Management/ Payment

• Who must pay TD in the event of a relapse, if the insurance company at this time is different to the one that covered the initial accident?

  Category: > Subject:

  • For common diseases and non-work-related injuries:
    
    The body offering coverage for the TD when the relapse occurs will also pay the allowance, calculating the benefit in line with contribution bases at the time of the relapse,  irrespective of who was covered in the first process.
    
    
  • In the event of a WRI  or OD:
    
    
    • If the WRI base pension is equal to or greater than the relapse base pension: the first insurance company will pay the relapse taking the relapse base pension as the base pension. The second insurance company will be exempt from making payments.
      
      
    • If the WRI base pension is lesser than the relapse base pension: the first insurance company will pay the amount according to the base insured in the first WRI and the second company will pay the difference between the first base pension and the relapse base pension.            

  This criterion will not be affected, even if more than 180 days elapse without the beneficiary working, as the process is not a cumulative as regards the maximum length of the TD. 
  
  If the worker is unemployed when the relapse occurs and there was no sick leave at this time, the first insurance company will be responsible for the TD according to the base pension of the first process or the injury-related salaries. However, the limitations set out in Art. 222 of the LGSS will apply to the payment.
  

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• What documents must be submitted in order to process Temporary Disability for Self-Employed Workers?

  Category: > Subject:

  At the body where the risk is agreed, the INSSor Mutual, where appropriate, a direct payment request for the temporary disability benefit, sick leave, documentation showing that you are up to date with the payment of Social Security contributions, as well as an activity declaration must be submitted.
  

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• How long does a self-employed worker have to submit the activity situation declaration? What are the consequences of not presenting the declaration?

  Category: > Subject:

  Self-employed workers have to present a declaration on the person that directly manages the commercial, industrial or other type of establishment or, where appropriate, the temporary or final termination of the activity at the INSS within a period of 15 days from the start of the TDsituation, so that the Administration can verify the situation of the recipient's establishment during the TD situation.       
     
  However, sanction procedures will only be initiated if the presentation of the declaration occurs 45 days after sick leave.    
         
  Non-presentation of the declaration or an untimely declaration will be considered a minor infringement and penalised with loss of the benefit for one month.
  
  It is an obligatory document, as a result of which it will be possible to continue with the process even if the declaration is not available. If the worker meets all the requirements, the process will be approved but the benefit will not be paid, and the suspension of the payment will be maintained until the declaration is presented.
  

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• If I am in a situation of temporary disability by direct payment, do I have to continue submitting the confirmation reports to the INSS or the ISM in order to receive payment of my benefit?

  Category: > Subject:

  • If the Public Health Service has issued the corresponding confirmation report or, if applicable, discharge report, the INSS or ISM will proceed to pay the temporary disability benefit automatically without the need for you to submit the confirmation and/or discharge reports.    
  • The period covered by the above-mentioned confirmation and/or discharge reports will be paid with the centralised monthly payroll, as was the case before the extraordinary situation of COVID-19 containment measures.

  • However, the National Social Security Institute can only issue payment if the corresponding confirmation and/or discharge reports have been issued beforehand.

  • If you do not receive payment, you should contact the Public Health Service (SPS) to find out if the confirmation and/or discharge report has been issued and to resolve, if applicable, the issue of the report, since the SPS is the competent body to issue confirmation and/or discharge reports.

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• To which entity does the payment of the temporary disability correspond in these cases?

  Category: > Subject:

  • When the TD derives from common contingencies,  the payment corresponds to the managing entity (INSS or ISM) or the mutual society if the company has opted for them to assume the payment of the benefit.
    

  • In the case of TD derived from occupational contingencies, payment corresponds to the managing body (INSS or ISM) or the mutual society with which the company has occupational contingencies covered or to the company that voluntarily collaborates in the management of TD derived from occupational contingencies. 

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• Who will be in charge of providing medical assistance and controlling medical reports in these cases?

  Category: > Subject:

  • In the case of TD of less than 365 days, medical assistance and control of the reports may correspond to the Public Health Service, the INSS, the ISM and, where applicable, to the collaborating Mutual Society or to  the company that assumes voluntary collaboration in cases in which they have coverage for TD derived from professional contingencies.
    

  • From day 365 onwards, the National Social Security Institute or the ISM will be responsible for medical assistance and monitoring of the process.

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• If I am a self-employed worker and have opted for a Mutual Society to be entitled to the extraordinary termination of activity benefit while receiving temporary disability payment directly from the INSS, who must pay me temporary disability?

  Category: > Subject:

  • If INSS was responsible for temporary disability payments at the time of opting for the Mutual Society, payment must still be made by the INSS after this option.

  • If temporary disability applies after the Mutual Society option or you suffer a relapse of the previous temporary disability, the Mutual Society will assume management and payment for that temporary disability.

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