Short Term Insurance Branches
Regarding work accident and occupational disease, sickness and maternity insurance branches, treatment benefits are provided under Universal Health Insurance while cash benefits fall within the Short Term Insurances.
The provisions relating to short term insurance branches shall not apply to the insurance holders who are civil servants during the period when they remain in this status.
1. Work Accident and Occupational Disease Insurance
Work accident is the incident which occurs;
- when the insurance holder is at workplace,
- due to the work carried out by the employer or by the insurance holder if he/she is working on behalf of own name and account,
- for an insurance holder working under an employer, at times when he/she is not carrying out his/her main work due to the reason that he/she is posted to another place out of the workplace,
- at times allocated for breastfeeding as per labor legislation,
- during insurance holder’s shuttling between the workplace and home by a vehicle provided by the employer and which causes, at short notice or later, physical or mental handicap in the insurance holder.
It is obligatory that work accident shall be reported,
- by employers, for the insurance holders subject to service contract, to local law enforcement agencies immediately and to the Institution no later than 3 workdays after accident occurs,
- by the insurance holders who are self-employed, to the Institution directly or through certified mail with work accident and occupational disease notification within 3 workdays after their health status are good enough to report, provided that this recovery period does not exceed one month.
Occupational disease refers to the temporary or permanent disease, physical or mental handicapped status, caused by a reason reiterated due to the quality of the work carried out by the insurance holder or by working conditions.
a) Temporary Incapacity Allowance
Based on the rest report granted by medical doctor or health committees authorized by the Institution, temporary incapacity allowance shall be paid;
- each day to the insurance holders suffering from temporary incapacity due to work accident or occupational disease,
- each day, starting from the third day of the temporary incapacity, to the insurance holders working on service contract and those subject to sickness insurance, in case they suffer from temporary incapacity due to sickness and provided that minimum 90 days of short term insurance premium is notified within one year before the starting date of the temporary incapacity,
- during the period of inpatient treatment or the period of rest report granted due to such treatment, to the insurance holders working on his/her own name and account, in cases of work accident or occupational disease or maternity and provided that any kind of premiums or debts related with premiums including universal health insurance are paid.
Temporary incapacity allowance to be paid in cases of work accident, sickness and maternity shall be half of daily earning for inpatient treatments and two thirds of the same for outpatient treatments. Where an insurance holder suffers from more than one of the cases of work accident, occupational disease, sickness and maternity, temporary incapacity benefit shall be payable at the highest level.
b) Permanent Incapacity Income
The insurance holders whose earning power in the profession is determined to be reduced by 10% due to the disease or disabilities caused by work accident or occupational disease shall be entitled to receive permanent incapacity income.
Permanent incapacity income shall be calculated based on the loss rate of earning power in profession of the insurance holder. In case of permanent full incapacity, the insurance holder is put on an income amounting to 70% of the monthly earning. Income to be granted to the insurance holder in case of permanent partial incapacity shall be calculated as full incapacity income and of the amount corresponding to the degree of incapacity shall be payable. Where the insurance holder is in need of permanent care of another person, income replacement rate shall be calculated as 100%.
c) Survivors’ Income
The right holders of the insurance holder, who passed away due to work accident, occupational disease or similar reasons, shall be put on survivors’ income at a rate of 70% of the monthly earning.
It is obligatory that the entire premium or any kind of debts related premiums, including the universal health insurance, should be paid so that the right holders of insurance holder, working on their own name and account, receive income.
Where the insurance holders passed away due to work accident or occupational disease, funeral and marriage allowance shall also be paid to his/her right holders.
d) Marriage Allowance
Marriage allowance shall be payable in advance, for once, at the amount of two years of pension or income they receive, upon marriage and request of the daughters, whose income or pensions should be terminated due to marriage.
In case a right holder who receives marriage allowance becomes right holder for the second time within two years following the termination date of the pension, no income or pension shall be payable until the end of two – year period; however such individuals shall be deemed to be universal health insurance holders.
e) Funeral Allowance
Funeral allowance shall be payable to the right holders of the insurance holder who deceased when receiving incapacity income due to work accident or occupational disease or permanent incapacity income, invalidity, duty disability or old – age pension and when his/her minimum 360 days of invalidity, old – age and survivors insurance premiums are notified for himself/herself.
2. Sickness Insurance
Sickness refers to discomfort causing the incapacity of the insurance holders, who work on service contract and on their own name and account, due to the reasons other than work accident or occupational disease.
a) Temporary Incapacity Allowance
Based on the rest report, in case the insurance holders working on service contract and those subject to sickness insurance suffer from temporary incapacity due to sickness, temporary incapacity allowance shall be paid to them for each day, starting from the third day of the temporary incapacity, and provided that minimum 90 days of short term insurance premium is notified within one year before the starting date of the temporary incapacity.
3. Maternity Insurance
Sickness and invalidity statuses of
- a female insurance holder or uninsured spouse of a male insurance holder working on service contract and on their own name and account,
- a female who receives income or pension due to her own works or uninsured spouse of a male insurance holder who receives income or pension, caused by the pregnancy or maternity status, starting from the date of pregnancy up to the first eight weeks or, in case of multi delivery, up to the first ten weeks following delivery, shall be considered as maternity status.
a) Temporary Incapacity Allowance in Maternity Status
In case the insured women working on service contract and those working on their own names and accounts (except partners of company) do not work actually and receive rest report during maternity period, temporary incapacity allowance shall be payable -provided that minimum 90 days of short term insurance premium is notified within one year before the birth-
- for eight – week periods before and after birth,
- for each day of not working calculated by, adding another two weeks to the said eight weeks before the birth in cases of multiple birth,
- for each day added to the rest period after birth in case she works until three weeks before birth upon her request and approval of medical doctor.
b) Breastfeeding Benefit
Breastfeeding benefit shall be payable for each newborn -provided that the newborn lives-
- to the women who are maternity insurance holders or to the male insurance holders of uninsured spouse giving birth,
- to the female insurance holders receiving income or pension due to their works on service contract and on their own names and accounts or to the uninsured spouse of the male insurance holders receiving income or pension due to their works.
In order to pay breastfeeding benefit to female insurance holder or to male insurance holder of uninsured spouse giving birth, it is obligatory
- for the insurance holders working on service contract to notify minimum 120 days short term insurance branches premium within one year before birth,
- for the insurance holders working on their own names and accounts to deposit minimum 120 days short term insurance branches premium and to pay any kind of premiums or debts related with premiums including universal health insurance.
In case female insurance holders, who are granted the right to receive breastfeeding benefit but whose insurance status is terminated, give birth to a children within 300 days starting from the termination date, these women or their spouses shall receive breastfeeding benefit provided that minimum 120 days premium is paid within fifteen months before the date of birth.
Source: Social Security Institution (SGK)
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