Commencement of the entitlement / Duration /Extension/ Loss or suspension/ Termination

Acquisition of a right to benefits

  • In case of common disease or non-work-related injury, from the fourth day the worker is on sick leave from work.
  • In case of work-related injury or occupational disease, from the day after the worker is on leave from work. The employer has to pay the full salary for the day the worker commenced sick leave.
  • The right to a subsidy can not begin during a situation of strike or lockout.

Duration / Extensions / Relapses

The benefit will be paid during the time the beneficiary is considered temporarily disabled (TD) and this will last for:

  • In the event of an injury or disease, due to whatever cause, 365 days extendible for a further 180 days when it is presumed that, in that period, the worker may be cured and medically discharged.
  • In the event of observation periods required for occupational disease, 6 months extendible for a further 6 when this is deemed necessary to assess and diagnose the disease.

For the purposes of determining the maximum duration period and a possible extension, relapses and observation periods will also compute.

Extension

Responsibility for granting an extension

The National Social Security Institute (INSS) or, where applicable, the Social Marine Institute (ISM) is exclusively responsible for granting an extension of TD due to common injuries or diseases from day 365 of the TD period onwards (up to a maximum of 180 days).

The INSS is exclusively responsible for granting the TD extension for professional contingencies from day 365 of TD onwards (to a maximum of 180 days), except in those cases where a Mutual Society Partnering with Social Security is responsible for coverage, in which case the provisions of the Resolution of the State Secretariat for Social Security of 16 January 2006 will apply: Proposal of the Mutual Society Partnering with Social Security and declaration by the INSS within 5 days; if it is not carried out within this timeframe, then the proposal is deemed to be accepted.

The extension decision will be mandatory for continuing to receive the TD financial benefit, except in the situation referenced in the previous section.

Duration of the extension

The extension will be exclusively granted for the time that the EVI (Disability Assessment Team)  considers is needed for recovery, up to a maximum of 180 days. If the estimated recovery time exceeds 180 days, then the extension will not be granted and instead a PD file will be opened, even where the debilitating sequelae are not permanent.

Monitoring during this situation

During the extension period, the worker will undergo medical check-ups from the INSS. The following decisions may be made as a result of such monitoring:

  • Medical discharge certificate: After a new medical examination, if the worker can be given a medical discharge at the proposal of the EVI or the ICAMS (Institut Català d´Avaluacions Médiques i Sanitàries) in Catalonia, the INSS will issue a decision declaring the medical discharge of the worker. The medical discharge issued by the INSS, from the TD extension, entails the termination of the TD without suspending its effectiveness due to the submission of a previous claim.
  • Continuation of the extension up to a maximum of 180 days. Launch of a  Permanent Disability (PD) process; article 169 General Social Security Act
  • PD Proposal

Loss or suspension of the right to a benefit

This right may be denied, cancelled or suspended due to:

  • Fraudulent conduct on the part of the beneficiary to obtain or conserve the benefit.
  • Salaried or self employment.
  • Rejection or abandonment of the treatment for no reasonable cause.
  • The beneficiary failing to attend a summons from the doctors attached to the National Social Security Institute and the Mutual Societies Partnering with Social Security for an examination and medical check-up will lead to the right being provisionally suspended pending verification of whether this was justified. The procedure for suspending the right and its effects will be determined by the regulations.

Extinction of the right to benefits

  1. Entitlement to benefit will cease:

    • On expiry of the maximum 545-day period from the date sick leave commences.
    • When the worker is medically discharged because he is cured or well enough to perform his usual work.
    • When the worker is discharged with or without being declared as suffering from a permanent disability.
    • When a retirement pension is granted.
    • Due to the beneficiary failing to appear at any of the official examination appointments established by the medical practitioners who are members of the National Social Security Institute, or the Mutual Society Partnering with Social Security.
    • Due to death.

    When calculating benefit duration, relapses will be considered part of the initial process. It will be considered a relapse of the same process when there is new sick leave for the same or similar pathology within one hundred and eighty calendar days following the effective date of the previous medical discharge.

    Having begun a permanent disability process before a period of 545 calendar days of the TD subsidy has elapsed, if the permanent disability benefit entitlement is denied, the National Social Security Institute (INSS) will be the only competent body that can issue, within 180 calendar days after the negative resolution, a new sick leave for the same or a similar pathology using the competent bodies to appraise, grade and review the worker's permanent disability status. In these cases the TD process will resume until the 545 days have elapsed.
  2. When the benefit entitlement expires once the 545 calendar days set in the previous section have elapsed, the worker must be examined within a maximum of 3 months in order to appraise their state of disability and assign the relevant degree of permanent disability.

    However, in cases in which the need for medical treatment continues due to the expectation of the worker's recovery or improvement, in order to return to work, the clinical situation requires this grading to be postponed, it may be delayed for a specific period, but never exceeding 730 calendar days, including the TD period and its extensions .

    During the periods set out in this section,  3 months and the delayed grading, there will be no obligation to contribute.
  3. The TD benefit entitlement having expired after the period of 545 calendar days has elapsed, with or without a declaration of permanent disability, a new TD benefit entitlement may only be generated for the same or similar pathology after a period exceeding 180 calendar days, starting from the permanent disability resolution.

    This new entitlement will arise provided that on the date of the new sick leave the worker meets the requirements to be a beneficiary of the TD subsidy due to common or professional disease, or accident, whether work related or not. For these purposes, the contribution period to qualify for TD benefit due to common disease will only include the contributions made after the permanent disability resolution.

    However, when considering the same or a similar pathology and 180 calendar days have not elapsed since permanent disability was denied, a new TD process may commence, once only, when the INSS considers, through the corresponding bodies authorised to appraise, grade and review the worker's permanent disability status, that the worker may recover and become capable of working. For this, the INSS will authorise sick leave for the sole purpose of the TD benefit.
  4. Medical discharge proposing permanent disability, issued before the process has reached a period of 365 days, will end the TD status.

    If, having expired the 365 day period, the INSS agrees to begin a permanent disability process, the TD status will end on the date such period is completed. When, in compliance with the powers set forth in article 170 of the LGSS, the INSS agrees the express extension of the TD status, and during this period a permanent disability process is started, the TD status will end on the date of the resolution to begin such process.
  5. Without prejudice to the provisions of previous sections, when the expiry is caused by medical discharge proposing permanent disability, the INSS agrees to start the permanent disability process, or because 545 calendar days have elapsed, with worker will have the economic effects of the TD extended until the permanent disability is graded.

    In the cases referred to in the above paragraph, the permanent disability economic benefit will be effective as of the date of the resolution by the managing Entity recognising such disability, unless the benefit is greater than that received by the worker as an extension of the TD benefit, in which case it will be backdated to the day following expiry of the TD.

    If the TD expires prior to the 545 calendar day period with no subsequent declaration of permanent disability, the obligation to contribute will remain provided the working relationship does not end or until said 545 calendar day period expires, if this occurs after the declaration of no permanent disability.
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