Management and Control / Appeals

From day 1 to 365, the following entities are responsible for controlling temporary disability (TD) situations:

• The Public Health Service (SPS), for issuing certificates of the start of sick leave, confirmation and medical discharge.

• The National Social Security Institute (INSS), for issuing medical discharges, for all effects and purposes, and for commencing permanent disability (PD) procedures. The INSS is also competent to issue a sick leave report in the case of a relapse in a process of under 365 days, which ended with a medical discharge issued by the INSS doctor.
  
• The Social Marine Institute (ISM), for issuing leave and discharge certificates (non-devolved health care), medical discharge certificates for all effects and purposes and for commencing PD procedures for workers falling within the scope of application of the Special Marine System.

• Social Security Mutual Society Partners, to issue sick leave, confirmation and discharge certificates for WI and OD diseases and discharge proposals for ordinary contingencies.

• Partner companies, for issuing sick leave, confirmation and discharge certificates for workers in their employ, provided they have been granted authority for healthcare management and for TD resulting from work-related injuries and occupational disease.
  

Once the 365-day term has expired, the INSS or the ISM will be the only bodies authorised in their respective spheres, to:

• Grant an express extension.
• Decide to commence PD procedures.
• Issuing the medical discharge certificate. 
• Issue a new sick leave certificate when this occurs within a period of 180 calendar days after the medical discharge for the same or a similar pathology.

1. Process with a very short estimated duration: less than five calendar days.
2. Process with a short estimated duration: from 5 to 30 calendar days.
3. Process with a medium estimated duration: from 31 to 60 calendar days.
4. Process with a long estimated duration: 61 or more calendar days.

The medical personnel who issue the sick leave and confirmation reports must determine, at the time of issue, the estimated duration of the process.

The medical personnel may alter the estimated duration at a later time, due to changes or updates in the worker's diagnosis or the evolution of their health problem. For this purpose, as set out in article 2.4 of Royal Decree 625/2014, of 18 July, they will issue a confirmation report stating the new estimated duration, and if applicable, framing the process as a different type to those stated in the previous section.

The medical report beginning the period of temporary disability, whatever the determining contingency may be, will be issued immediately after the worker's medical examination, by the same medical personnel, using the form shown in annex I of Order ESS/1187/2015, of 15 June.

Process with a very short estimated duration: less than five calendar days.

When the medical personnel of the public health service or mutual society considers that the estimated duration of the process will be very short, they will issue the sick leave report and medical discharge report at the same time. To do this they will use a single report form, stating:

• the data relating to the sick leave,
• the data identifying the discharge and its date, which may be the same day as the sick leave begins or up to three calendar days after it.

Changing the duration of the process: Confirmation report.

However, the worker may ask for a medical examination on the day set for medical discharge, and if the medical personnel consider that the worker is not yet fit for work, they can change the originally estimated duration of the process, effectively issuing a sick leave confirmation report. This first confirmation report will cancel the medical discharge stated in the sick leave report, and will indicate the diagnosis, the new estimated duration and the type of process, and the date of the next medical checkup.

Other TD processes

When the medical personnel of the public health service or mutual society consider the process will have a short, medium or long estimated duration, they will enter the date of the next scheduled medical checkup on the sick leave report, which must always be within:

• seven calendar days from the date of the sick leave report, in processes with a short or medium estimated duration, 
  
• fourteen calendar days in processes with a long estimated duration.

On the date of the first medical checkup they will issue the medical discharge report, or if the sick leave needs to continue, the first confirmation report.

Competence to issue medical sick leave reports:

• Public health service, in TD processes arising from:

common contingencies of workers in Social Security

professional contingencies of workers in companies who have protected these contingencies with the INSS

• Medical service of Social Security mutual society partners for TD processes arising from professional contingencies of:

workers in companies associated with a mutual society

self-employed workers who have joined a mutual society for protection from such contingencies.

• Company technician collaborating voluntarily in the management of professional contingencies: IT processes derived from professional contingencies of the workers of these companies.
   
• INSS/ISM Medical Inspector: sick leave reports on relapses in a process of less than 365 days which ended with a medical discharge report issued by the INSS doctor
   
• The INSS, through the EVI/CEI:

sick leave after medical discharge without a declaration of Permanent Disability formalised before reaching 365 days of TD

sick leave after medical discharge without a declaration of Permanent Disability between 366 and 545 days of TD

Information included in the sick leave report.

