objects although these may simply be office files), and when repeatedly undertaken by older workers, may lead to ailments and disability. Thus, age coupled with an age-affected work activity may lead to compensability. From this perspective, none of the ECC's listed factors should be disregarded to the exclusion of others in determining compensability.
In any determination of compensability, the nature and characteristics of the job are as important as raw medical findings and a claimant's personal and social history. This is a basic legal reality in workers' compensation law. We are therefore surprised that the ECC and the GSIS simply brushed aside the disability certification that the military issued with respect to De Castro's disability, based mainly on their primacy as the agencies with expertise on workers' compensation and disability issues.28 (Emphasis supplied)
Although intraocular pressure (IOP) remains an important risk factor for glaucoma, it is clear that other factors can also influence disease development and progression. More recently, the role that blood pressure (BP) has in the genesis of glaucoma has attracted attention, as it represents a clinically modifiable risk factor and thus provides the potential for new treatment strategies beyond IOP reduction. The interplay between blood pressure and IOP determines the ocular perfusion pressure (OPP), which regulates blood flow to the optic nerve. If OPP is a more important determinant of ganglion cell injury than IOP, then hypotension should exacerbate the detrimental effects of IOP elevation, whereas hypertension should provide protection against IOP elevation. Epidemiological evidence provides some conflicting outcomes of the role of systemic hypertension in the development and progression of glaucoma. The most recent study showed that patients at both extremes of the blood pressure spectrum show an increased prevalence of glaucoma. Those with low blood pressure would have low OPP and thus reduced blood flow; however, that people with hypertension also show increased risk is more difficult to reconcile. This finding may reflect an inherent blood flow dysregulation secondary to chronic hypertension that would render retinal blood flow less able to resist changes in ocular perfusion pressure.33 x x x (Emphasis and underscoring supplied)
In recent years, we've learned a lot about ocular perfusion pressure (OPP), i.e., the pressure difference between blood entering the eye and IOP. It's clear that three forces — OPP, IOP and blood pressure — are interconnected in the glaucoma disease process. The mechanics of that relationship, however, remain ambiguous.cralawred
x x x x
The ties between hypertension and glaucoma are less well established but the data, in addition to my involvement in a new study (discussed below), have convinced me they probably do exist. Therefore, I believe potential hypertension, along with potential low blood pressure, should be investigated in patients whose glaucoma continues to progress despite what appears to be well controlled IOP.cralawred
x x x x
We suspect there is a close relationship among IOP, OPP, blood pressure and glaucoma, but the exact nature of these associations remains elusive. Complicating matters is the physiological phenomenon known as autoregulation.34chanrobleslaw
Aims: To determine whether systemic hypertension and glaucoma might coexist more often than expected, with possible implications for treatment.
Methods: Case-control study using general practitioner database of patients with glaucoma matched with controls for age and sex.
Results: Hypertension was significantly more common in the 27[,]080 patients with glaucoma (odds ratio 1.29, 95% confidence intervals 1.23 to 1.36, p<0.001) than in controls, x x x35
* Per Raffle dated October 13, 2014.
1Rollo, pp. 3-19.
2 Id. at 20-B-27; penned by Associate Justice Michael P. Elbinias and concurred in by Associate Justices Rosmari D. Carandang and Arturo G. Tayag.
3 Id. at 31-34; penned by ECC Executive Director Elmor D. Jurídico.
4 Id. at 28-30; penned by Associate Justice Michael P. Elbinias and concurred in by Associate Justices Rosmari D. Carandang and Danton Q. Bueser.
5 Herein respondent.
6 Government Service Insurance System, the herein petitioner.
7Rollo, pp. 3 1-34; dated June 24. 2004, penned by ECC Executive Director Elmor D. Juridico.
8 Id. at 20-B to 21.
9 Herein respondent.
10Rollo, pp. 33-34.
11 CA rollo, pp. 2-9.
12Rollo, p. 26.
