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

Acquisition of a right to benefits

  • In the event of common disease or non-work-related injury, from the 4th day the worker is on sick leave from work.
  • In the event 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 had to go on sick leave.
  • The right to a subsidy cannot begin during a situation of strike or lockout.

Duration

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 have been 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 Law on Social Security
  • 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-employed.
  • 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.

Termination of a 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 aretirement 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. A relapse will be considered to be part of an initial process when sick leave is granted for the same or similar pathology within 180 calendar days of the previous medical discharge date.

    If an application for permanent disability has been filed prior to the conclusion of the 545 calendar days of the TD benefit and the right to permanent disability benefit is then denied, the National Social Security Institute (INSS) will be the only body authorised to grant a new period of sick leave for the same or a similar pathology within the 180 days following the negative ruling, through the bodies which are qualified to assess, grade and review the worker's permanent disability. 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.

    Nevertheless, in those cases in which medical treatment is still required in view of a possible recovery or improvement in the state of the worker and his subsequent return to work, if the worker's clinical situation makes it advisable to postpone that classification, it may be postponed for the necessary period, but the period of TD leave and the extension may not, under any circumstances, exceed 730 calendar days.

    During the periods provided for in this section, of three months and the delay in classification, there will be no obligation to pay Social Security contributions.
  3. Once the right to TD benefit has concluded due to expiry of the 545 calendar day period, with or without permanent disability having been declared, the worker will only be entitled to apply for further TD benefit for the same or a similar pathology once a period exceeding 180 days has elapsed since the permanent disability ruling.

    This new entitlement will be granted, provided that on the date sick leave is again granted, the worker fulfils all the requirements to receive the temporary TD resulting from a common disease or injury, work-related or otherwise. 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. A medical discharge with a proposal of permanent disability issued before the process reaches the maximum 365 days will end the situation of TD.

    If, once the 365-day period has expired, the INSS were to agree the commencement of permanent disability proceedings, the TD will cease on the date the aforementioned period expires. 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. The provisions of the previous points notwithstanding, when cessation is due to medical discharge and accompanied by a permanent disability proposal, by an agreement by the INSS to begin permanent disability proceedings, or due to the expiry of the 545-calendar-day period, the worker will be entitled to continue receiving TD benefit the classification of his permanent disability.

    In the cases referred to in the previous paragraph, the worker will begin to claim permanent disability benefit on the date of the resolution by the Managing Entity recognising this situation, unless this benefit is higher than that being received by the worker as extended TD benefit, in which case it will be backdated to the day following expiry of the period of TD.

    If the TD ends prior to conclusion of the 545-calendar-day period and the worker is not subsequently declared as having a permanent disability, social security contributions shall have to be paid until the employment relationship is terminated or until the aforementioned 545-calendar-day period expires, if this were to take place after the declaration stating there to be no permanent disability.
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