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Darmstadt (dpa / lhe) - Statutory health insurance companies must exceptionally pay sick pay even if you report sick late.
If an insured person is referred to a later appointment in a doctor's practice for organizational reasons and cannot prove a complete incapacity for work, the statutory health insurance may not refuse to pay the sickness benefit, as the Hessian State Ministry of Social Affairs announced on Tuesday in Darmstadt (Az. L 1 KR 125 / 20 and L 1 KR 179/20).
In the first case, an insured person from the Darmstadt-Dieburg district became unable to work in 2018 and received sick pay.
The end of the certified incapacity for work fell on a Friday.
On the following Monday, the insured phoned the doctor's office to get an appointment for the same day.
The doctor was on vacation and an appointment with his substitute was only possible on Wednesday.
In a similar procedure, a woman from the Odenwald district was referred to a later appointment by her family doctor for organizational reasons.
The two judgments are final.
A revision was not permitted in each case.
In the negotiated cases, the respective health insurance companies refused to pay any further sick pay because the incapacity for work had not been fully established.
According to the Social Security Code, an insured person must have a continuation of this inability to work certified by a doctor no later than the next working day after the end of the last determined incapacity in order to continue receiving sick pay.
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However, the regional social court found the two insured persons right and sentenced the health insurance companies to pay the sick pay.
An inability to work must be proven completely.
However, if the insured has done everything in his power and reasonable to receive the medical certificate, the health insurance company must pay sick pay despite a lack of evidence.
Such an exceptional case exists if the appointment agreed in good time has been postponed by the doctor's practice or the doctor's practice only offers the insured a later appointment.
According to the court, the insured cannot be expected to see another doctor or even the emergency medical service.
A “doctor hopping” is legally not desired.