The sick leave report will provide the personal details of the worker, the date sick leave began, the contingency which caused it, the diagnosis code, the national code of the worker's occupation, the estimated duration of the process, and if applicable, a clarification that the process is a relapse from an earlier one, and in this case, the date sick leave started in the earlier process.

It will also state the date of the next medical examination.

Delivery of copies to the worker:

The medical personnel who issue the medical sick leave, confirmation and discharge reports will give the worker two copies, one for the interested party and one for the company.

The confirmation reports will be issued by the corresponding medical personnel of the public health service, or of the mutual society when the temporary disability arises from a professional contingency it covers, using the form shown in annex II.

Rules for issue according to the estimated duration of the process:

• For processes with a very short estimated duration: confirmation reports need not be issued, unless the duration of the TD process changes.
  
• Processes with a very short estimated duration: the first confirmation report will be issued within a maximum of seven calendar days from the date the sick leave began. The second and subsequent confirmation reports will be issued every fourteen calendar days, maximum.
  
• Processes with a medium estimated duration: the first confirmation report will be issued within a maximum of seven calendar days from the date the sick leave began. The second and subsequent confirmation reports will be issued every twenty-eight calendar days, maximum.
  
• Processes with a long estimated duration: the first confirmation report will be issued within a maximum of fourteen calendar days from the date the sick leave began. The second and subsequent confirmation reports will be issued every thirty-five calendar days, maximum.

Changes or updates to the diagnosis or variation in the estimated duration.

• If there is a change or update to the diagnosis or a variation in the estimated duration as the worker's health evolves, a confirmation report will be issued stating the updated diagnosis, the new estimated duration and the date of the next checkup. The subsequent confirmation reports will be issued according to the new estimated duration.

Medical attention by another Public Health Service.

• When a worker in a TD situation begins receiving Medical Assistance from a different public health service than before, this circumstance will be reflected in the immediately preceding confirmation report, filling in the corresponding section. Each report will also indicate the date when the next medical checkup should be performed by the new public health service.

Delivery of copies to the worker:

• The medical personnel who issue the medical sick leave, confirmation and discharge reports will give the worker two copies, one for the interested party and one for the company.

Reaching 365 days of TD.

• When the medical personnel of the public health service, or the medical personnel of the mutual society in the case of a professional contingency covered by it, issues the last confirmation report before reaching 365 calendar days of duration, they will inform the worker during the medical examination that at the end of that period, the control of the process will pass to the INSS, as set out in article 170 of the Consolidated Text of the General Social Security Act, and that the medical personnel will not issue any more confirmation reports. The above is without prejudice to the public health service or mutual society continuing to provide the medical assistance their condition requires.
  
• For this purpose, in this confirmation report, instead of the date of the next medical checkup, the medical personnel will fill in the section corresponding to passing control to the INSS, indicating the day of reaching 365 calendar days in the TD situation.
  
• The public health service will inform the INSS online of the date when the 365 day mark is reached immediately on the same day, or no later than the next working day.

TD with a mutual society. Report by the INSS on reaching 330 days.

• In processes where the subsidy is managed by a mutual society, whatever the contingency causing it, the INSS will inform it immediately when the process has reached 330 calendar days of duration according to the data in the system's databases, indicating that on reaching 365 days, the managing body will exercise the competencies corresponding to it, in accordance with article 170 of the Consolidated Text of the General Social Security Act, approved by Royal Decree-Law 8/2015, of 30 October.
  
• Dealing with processes arising from professional contingencies, after receiving this communication and before the temporary disability reaches 345 calendar days, the mutual society can give the INSS a reasoned proposal to act along one of the lines indicated in the second paragraph of the aforementioned article 128.1.a). This proposal will not be binding for the INSS.
  
• This Institute will issue an express ruling in the exercise of the cited competencies, whatever the contingency.
  

Medical discharge report

• The medical report ending the period of temporary disability, whatever the determining contingency may be, will be issued immediately after the worker's medical examination, by the same medical personnel, using the form shown in annex I of Order ESS/1187/2015, of 15 June.
  
