Sickness benefit is to (partly) replace the loss of income resulting from an inability to work due to illness (sick leave).
Sickness benefit is only payable to persons insured in a system that provides for sickness benefit. This includes apprentices and employees, but also recipients of cash benefits from the unemployment insurance scheme (e.g. recipients of unemployment benefit).
Sickness benefit is payable from the fourth day of sick leave for the duration of the sick leave.
There are, however, upper limits. These are set by law:
Minimum entitlement period of 26 weeks; this entitlement period automatically extends to 52 weeks if the person was insured under the health insurance scheme for at least 6 months within the last 12 months before sick leave started.
Amount of sickness benefit
Sickness benefit amounts to
from the 4th to the 42nd day of inability to work -> 50 % of the assessment basis.
from the 43rd day of inability to work -> 60 % of the assessment basis.
Under certain circumstances, the WGKK can grant an additional allowance for dependants.
The assessment basis for sickness benefit is the income from work on which insurance contributions are to be paid per day that the insured person would be entitled to in that contribution period which preceded the end of the full entitlement to remuneration.
If there is entitlement to special payments, sickness benefit is increased by 17 percent.
Recipients of benefits from the unemployment insurance scheme are entitled to sickness benefit in the amount of the last benefit they received from this scheme.
Sickness benefit is not payable ...
... if the inability to work is the result of willingly participating in a fight or a direct consequence of drunkenness or drug abuse.
Suspension of sickness benefit
General entitlement to sickness benefit can be suspended for certain reasons. The most important ones are:
- if and as long as the WGKK is not informed of the sick leave (normally done by the general practitioner)
- if and as long as the salary or wage continues to be paid (employment law entitlements). Attention! Entitlement to half a salary/wage means half the amount of sickness benefit
- if and as long as a person continues to receive holiday remuneration or severance pay
- if and as long as a person does his military or alternative service
- if and as long as a person refuses to undergo an examination by the WGKK doctor
- if stipulations of the sickness rules or doctor’s orders are repeatedly breached
Payment of sickness benefit must be applied for. The WGKK requires proof of employment and remuneration (“Arbeits- und Entgeltbestätigung”) issued by the employer which contains information on the amount of income and the duration of potential continued payment of remuneration. The WGKK also needs the sick leave confirmation note (where the duration of sick leave must be attested by a doctor) as well as any proof of stay at a hospital etc. If a cash benefit is paid under the unemployment insurance scheme, the required data are given to the WGKK electronically.
Attention: please don’t forget to give us your bank details!
Liability to tax
According to the Income Tax Act, sickness benefit is subject to income tax. The WGKK is obliged to keep 25.0 percent income tax of any amount exceeding EUR 30.00 per day and to transfer this to the tax authorities. The amount of income tax withheld can be seen in the sick leave confirmation note (which insured persons receive at the end of their sick leave).
Establishing inability to work
Inability to work due to illness is generally established by the attending doctor under contract who then informs the WGKK. If the insured person is treated by a non-accredited doctor who establishes inability to work, the insured person must immediately inform the WGKK and present the doctor’s note.
In the case of out-patient treatment at a hospital, the out-patient card issued by the hospital does not constitute a sick note. Again, the doctor under contract establishes whether there is inability to work.
If insured persons are still unable to work once they leave the hospital after a stay there, they have to have their sick leave attested by a doctor under contract within 10 days.
Patients should tell the doctor whether their illness is due to an accident at work, the result of an earlier accident at work, an occupational disease or a different type of accident.
The WGKK also asks to be informed if during the inability to work the patient applies for or receives a pension under the statutory pension insurance scheme or such an application is rejected.
Attention! Permitted times to go out must not be exceeded!
Visiting the patients
By law, the WGKK has to check on persons in connection with their sick leave. The purpose of these checks is to prevent the abuse of insurance contributions in individual cases.
These checks are both in individual cases also on the employer’s request and randomly conducted by our health workers in the individual districts. The respective branches coordinate the checks.
Medical assessment through the WGKK
The WGKK doctors, in the interests of the community of insured persons, are instructed to check the health status.
The request to undergo a medical examination must be followed.
If for important reasons (e.g. confinement to bed) the patient cannot meet this request, the WGKK must be informed immediately and be sent the attending doctor’s confirmation. A valid reason must be given for not keeping the appointment.
Obligation to inform
Recipients of benefits are obliged to inform the WGKK of any change
(e.g. starting employed work, change in location etc.) within two weeks. Both the attending doctor and the WGKK have to be informed of each change in the insured person’s location during sick leave immediately.
If an insured person is planning to leave the area of the health fund’s permit during sick leave, this requires the prior approval by the WGKK.
For more information and for applications for sickness benefit, insured persons should please contact the WGKK branches (addresses)