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:
- 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).
- At the request of the worker or their legal representative.
- 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.
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.
The delivered outcome must be announced on the following:
- 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.
- 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.
- 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.