• The medical discharge will determine the end of the temporary disability and its associated subsidy on the day it is issued, without prejudice to the continued provision of medical assistance to the worker, as their condition indicates.
  
• The medical discharge will determine the obligation for the worker to return to work on the same day it becomes effective.

Cases leading to medical discharge:

• As well as the other medical discharge cases set out in the issue of the medical reports justifying sick leave, and regardless of the estimated duration of the process, the medical discharge will be issued for a cure or recovery that permits performing the worker's usual tasks; when the medical personnel consider that the worker has recovered their capacity to work; due to a proposal of permanent disability, or due to the start of a maternity situation.
  
• If the worker does not attend the medical examination set out in the sick leave and confirmation reports, the medical discharge may be issued due to failure to attend.

Competence to issue medical discharge reports:

• Public health service, in TD processes arising from:
  
• Common contingencies of workers in Social Security 
• Professional contingencies of workers in companies who have protected these contingencies with the INSS
  
• Public Health Service medical inspector in TD processes arising from:
  
• Common contingencies
• Professional contingencies of workers in companies who have protected these contingencies with the INSS
  
• Medical service of Social Security mutual society partners for TD processes arising from professional contingencies of:
  
• Workers in companies associated with a mutual society
• Self-employed workers who have joined a mutual society for protection from such contingencies.
  
• Competent staff in the collaborating volunteer company for the management of professional contingencies:
  
• TD processes arising from professional contingencies of the workers of these companies.
  
• INSS/ISM medical Inspector:
  
• Medical discharge by the competent INSS personnel.

Information included in the medical discharge report

• It must contain the cause of the medical discharge, the code of the final diagnosis, and the date the sick leave started.

Delivery of copies to the worker:

• The medical personnel who issue the medical sick leave, confirmation and discharge reports will give the worker two copies, one for the interested party and one for the company.

Medical discharge proposal:

• When the discharge proposal made to the Public Health Service by a mutual insurance society is not resolved and announced within five days (eleven days until 1 March 2015, as per the second transitional Provision of RD 625/2014 of 18 July), the mutual insurance society may submit the discharge request to the INSS or to the ISM, where applicable, in accordance with the competences set forth in additional Provision 52 of the General Social Security Act. 
  
• The managing entity will make a decision within 4 days (8 days until 1 March 2015, as per the second transitional Provision of RD 625/2014 of 18 July) from the date it receives the request.
  
• If, after examining the worker, the doctor considers the worker to be fit for work, then he/she will issue the medical discharge for all relevant purposes.
  

Once the 365-day TD period has expired, the National Social Security Institute (or the Social Marine Institute) will be the only competent entity for:

• Authorising an express extension for up to a further 180 days.

• Deciding to commence a permanent disability procedure.

• Issuing the medical discharge certificate. If the worker does not agree with the medical discharge issued by the managing Entity, he can declare his disagreement in the legally established terms.

In processes managed by the public health service, each quarter, counted from the date the sick leave begins, the public health medical inspection service, or the primary care doctor under the supervision of the medical inspection service, will issue a report monitoring the disability, which must expressly state opinions on the matters which from the medical point of view, justify the need to maintain the worker's temporary disability process.

When medical discharges are issued in TD processes resulting from professional or workplace-related causes prior to expiry of the 365-day term of that situation, the worker may lodge a request with the competent managing Entity for the discharge to be reviewed, in accordance with the following sections:

• The managing Entity should give priority to processing this procedure in order for a resolution to be issued as quickly as possible.

• The worker involved may request a review of the medical discharge issued by the partner entity within 10 working days of the notification date, by submitting an application to this effect to the competent Managing Entity, stating their reasons for disagreeing with the medical discharge. This application must be accompanied by the previous medical history relating to the temporary disability process in question, or, where applicable, a copy of the request for this medical history to the partner entity, so that the Managing Entity has information on the medical and clinical records in advance.
  
  Any interested party who initiates the review procedure must inform the company on the same day that they submit their application or the next working day.

• By commencing this procedure the medical discharge will be suspended and the worker's TD status resulting from professional or workplace-related causes will be deemed extended while the procedure is ongoing. If applicable, payment will continue as delegated payment, although it may be subsequently ruled that these TD benefits have been wrongly paid out, in the terms set forth in the following paragraphs.

