Sickness benefit (Germany)

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In Germany, sickness benefit is a compensation benefit provided by the statutory health insurance according to Book V of the Social Code (SGB V). It is paid in particular if an insured person is unable to work as a result of an illness lasting longer than six weeks (→ continued  payment in the event of illness ) or is treated as an inpatient at the expense of the health insurance company. Under certain conditions, however, sickness benefits can also be claimed by a parent who has to be absent from work under the age of twelve to supervise, care for or care for their sick co-insured child. Colloquially it is often referred to as " child sickness benefit " in these cases .

Eligibility requirements

Inability to work or inpatient treatment

In order to receive sick pay, a health insured person must be unable to work due to illness ( Section 44 (1) SGB ​​V ). The inability to work is the insured event . It occurs if the insured person is no longer able to carry out the activity he last performed before the incapacity for work due to illness, or only at the risk of the illness worsening. In contrast to private health insurance, statutory health insurance also means you are unable to work if you cannot do your job to the full. There is no partial incapacity for work. Unemployed people are unable to work if, due to illness, they are no longer able to do light work in the amount of time for which they have made themselves available at the employment agency. It does not matter what activity the insured was doing before becoming unemployed.

There is also an entitlement to sickness benefit if the inability to work is the result of an unlawful termination of pregnancy or sterilization required by illness ( Section 24b (2) sentence 2 SGB V).

Anyone who is treated as inpatient in a hospital, preventive or rehabilitation facility at the expense of the health insurance company is also entitled to sickness benefit, even if they are not unable to work.

Insurance entitled to sick pay

The right to sickness benefit may not be excluded according to Section 44 (2) SGB V. As a rule, employees and unemployed people who receive unemployment benefit are insured with a right to sickness benefit .

The insurance does not cover employees who are not entitled to continued pay in the event of illness for at least six weeks . This is the case, for example, if the employment relationship is limited to less than ten weeks from the outset. Full-time self-employed persons are also not insured . In both cases, members can declare that membership should include entitlement to sick pay (electoral declaration).

Recipients of unemployment benefit II are not entitled to sickness benefit unless they are insured with a claim to sickness benefit due to another circumstance, e.g. B. because they were employed subject to compulsory insurance before the incapacity for work or are employed subject to social security contributions in addition to ALG II. Unemployment benefit II continues to be paid during the incapacity for work. Family insured persons and other insured persons who typically do not suffer any loss of earnings in the event of incapacity for work are not entitled to sickness benefit.

Time at which the entitlement to sickness benefit arises

In cases of illness-related incapacity for work, entitlement to sickness benefit arises on the day of the medical diagnosis ( Section 46 of the Book V of the Social Code), for recipients of unemployment benefit, on the other hand, on the day on which the insured person is actually unable to work ( Section 47b of the Book V of the Social Code).

For self-employed persons who can claim sickness benefit, sickness benefits arise from the seventh week of inability to work. According to Section 53 (6) SGB V, the health insurance companies can offer tariffs for the self-employed, in which the entitlement to sickness benefits arises earlier, but also later.

In the case of hospital treatment or inpatient rehabilitation, entitlement arises on the day of admission.

Suspension of sickness benefit

The entitlement to sick pay is suspended as long as and to the extent that the employer actually continues to pay the wages or unemployment benefits are paid, i.e. usually during the first 6 weeks of incapacity for work. Sick pay is also suspended during parental leave and during the period in which certain other compensation benefits are being drawn. Since employees cannot claim continued pay during the first 4 weeks of their employment, they can receive sick pay during this time.

The entitlement to sick pay is also suspended as long as the incapacity for work is not reported to the health insurance company; this does not apply if the report is made within one week of the inability to work. The notification is an obligation of the insured person.

No sickness benefit will be paid during a period in which sickness benefit is inactive. The duration of benefits is reduced accordingly.

Duration of sick pay

According to Section 48 of the Social Code Book V, sickness benefits are generally paid without any time limit, but due to the same illness for a maximum of 78 weeks (i.e. 546 calendar days) within a block period of 3 years. If another illness occurs during the incapacity for work, the benefit period is not extended.

The duration is shortened by the days on which the entitlement has been suspended. Such a suspension of the claim can be due to the continued payment of wages by the employer, for example. As a rule, employees receive continued pay from their employer for the first 6 weeks of their inability to work and then sick pay for 72 weeks. In the event of persistent incapacity to work, sick pay will continue to be paid even after the termination of the employment relationship if the incapacity for work already existed at the time of termination.

