YOUR MUTUAL OFFERS YOU A SUMMARY OF ROYAL DECREE 625-2014. MANAGEMENT AND CONTROL OF IT PROCESSES

22/09/2014

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Fraternidad-Muprespa

In our desire to keep you informed, below we offer you a summary prepared by our Advisory and Legal Services Center on the Royal Decree 625/2014, of July 18, which regulates certain aspects of the management and control of the processes for temporary disability in the first three hundred and sixty-five days of its duration (BOE 07-21-2014), which we hope will be of interest to you.

This standard has entered effective on September 1, 2014.
As of September 1, 2014, it replaces R/D 575/1997 of April 28.

1. Scope of application.

The provisions of this rule will apply, during the first 365 days, to temporary disability (IT) processes, whatever the contingency and are included in any of the regimes that make up the Social Security system.

2. Medical declarations of sick leave and confirmation of sick leave in temporary disability processes.

The issuance of the medical leave report is the act that causes the initiation of the actions leading to the recognition of the right to the IT subsidy.

In the event that the cause of the medical leave is a work accident or occupational disease and the worker provides services in an associated company, for the management of the benefit for such contingencies, at a mutual, or it is a worker for self-employed member of a mutual For the management of the financial benefit for IT derived from the same contingencies, the corresponding reports of withdrawal, confirmation of withdrawal or discharge will be issued by the medical services of the company itself.mutual.

In order for medical actions to have the greatest technical support, the doctors who are responsible for said actions will be made available.optimal duration tables typified by the different pathological processes likely to generate disabilities, as well as tables on the degree of incidence of those processes in the different work activities.In other words, the Optimal Duration Tables will detail the optimal duration of the pathological processes and the degree of impact on work activity and based on these aspects, the doctor will issue a sick leave or confirmation report with an estimated date.

For these purposes, four groups of withdrawal processes are established depending on their duration:

Estimated duration less than 5 calendar days, the physician of the public health service, or of the mutual, will issue the discharge report and the discharge report in the same medical act.

The physician, depending on when he foresees that the worker will recover his working capacity, will record in the report the date of discharge, which may be the same as the date of discharge or any of the three calendar days following this.
Estimated duration between 5 and 30 calendar days, the physician of the public health service, or of the mutual, will issue the sick leave report stating in it the date of the planned medical review that,In no case will it exceed more than 7 calendar days to the date of initial discharge. On the review date, the discharge report will be issued or, if the disability remains, the confirmation of discharge report. After this first confirmation report, the subsequent ones, when necessary,They cannot be issued with a difference of more than 14 calendar days.
Estimated duration of between 31 and 60 calendar days, the physician of the public health service, or of the mutual, will issue the sick leave report stating in it the date of the planned medical review that,In no case will it exceed more than 7 calendar days to the date of initial cancellation, then issuing the registration report or, where applicable, the corresponding confirmation of cancellation. After this first confirmation report, the subsequent ones, when necessary,They cannot be issued with a difference of more than 28 calendar days.
Estimated duration of 61 or more calendar days, the physician of the public health service, or of the mutual, will issue the sick leave report in which it will set the date of the planned medical review, which in no case will it exceed more than 14 calendar days to the date of initial cancellation, then issuing the registration report or, where applicable, the corresponding confirmation of cancellation. After this first confirmation report, the subsequent ones, when necessary,They cannot be issued with a difference of more than 35 calendar days.

Whenever a modification or update of the diagnosis occurs, a confirmation report will be issued that will include the duration estimated by the issuing doctor. The following confirmation parts will be issued based on the new estimated duration.

3. Medical discharge statements.

In any case, the physician of the public health service, or of the mutual, will issue the discharge report when it considers that the worker has recovered his or her working capacity.

