How sickness benefit works – Find out everything!

Learn all about how sickness benefits work and how to start your process!

THE sickness benefit It is also called “temporary disability benefit” and works as a type of social security insurance.

In Brazil, this benefit is regulated by Law 8.213/91, which would be the social security benefits law.

And generally speaking, the person who is entitled to insurance receives an income during the period that the incapacity to work lasts, so let's understand more details below:

Check out what you'll see:

• How does sickness benefit work? 
• What do you need to apply for sickness benefit? 
• How does the sickness benefit process work? 
• What illnesses give rise to the right to the benefit? 
• Conclusion.

How does sickness benefit work?

Firstly, it is important to highlight that it is not the illness itself that grants the right to this type of assistance.

Therefore, it is necessary for a medical expert to prove the incapacity.

There are two types of sickness benefit, the one that is aimed at common illnesses and accidents.

On the other hand, the second type of assistance would be accident-related, related to occupational disease and work accidents, guaranteeing the right to job stability for up to one year after the end of the period of receiving the assistance.

In this second case, if there is fault or intent on the part of the employer, the worker also has the right to compensation.

Furthermore, the benefit lasts for a certain period, but what to do when the disability remains?

In this scenario, it is necessary to request a new report from your doctor that proves the incapacity.

Soon after, the request for extension must be done by calling 135 or even online, through My INSS.

It is essential that this request is made within the last 15 days of the absence.

If you do not meet this deadline, you will need to request the benefit again.

Finally, will you can combine the aid with other benefits?

In general, there are two ways to obtain assistance, along with other insurance: if you receive accident assistance or a survivor's pension.

Therefore, we recommend visiting this link for further details about the insurance.

What is the amount for sickness benefit?

As of 11/13/2019, all salaries are now considered when calculating the value of your insurance.

This way, we can include salaries from the beginning of your career.

Therefore, you know the amount you will receive when calculating the simple arithmetic average of 100% of the contribution salaries from July 1994 until the day you were removed from your work activity.

After finding the average, it is necessary to apply the 91% coefficient, and the result cannot be greater than the average of the last 12 contribution salaries.

What do you need to apply for sickness benefit?

To apply, it is important that you have the following on hand: documents:

Official identification document with photo, work card or contribution cards, CPF number and worker identification number (PIS/PASEP).

You will also need to have a medical report on hand that proves the illness, as well as the treatment indicated for your case.

This report must also contain the time away from work and a justification for the incapacity.

Finally, the report must include your identification, date, signature, ICD (International Classification of Diseases), stamp and CRM of the doctor, in addition to being signed by the company and indicating the last day you performed your work activities.

In addition to the documents, please note that you must meet the following requirements in order to apply:

Insured status

The first requirement to obtain the sickness benefit would be the insured status.

This quality indicates that you have the right to receive a benefit from the INSS, and to have it you must register with the INSS (RGPS).

By the way, it is important to pay INSS.

Therefore, the quality of insured is guaranteed in two cases: when the contribution responsibility is not yours and when it is your responsibility.

In the first place, it is not your responsibility to contribute for the INSS when you are a taxpayer who provides services to a certain company.

Thus, we can include the following professionals: domestic employee, employer, special insured or a casual worker.

In all the cases above, the contribution is made automatically, with the amount being deducted from your payment each month.

In the second case, which reflects the individual who he has responsibility to contribute, know that it includes the self-employed professional.

That is, the value of your contribution cannot be automatically discounted.

Therefore, it is important to prove payment so that the insured status is recognized.

Shortage 

Secondly, the waiting period represents the minimum time that you must contribute to the INSS in order to be entitled to the benefit. sickness benefit or any other insurance.

To make it easier to understand, we can compare it to the lack of health plans:

Basically, this waiting period corresponds to the time you must wait to have the opportunity to activate coverage for certain services and assistance.

These services are generally the most expensive.

Returning to the INSS-related need, it is essential that you contribute for at least 12 months to be entitled to this benefit.

Inability to work

Finally, it is important to prove the mental or physical impossibility of carrying out your professional activity.