The same illness in the aforementioned sense exists if it is based on the same, unresolved cause of the illness. It does not always have to have been in need of treatment, rather it is sufficient if a medically unhealed underlying disease continues to exist and after a symptom-free or symptom-free interval again causes symptoms, for example several fever attacks at longer intervals in the case of malaria disease or a renewed inability to work due to a degenerative disease Spinal disease.

Diseases that are only the same, e.g. B. several, independent colds, are not the same illness and justify new claims and a new three-year period.

After the start of a new three-year period, according to Section 48 (2) SGB V, there is a renewed entitlement to sickness benefit due to the same illness only if the person insured with sickness benefit has not been unable to work for at least 6 months because of this illness and if he was gainfully employed or the employment agency was available.

Amount of sick pay

According to Section 47 SGB ​​V, the (gross) sickness benefit amounts to 70% of the regular (gross) wages subject to contributions or earnings before the onset of incapacity for work (standard wage), but not more than 90% of the net wage. Normal remuneration is only up to the income threshold considered. Decisive for the calculation of the amount of the sick pay is the wage less one-off wages that was achieved in the last pay accounting period billed before the start of the incapacity for work, at least during the last billed four weeks (assessment period). If the remuneration fluctuates (e.g. piecework wages), the average of the last three months is used.

Since the sick pay is paid per calendar day, the average wage for one calendar day is calculated from the wages achieved in the assessment period according to the rules set out in Section 47 (2) SGB V. Added to this is the three hundred and sixtyth part of the one-time contribution subject to wages for the last twelve calendar months before the start of the incapacity for work.

Recipients of unemployment benefit are granted sickness benefit in the amount of the benefit amount of the unemployment benefit.

Sick pay is generally subject to contributions to pension, unemployment and long-term care insurance. When calculating the contribution, 80% of the assessment fee is taken into account. Sick pay recipients pay the contributions with half the contribution rates from the gross sick pay. The health insurance company pays the rest (usually higher). If unemployment benefits have been received up to now, the health insurance company alone pays the contributions. The sickness benefit recipient bears the premium for childless long-term care insurance contributions alone. The contributions to be borne by the sick pay recipient are withheld from the sick pay by the health insurance company and transferred to the collection point together with the contributions to be borne by it . In health insurance there is no contribution while receiving sickness benefit.

payment method

If the entitlement to sick pay lasts for an entire calendar month, the beneficiary receives sick pay for 30 days. In partial months, sick pay is paid for the number of actual calendar days in that month. The application of this thirtieth-part rule creates distortions at the start or end of sick pay payments in all months that do not have 30 days. The employer pays the salary for those days on which the employee is unable to work within the first six weeks, as well as for the days on which he is able to work again after the end of the incapacity, the employer may use the actual number of days in the month or also assume 30 days per month. In February there is an underpayment of up to 2/30, in the months of January, March, May, July, August, October, December an overpayment of up to 1/30. However, the employer can also assume the number of working days in the month in question.

The sick pay is paid out on the basis of the certificate of incapacity for work that the sick pay recipient receives from the doctor. On the certificate of incapacity for work, the doctor certifies the last visit to the practice, the expected duration of the incapacity for work, if applicable the last day of incapacity for work and the diagnoses. The health insurance companies only pay the sick pay up to the day of the medical diagnosis. This avoids an overpayment of sick pay in the event that the incapacity for work ends before the predicted longer duration of the incapacity for work.

Sick pay if the child is ill

Parents who are insured with the right to sickness benefit are entitled to sickness benefit according to Section 45 of the Social Code Book V if they stay away from work to supervise, care for or care for their sick and insured child. The same applies to stepchildren and grandchildren, whom the member mainly entertains, as well as to foster children. The child must not be more than 11 years old, there is no age limit for disabled and dependent children. The need to supervise, care for or care for the child must be certified by a medical certificate and there must be no other person living in your household who can supervise, look after or care for the child.

Entitlement to sickness benefit if the child is ill is limited to 10 working days for each calendar year and for each child, and to 20 working days for insured single parents. An insured person can only claim sick pay per calendar year for a maximum of 25 working days in the case of several children, and for insured persons with a single parent for a maximum of 50 working days.

One parent is entitled to sickness benefit without any time limit if, according to a medical certificate, the child suffers from an illness,

  • which is progressive and has already reached a very advanced stage,
  • in which a cure is excluded and palliative medical treatment is necessary or requested by one of the parents and
  • which can only be expected to have a limited life expectancy of weeks or a few months.