13 FURTHER AMENDING CERTAIN ARTICLES OF PRESIDENTIAL DECREE No. 442 ENTITLED "LABOR CODE OF THE PHILIPPINES."
14 Citing Government Service Insurance System v. Court of Appeals, 417 Phil. 102 (2001); Government Service Insurance System v. Ibarra, 562 Phil. 924 (2007); Bonilla v. Court of Appeals, 395 Phil. 162 (2000); Government Service Insurance System v. Cordero, 600 Phil. 678 (2009); and Caslor-Garupa v. Employees' Compensation Commission, 521 Phil. 311 (2006). Citing Government Service Insurance System v. Cuanang, G.R. No. 158846, June 3, 2004 430 SCRA 639
16Rollo, p. at 7.
17 Id. at 61-70.
18 SECTION 1. Grounds. - (a) For the injury and the resulting disability or death to be compensable, the injury must be the result of employment accident satisfying all of the following conditions: x x x x
(b) For the sickness and the resulting disability or death to be compensable, the sickness must be the result of an occupational disease listed under Annex "'A" of these Rules with the conditions set therein satisfied; otherwise, proof must be shown that the risk of contracting the disease is increased by the working conditions.
(c) Only injury or sickness that occurred on or after January 1, 1975 and the resulting disability or death shall be compensable under these Rules.
19 Citing No. 29 of List of Occupational and Compensable Diseases, Annex "A" of the Amended Rules on Employees' Compensation, which states:chanroblesvirtuallawlibrary
29. Essential Hypertension.
Hypertension classified as primary or essential is considered compensable if it causes impairment of function of body organs like kidneys, heart, eyes and brain, resulting in permanent disability; Provided that, the following documents substantiate it: (a) chest X-ray report, (b) ECG report (c) blood chemistry report, (d) funduscopy report, and (e) C-T scan.
20 Citing Hatta Hataie v. Employees' Compensation Commission, G.R. No. 92803, March 22, 1991, 195 SCRA 580.
21Rollo, pp. 41 -46.
22 Those which the CA cited in its assailed Decision.
23 Citing Philimare, inc/Marlow Navigation Co., Ltd. v. Suganob, 579 Phil. 706 (2008) and Government Service Insurance System v. Casco, 582 Phil. 267 (2008).
24 529 Phil. 390 (2006).
25 In layman's terms, "essential hypertension" is defined as:chanroblesvirtuallawlibrary
1) "a common form of hypertension that occurs in the absence of any evident cause, is marked hemodynamically by elevated peripheral vascular resistance, and has multiple risk factors (as family history of hypertension, high dietary sodium intake, obesity, sedentary lifestyle, and emotional stress)— called also idiopathic hypertension, primary hypertension." http://www.merriam-webster.com/medical/essential%20hypertension. Last visited November 19, 2014.
2) "persistent and pathological high blood pressure for which no cause can be found." http://medical-dictionary.thefreedictionary.com/essential+hypertension. Last visited November 19, 2014.
In other words, "essential hypertension" means elevated blood pressure that does not have a known cause.
26Government Service Insurance System v. Baul, supra note 24 at 395-401.
27 610 Phil. 568 (2009).
28 Id. at 580-582.
29Rollo, p. 33.
30 CA rollo, p. 12.
31Rollo, p. 6.
32 CA rollo, p. 54.
33 He, Z, Vingrys, A. J., Armitage, J. A. and Bui, B. V. (2011), The Role Of Blood Pressure In Glaucoma. Clinical and Experimental Optometry, Vol. 94; Issue 2, pages 133-149. doi: 10.1111/j. 1444-0938.2010.00564.x http://onlineHbrary.wiley.com/doi/10.1111/j.1444-0938.2010.00564.x/full. Last visited: November 19,2014.
34 Varna, Rohit, MD, MPH, Blood Pressure's Impact on Glaucoma, Article Date: 4/1/2010. http://www.ophthalmologymanagement.com/articleviewer.aspx?articleID=104193. Last visited- November 19, 2014.
35 M J S Langman, R J Lancashire, K K Cheng, and P M Stewart, Systemic Hypertension And Glaucoma: Mechanisms In Common And Co-Occurrence, accepted 23 December 2004, British Journal of Ophthalmology, http://bjo.bmj.eom/contenl/89/8/960.full. Last visited November 19, 2014.
36 Government Service Insurance System v. Cuanang, supra note 15 at 648.
37 CA rollo, pp. 51, 52, 54-60, 62-86, 101, 120, 124.