People with statutory health insurance are entitled to sick pay if they are unable to work, as well as during hospitalization or treatment at a preventive care or rehabilitation facility. Sick pay amounts to 70 percent of the last salary subject to contributions, but no more than 90 percent of net pay.
Sick pay can be received for a maximum of 78 weeks within a three-year period due to the same illness. In most cases, the first six weeks are covered by continued pay from the employer; after that, there are still 72 weeks during which the health insurance fund provides income.
A new entitlement arises only after the insured person has not been unable to work due to the same illness for at least six months. However, if another illness prevents the insured person from working, a separate three-year period applies to that illness. The new illness, however, must not have already developed during the previous period.
Uninterrupted Medical Certificate
Previously, the doctor had to issue a new medical certificate no later than the business day following the last day of the sick leave. For example, if the medical certificate was valid through Friday, the insured person had to see the doctor by Monday at the latest.
For individuals whose employment ends while they are receiving sick pay, or who were already unemployed before receiving sick pay, the membership that exists solely for the purpose of receiving sick pay ends on the day of the last (timely) certified incapacity for work. In these cases, a delayed medical determination
of the continuing inability to work (AU) previously resulted not only in the termination of membership but also in the complete and permanent loss of entitlement to sick pay, even if the maximum duration of 78 weeks had not yet been reached. The same applied if the insured person could not be certified as continuing to be unable to work solely because they were unable to visit the doctor due to illness or because they had not found the doctor at the practice. The reason for this is that entitlement to sick pay depends not only on the start of the certified incapacity for work—as is the case, for example, with continued pay—but also on the date of the medical determination.
This practice could lead to those affected facing a financial crisis that threatened their livelihood. In contrast, the entitlement to sick pay for insured persons who were employed was reinstated as soon as their continued incapacity for work was medically certified again. In the meantime, only the payment of sick pay was suspended.
New Regulation
With the Appointment Service and Care Act (TSVG), lawmakers are now making another attempt to finally close the so-called sick pay gap. For insured individuals whose coverage depends on receiving sick pay, the entitlement to sick pay remains in effect immediately, even if the continued inability to work due to the same illness is not medically certified in a timely manner on the next business day but rather within one month after the end of the last period of incapacity.
However, in the event of a delayed medical certification, the entitlement to sick pay is suspended until the continued incapacity for work due to the same illness is medically certified—that is, during the certification gap. This corresponds to the rule that previously applied to insured persons who remain employed while receiving sick pay. In the future, therefore, the entitlement to sick pay will be reinstated at the time of the new medical determination for both insured persons who are employed and those who are not.
Not a Blank Check
In practice, it frequently happens that health insurance providers suspend sick pay payments because medical certificates are submitted late. Insured individuals should therefore ensure that they send the relevant copy of the medical certificate to their health insurance provider within seven days, even while their employer is still providing continued pay. This is because anyone who is unable to work for an extended period and may need to receive sick pay can only secure their entitlement if this deadline is met. Even though the legislature has addressed some hurdles regarding sick pay through the TSVG, the previous fundamental requirements for uninterrupted proof of incapacity for work remain in effect even after the legal amendment. To avoid gaps in sick pay, those affected should therefore continue to do everything possible to have their subsequent incapacity for work medically certified immediately after the cause of the incapacity has ceased and to submit the certificate to their health insurance provider.
Tjark Menssen is a lawyer at DGB Rechtsschutz GmbH.