Inability may also be related to physiological or pathological factors, illnesses or accidents that compromise the ability to work, and may manifest with varying intensity.

It is worth noting that the severity of the inability to perform your work is something analyzed by a medical expert.

Therefore, the professional must inform in the report the type of benefit that should be granted to the insured.

But, what do you mean by the type of benefit?

Well, people who are completely unable to carry out their work activity, but have an expectation of recovery, can request the sickness benefit.

Otherwise, people who are completely unable to work and who will not be able to recover are not eligible for this insurance.

As a result, they are targeted for disability retirement benefits.  

How does the sickness benefit process work?

You must schedule an appointment with the INSS so that the medical examination can be carried out.

Therefore, call 135, where calls are free for those using a landline or public telephone.

Additionally, the assessment can be scheduled digitally through Meu INSS.

After that, simply print the request receipt and if you have already been dismissed, the company manager must sign and stamp it, as well as confirm the date of your last day of work.

It is worth highlighting the following:

If you are unable to attend on the scheduled day, it is necessary to reschedule up to 3 days in advance of the scheduled date.

Rescheduling can also be done by calling the center or accessing Meu INSS, but it can only be done once.

By the way, if you are trying to request the sickness benefit for a patient who is hospitalized or bedridden at home, rescheduling can be done up to 7 days before the scheduled date.

In these cases, it is possible to receive care without visiting the INSS agency, through hospital or home examination.

However, for this type of special care, the patient's doctor must sign a document proving that he or she is unable to go to an agency.

Therefore, the representative takes the request to an agency, also including information about the patient's location, such as address and telephone number.

When should the appointment be made?

If you are a registered worker, you must apply 15 days after being away from work due to illness.

In this sense, the first 15 days of absence must be paid by the company.

Other INSS policyholders, such as optional workers, MEIs and individual contributors, must request insurance at the beginning of their incapacity to work.

It is very important that you pay attention to the deadlines, considering that retroactive payments will not be made if the request is made after 30 days of absence.

AND if there is no date available to schedule the INSS medical examination in 15 days?

Well, all you need to do is request an appointment for the earliest possible date and keep the receipt that proves the day you contacted us to make the request.

In this case, you have the right to request retroactive amounts.

Finally, when you receive the result of your request from the sickness benefit?

Generally, after the assessment, the result is released on the same day at 9 pm. Simply call the center to consult or access the Social Security Portal.

What illnesses give rise to the right to the benefit?

Remember how we mentioned above the requirements to apply for assistance and the need to prove need, that is, contribution for 12 months?

In some cases, it is not necessary to make a contribution, such as when the person has an occupational disease or has suffered an accident of any nature.

Insured persons who, after registering for social security, are affected by any of the following illnesses, are also exempt from the need to contribute:

• Parkinson's disease; 
• Ankylosing spondyloarthrosis; 
• Severe nephropathy; 
• Severe liver disease.
• Active tuberculosis; 
• Hansen's disease; 
• Mental alienation; 
• Advanced stage of Paget's disease (osteitis deformans); 
• Malignant neoplasm; 
• Blindness; 
• Irreversible and disabling paralysis; 
• Severe heart disease; 
• Acquired Immunodeficiency Syndrome — AIDS; 
• Radiation contamination based on the conclusion of specialized medicine.

However, please be aware that a person with one of the above illnesses does not have immediate entitlement to the benefit.

It is essential to meet the other requirements, in addition to undergoing a medical examination to prove incapacity.

Conclusion

Finally, we decided to highlight what you should do if your sickness benefit claim is denied:

There are usually two alternatives, the first being appeal administratively.

An appeal may be filed if the INSS denies that you are insured, for example, if you have stopped contributing for more than 12 months.

However, it is not valid to appeal administratively when the medical examination indicates that you are not unable to perform your work activities.

This is done only through a legal action.

In this sense, look for a lawyer you trust to come and review all your documents and let you know if there is any chance of filing a lawsuit and winning.

As a result, the medical expert will not be from the INSS, but rather one appointed by the judge himself, thus enabling the receipt of the benefit.