When the medical discharge is issued by a medical inspector, during the following 180 calendar days, only the entities of the system may issue a new discharge for the same or similar pathology.
In IT processes derived from professional contingencies (CP), in workers protected by the Mutual Insurance Companies, they will be empowered to issue the medical discharge of Mutual Insurance physicians.
Medical discharge determines the obligation for the worker to return to work on the same day that the effects of discharge occur.
The 24-hour period that the worker has to present the registration report to the company is maintained. If the employment relationship with the company has been terminated, the registration report must be submitted directly to the Managing or Mutual entity.
The obligation of the company to transmit the registration reports through the RED System is transferred to this new wording, within a period of no more than 3 business days from its receipt. Failure to comply with this obligation is an infraction classified in the Law of Infractions and Sanctions in the Social Order and that may lead to the suspension of the company's mandatory collaboration in the delegated payment of the IT provision.
A new obligation is established for the Mutual Fund to notify the company of the termination of the right, its cause and the effective date thereof.

4. Monitoring and control of financial benefits and temporary disability situations.

The INSS, the ISM, if applicable, and The mutual insurance companies, through their medical and non-health personnel, will exercise control and monitoring of the provision. economic of the IT subject to management, being able to carry out for this purpose those activities that aim to verify the maintenance of the facts and the situation that gave rise to the right to the subsidy,from the moment the sick leave medical report is issued.

5. Complementary and control reports.

The obligation to periodically complete complementary medical reports continues to be maintained. This obligation concerns only the SPS doctors and in relation to the processes whose management is the responsibility of the SPS.

These reports will be accessible to the medical inspectors of the INSS and ISM and to the physicians of the Mutual regarding the processes of workers protected with them.

6. Proposals for medical discharge formulated by mutual insurance companies in processes derived from common contingencies.

In temporary disability processes derived from common contingencies whose coverage corresponds to a mutual, when it, in view of the medical reports of sick leave or confirmation of sick leave, of the complementary reports or of the control and monitoring actions carried out, considers that the worker may not be prevented from working, it may formulate, through the doctors assigned to it, motivated proposals for medical discharge., which will be accompanied by the reports and tests that, if applicable, have been carried out. The mutual insurance companies will simultaneously inform the affected worker, for their knowledge, that the registration proposal has been sent.
The mutual insurance registration proposals They will be directed to the medical inspection units of the public health service, who will immediately forward them to the physicians or medical services to whom the issuance of the medical reports of the process corresponds. These doctors must make a statement either confirming the medical discharge or admitting the proposal, through the issuance of the corresponding medical discharge report. In the event that the withdrawal is confirmed, the diagnosis, the medical treatment provided, the causes that justify the discrepancy will be recorded and the medical attention and checks that are considered necessary will be indicated. The medical inspection will transfer to the mutual this report together with the action carried out within a maximum period of 5 days from receipt of the registration proposal. In the event that the medical inspection of the corresponding public health service does not receive a response from the doctors or medical services, or if it disagrees with it, it may agree to effective and immediate medical discharge. In any case, the inspection will inform the mutual, within the period of 5 days following the date of receipt of the discharge proposal, the action carried out together with the reports that the physician had sent.
When the discharge proposal made by a mutual was not resolved and notified within the period of 5 days established in the previous section, the mutual may request registration from the INSS or, where appropriate, from the ISM, in accordance with the powers provided for in the fifty-second additional provision of the General Social Security Law. The managing entity will resolve within 4 days of receipt. The INSS and, where appropriate, the ISM, will monitor the behavior of the new IT process management and control procedure.

7. Rules relating to the determination of the contingency causing temporary disability.

The public health service, the ISM or the mutual, who have issued the sick leave report, may request, with reasons, before the INSS the review of the initial consideration of the contingency.
The mutual doctor who assists the worker may initially, after a mandatory medical examination and carrying out, where appropriate, the corresponding tests, consider that the causing pathology is of a common nature and refer the worker to the public health service for treatment., without prejudice to providing the necessary assistance in cases of emergency or life-threatening risk. For this purpose, it will provide the worker with a medical report describing the pathology and indicating its diagnosis, the treatment provided and the reasons that justify determining the causative contingency as common, which will be accompanied by reports relating to the tests that, if applicable, have been performed.

Yes, in view of the report of the mutual, the worker goes to the public health service and the latter's doctor issues a sick leave report for a common contingency, the beneficiary may make a claim in relation to the consideration given to the contingency before the INSS.