• The INSS or ISM, as applicable, will notify the appropriate Social Security Mutual Society Partner that the special review procedure has begun so that it may submit, within a deadline of 4 working days, the records relating to the temporary disability process and a report detailing the reasons for which it has issued the medical discharge. If the aforementioned documentation is not submitted, the appropriate decision will be issued in consideration of the information provided by the interested party.
  
  The Social Security Mutual Society Partner can state their disagreement with the issued medical discharge certificate, which will cause the procedure initiated by the interested party to be filed immediately with no further processing.

• Likewise, the competent Managing Entity will notify the company of the start of the procedure within 2 working days of the application being submitted by the worker. When the interested party has submitted the sick leave certificate issued by the SPS to the company, the company must immediately inform the INSS or the ISM of this circumstance so that they can coordinate the subsequent actions.
  
  In turn, when the interested party requests sick leave due to a common contingency and, a previous TD process due to an occupational contingency in which a medical discharge certificate was issued is known, the Spanish Public Health Service must inform the interested party of the possibility of starting this special review procedure within 10 calendar days after the date of notification of the medical discharge certificate issued by the collaborating body and, in addition, the Managing Body must be immediately informed of the fact that there are two different TD processes underway which could be related.
  
  In these cases, the TD benefit for common contingencies will start to be paid until the procedure decision date, without prejudice to the fact that when the medical discharge certificate issued by the Social Security Mutual Society Partner is null and void, the Mutual Society has to reimburse the Managing Body with the benefit paid to the interested party and pay back the interested party the resulting difference in their favour.

• The provincial Director of the corresponding managing Entity will issue the appropriate ruling within a maximum of 15 working days from when the partner entity submits the documentation, once he has received the mandatory report from the disability assessment team for his examination and appraisal.

• The resolution issued will define the date and effects of the medical discharge or the continuation of sick leave, together with the cause (common or professional) of the TD process and, if appropriate, the wrongful nature of other sick leave processes that may have been determined by the SPS while these procedures were ongoing. The procedure will therefore conclude with one of the following pronouncements:

• Confirmation of the medical discharge issued by the Social Security Mutual Society Partner and expiry of the TD process on the date of the discharge.

• Continuation of the TD situation resulting from professional or workplace-related causes, deeming the worker to continue to suffer from ailments that prevent him from working. Therefore the medical discharge issued by the partner entity will be rendered null and void.

• Definition of the cause (common or professional) of the TD, when there are processes which coincide in the same time period and give rise to different sick leave periods. Likewise the appropriate outcomes will be ruled resulting from the cause of the TD being defined.

• When the worker recovers and is fit to return to work while procedures are ongoing, the medical discharge issued by the partner entity may be declared null and void because it is deemed premature. In these cases, the resolution will determine the new date on which the medical discharge shall be considered effective and hence TD expires.
  
• When the competent managing Entity confirms the medical discharge issued by the partner entity or sets a new date for TD expiry, any TD benefits for professional or workplace-related causes paid out to the worker subsequent to the date set forth in the resolution will be considered wrongfully received.

• Any correspondence between the EEGG, the partner entity, the SPS and the company will preferably be online or by telephone, enabling a swift exchange of information.

• If the maximum 365-day period for TD status is completed while this special procedure is being processed, the competent managing Entity will make a decision in accordance with the provisions of article 170 of the LGSS.

• While this procedure is ongoing, the worker may not receive both income from professional activities and TD benefit.

• The resolutions issued by the managing Entity, within the scope of its competences in this procedure, may be considered to be issued to resolve a prior claim, in accordance with article 71 of Law 36/2011, of 10 October, regulating social jurisdiction, which shall be stated in the resolution issued.

START OF THE PROCEDURE

The procedure to categorise the cause of the TD processes can be initiated from the date the sick leave certificate is issued: 

1. By the National Social Security Institute (INSS), or as a result of a reasoned request from the Labour and Social Security Inspectorate, the Public Health Service (SPS) in charge of managing Social Security healthcare, or at the proposal of the Social Marine Institute (ISM).  
2. At the request of the worker or their legal representative.  
3. At the request of Social Security mutual society partners or of partner companies, in those matters directly affecting them.

Applications must be accompanied by all the documentation required to categorise the disease or injury, including, where applicable, the medical reports and tests conducted.

Referral of the worker to the SPS by the mutual society.