According to Section 45 (3) SGB V, insured persons who are entitled to sickness benefit have an indispensable right to unpaid leave from work for the duration of this claim against their employer, unless they are entitled to paid leave for the same reason.

Particularities in the case of non-employed persons and for employment contracts limited to a maximum of ten weeks

In 2009 there was a change in sick pay. For non-employed persons and employees with fixed-term contracts for a maximum of ten weeks, the entitlement to sickness benefit from the health insurance company has been canceled without replacement from January 1, 2009.

The regulations for the continued payment of wages by the employer in the event of illness remained unchanged. Section 3 EntgFG, Paragraph 3 states that in the first four weeks of employment there is no continued payment of wages by the employer in the event of illness.

Since August 1, 2009, the employee in such an employment relationship can submit an election declaration to the health insurance company and the employer in order to still receive sickness benefit if necessary. In return for an individually requested contribution increase of 0.3% points (plus a 0.3% employer's contribution), he can receive sickness benefit from the health insurance company for periods in which no other claim, e.g. B. through continued payment of wages.

Comparable services

Benefits are similar to sick pay

Injury allowance and pension sickness benefit are paid out by the health insurance company with which the recipient is insured, on behalf of the accident insurance institution (e.g. professional association ) or the pension office. The health insurance companies settle the disbursed services with the responsible institution.

There is also daily sickness allowance insurance as loss of earnings insurance with a private health insurance company . However, this differs from the sickness benefit of the legally insured persons in the concept of incapacity for work (100% incapacity for work as a prerequisite for entitlement to benefits) and the duration of benefits (unlimited or until incapacity has occurred in the previously exercised occupation in accordance with the model conditions ).

Tax treatment

Sick pay payments from statutory health insurance are tax-free, but are subject to the progression proviso , i. H. increase u. U. the taxes payable on other taxable income or emoluments ( Section 32b (1 ) EStG ).

Web links

Individual evidence

  1. ↑ Section 2, Paragraph 1, Clause 1 of the Inability to Work Guidelines (PDF; 102 kB) of the joint federal committee according to Section 92, Paragraph 1, Clause 2, No. 7 of SGB V
  2. ↑ § 2 Paragraph 3 of the Inability to Work Guidelines
  3. ↑ § 49 Paragraph 1 No. 1 SGB V
  4. ↑ Section 146, Paragraph 1, Sentence 1, SGB III
  5. ↑ See § 49 Paragraph 1 No. 3, 3a, 4 SGB V
  6. ↑ Section 3, Paragraph 3 of the Continued Payment Act
  7. ↑ Federal Social Court, judgment of November 8, 2005 - B 1 KR 30/04 R, paragraph 17; Judgment of 12 March 2013, B 1 KR 7/12 R, paragraph 16
  8. ↑ § 48 Paragraph 3 SGB V
  9. ↑ [1] Retrieved June 15, 2015.
  10. ↑ Judgment of the Landessozialgericht München Az .: L 4 KR 268/06
  11. ^ Federal Social Court judgment of December 7, 2004, B 1 KR 10/03 R, paragraph 16; also Federal Labor Court judgment of November 14, 1984, 5 AZR 394/82
  12. ↑ See definition of the term pay in § 14
  13. ↑ See definition of the term labor income in § 15
  14. ↑ § 47 Paragraph 6 SGB V
  15. ↑ One-off wages are benefits that are attributable to wages and are not paid for work in a single payroll accounting period ( Section 23a )
  16. ↑ § 47b Abs. 1 SGB V
  17. ↑ § 345 No. 5 SGB III, § 166 Abs. 1 No. 2 SGB VI, § 57 Abs. 2 SGB XI
  18. ↑ § 347 No. 5 SGB III, § 170 Paragraph 1 No. 2 a) SGB VI, § 59 Paragraph 2 SGB XI
  19. ↑ Section 224 (1) SGB V
  20. ↑ § 47 Paragraph 1 Clause 6 and 7 SGB V
  21. ↑ § 45 Paragraph 1 Sentence 2, § 10 Paragraph 4 SGB V
  22. ↑ Book Five of the Social Code, Section 44, Paragraphs 2, 3.
  23. ↑ Pronova BKK AG information ( Memento from June 14, 2012 in the Internet Archive )
  24. ↑ Mediafon, Insurance News