Aachen Social Court, 14/03/2017, Ref.: S 13 KR 312/16
According to § 44 Para. 1 SGB V, insured persons are entitled to sickness benefit if the illness makes them unfit for work or if they are treated as an inpatient in a hospital, a preventive care or rehabilitation centre (§ 23 Para. 4, §§ 24, 40 Para. 2 and § 41) at the expense of the health insurance fund. Incapacity for work (AU) is the inability, due to illness, to continue the last occupation or a similar occupation or activity (BSG, judgement of 30 May 1967 - 3 RK 15/65).
According to § 46 Para. 1 No. 2 SGB V, however, the entitlement to sickness benefit only exists if the incapacity for work is medically certified. Furthermore, the entitlement only continues until the day on which the immediately subsequent further incapacity to work due to the same illness is medically certified.
Background to the legal dispute: Entitlement to sick pay
In the present case, the plaintiff and the defendant, a health insurance company, were in dispute about the entitlement to sickness benefit for the period from 1 March to 31 July 2016. The plaintiff, who had been unemployed since July 2014 and was receiving unemployment benefit until February 2016, was unable to work from 8 January 2016 due to moderate depression. After her unemployment benefit expired, she received sickness benefit from 29 February 2016. However, due to gaps in the certificate of incapacity for work, the health insurance fund refused to continue payment from 1 March 2016.
Decision of the health insurance company: Refusal of sickness benefit
In a decision dated 9 March 2016, the health insurance fund refused to continue paying sick pay from 1 March 2016. It justified this by stating that the entitlement to sickness benefit only existed if the incapacity for work was certified by a doctor without any gaps. As there were gaps of a few days between the individual certificates from the treating doctor, the health insurance fund considered the claim to have lapsed. The claimant then filed a lawsuit and argued that she had not been able to see her doctor in time due to her depressive illness.
Judgement: Social court rules in favour of the plaintiff
The Aachen Social Court ruled in favour of the claimant and declared the health insurance company's rejection notices to be unlawful. The claimant was entitled to sick pay for the period from 1 March to 31 July 2016. The court found that the claimant had been unable to work due to her illness and that the gap in the certificates was therefore justified. The treating doctor also confirmed that the incapacity to work had existed continuously since 8 January 2016.
Legal basis and exceptions: Incapacity to act as a decisive factor
According to § 192 Para. 1 No. 2 SGB V, incapacity for work must be medically established. The court stated that in exceptional cases, a retroactive determination of incapacity to work is permissible if the person concerned was unable to seek medical help in good time due to their illness. In this case, the court recognised that the plaintiff was actually incapable of acting. The claimant had taken the necessary steps to secure her entitlement to sickness benefit immediately after the end of her incapacity to work.
The judgement makes it clear that in special cases, such as serious mental illnesses, exceptions to the strict application of sick pay regulations are possible.
Source: Social Court Aachen
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