After carrying out a preliminary medical examination and, where applicable, conducting the relevant tests, the mutual society doctor who treats the worker may consider the disease or injury to be common in nature and may refer the worker to the SPS for treatment, without prejudice to providing the care required in emergencies or life-threatening situations. To this end, he/she will provide the worker with a medical report describing the disease or injury and stating the diagnosis, the treatment given and the reasons for defining the disease or injury as common, which will be accompanied by the reports on any tests that have been conducted.

Issuing of the medical leave certificate by the SPS.

Worker contingency determination request

If, in light of the mutual society's report, the worker attends the SPS and the doctor there issues a sick leave certificate for a common disease or injury, the worker may appeal against this categorisation to the INSS, which will consider the case and make a decision by applying the procedure regulated in article 6 of Royal Decree 1430/2009 of 11 September.

Initiation of contingency determination record file

For his or her part, the doctor who issues the sick leave certificate may express their disagreement with the categorisation of the disease or injury provided by the mutual society, under the terms set forth in the above-mentioned article 6, without prejudice to the medical certificate being fully effective.

Notification to those involved about the start of the procedure. Request for reports.

The INSS will notify the competent SPS, the Social Security mutual for work-related injury and occupational disease or the partner company, as applicable, about the start of the procedure, when this procedure was not initiated at their request and in those matters that affect them so that they may, within a maximum deadline of four working days, provide the records in their possession relating to the case and provide information about the disease or injury they believe to be the cause of the pathological process and the reasons for same.

The worker will also be informed about the start of the procedure where this was not launched at their request, notifying them that they have ten working days to provide the documentation and put forward any arguments they deem relevant.

In addition, the INSS may request the reports and take any action it deems necessary to categorise, gain information about and confirm the data by virtue of which it must issue a decision.

PROCESSING

The disability assessment team will issue a preliminary report which it will send to the provincial director of the INSS, in which it will state its opinion on the disease or injury that gave rise to the disability process.

Once the disability assessment team has issued its report, the competent provincial director of the INSS will make the relevant decision within fifteen working days from the date the documentation was submitted by the parties involved, or from the expiry of the periods granted in the notification of the start of the case.

Where the Special Seafarers Scheme is applicable, the preliminary report of the relevant disability assessment team will be sent to the provincial director of the ISM, so that the latter may make the relevant decision and then notify the parties involved.
 
DECISION

The delivered outcome must be announced on the following:

1. Categorisation of the disease or injury which gave rise to the temporary disability situation as either common or occupational and whether it is a relapse to a previous process.  
2. Relevant effects, in the TD process, as a result of categorising the cause, when ailments arising from various diseases or injuries occur at the same time.  
3. Party responsible for the financial and healthcare benefits.

Effects of the decision. Amendment of the categorisation:

Common disease or injury to vocational disease or injury.

When the SPS has issued a sick leave certificate for common diseases or injuries, payment of the TD benefit for such cases will begin and go on until the date a decision is made on the procedure, even though when the decision categorises the disease or injury as occupational, the mutual society that covers it must pay the worker any difference owed to them, and reimburse both the managing entity for the benefit paid, where applicable, by offsetting the relevant amounts, and the SPS for the cost of the healthcare provided. In addition, when the vocational disease or injury is covered by the managing entity, the latter will pay the worker any amounts owed to them.

Vocational disease or injury to common disease or injury.

Likewise, when the decision categorises the disease or injury as common in nature, amending the previous categorisation as vocational and protection for same has been provided by a mutual society. The managing entity and the SPS must reimburse the mutual society for any expenses incurred through financial and healthcare benefits up to the amount applicable for such benefits in the case of common diseases or injuries. In addition, when both diseases or injuries are covered by the same mutual society, it will offset the relevant amount in its accounts Notification of the decision

Communicating of the decision. Appeals.

The worker, company, mutual society and SPS will be notified of the decision. Any correspondence between the managing entities, the mutual society and the company, will preferably be via computer or online electronic means, which allow for a swift exchange of information.

The decisions made by the managing entity, within the scope of its powers as set forth in article 6 of RD 1430/2009 of 11 September, are considered issued for the same purposes as the decision on a prior claim, pursuant to the provisions of article 71 of Law 36/2011 of 10 October, regulating the social jurisdiction.