For his part, the physician who issues the sick leave report may express his disagreement regarding the consideration of the contingency granted by the mutual, in the established terms. The resolution issued will establish the common or professional nature of the causing contingency and the subject obliged to pay the benefits derived from it and to provide health care, if applicable.

8. Processing of medical reports and issuance of medical discharges by the National Institute of Social Security or, where appropriate, the Social Institute of the Navy.

The doctor who issue medical certificates for discharge, confirmation and discharge will give the worker two copies of it, one for the interested party and another for the company.

Within a period of 3 days from the day of the issuance of the medical certificates of sick leave and confirmation of the sick leave, the worker will deliver the copy intended for him or her to the company. However, if during the period of medical leave the termination of employment contract, the worker will be obliged to present to the managing entity or the mutual, as appropriate, within the same period of 3 days set for the company, copies of the confirmation of cancellation.

Within 24 hours following its issuance, the medical discharge report destined for the company will be delivered by the worker to the company or, in the indicated cases of termination of the contract, to the managing entity or mutual.

The public health service or, where applicable, the mutual, they will send the medical reports of discharge, confirmation and discharge, to the INSS, electronically, immediately, and, in any case, on the first business day following its issuance.
Companies have the obligation to send to the INSS, immediately and, in any case, within a maximum period of 3 business days from the receipt of the report presented by the worker, through the Electronic Data Submission (RED) system,medical discharge reports, confirmation of discharge and discharge that the workers present to them, completed with the data that corresponds to the company.

Failure to comply with the aforementioned obligation may constitute, where appropriate, an infraction of those classified in the Law on Infractions and Sanctions in the Social Order (RDL 5/2000).
The INSS will process the medical reports intended for itself and, in turn, also through the established computer media and will distribute and forward immediately, and, in any case, on the first business day following receipt, the reports intended for the ISM and the mutual, depending on the entity to whom management of the process corresponds.
Failure to send the medical reports to the INSS may result in the Ministry of Employment and Social Security, at the proposal of the managing entity or the mutual, leave in mandatory company collaboration suspended in the delegated payment of economic benefits for temporary disability.

The agreed suspension will be transferred to the General Treasury of Social Security, as well as to the managing entity or mutual.
When the discharge medical report is issued by the medical inspector assigned to the INSS or, where applicable, the ISM, they will immediately transfer a copy of the report to the corresponding public health service for their information and, in any case, on the first business day following that of said issuance, and another copy to the mutual, in the case of workers protected by it, with the purpose that this issue an agreement declaring the right extinguished due to discharge, its reasons and effects, and notify the agreement to the company. Likewise, the medical inspector will deliver two copies to the worker, one for his or her information and the other for the company, expressing the obligation to return to work the day following the day of issue.
When in an IT process the medical discharge report has been issued by the INSS or, where applicable, by the ISM, through the medical inspectors assigned to said entities,during the following 180 calendar days On the date on which the discharge was issued, these entities will be the only ones competent, through their own doctors, to issue a new medical discharge for the same or similar pathology.

9. Requirements for workers for medical examination.

The INSS or, where appropriate, the ISM,may provide that workers who are in an IT situation be recognized by medical inspectors of said managing entities.The same power will correspond to the mutual companies, with respect to the beneficiaries of the economic benefit for IT derived from common contingencies included in their scope of management, so that they are recognized by the doctors dependent on them.
The summons for a medical examination referred to in this article must be communicated to the worker with a minimum notice of 4 business days.

In said summons you will be informed that if you do not attend the recognition, the financial benefit will be provisionally suspended., and that if the lack of appearance is not justified within a period of 10 business days following the date set for recognition, the right to the subsidy will be terminated.

If the worker justifies, before the date set for the medical examination or on that same day, the reasons that prevent him from appearing there, the managing entity or mutual, may set a later date for its completion, notifying the interested party with the minimum advance notice already indicated.
When the worker who would have been summoned to a medical examination by a mutual insurance company, do not attend it on the set date, it will agree to the precautionary suspension of the subsidy from the day following the day set for recognition, which will be immediately communicated to the interested party, indicating that they have a period of 10 business days from the date on which the non-appearance occurred, to justify it.

The managing entity or mutual will communicate the agreed suspension electronically to the company and the General Treasury of Social Security.
If the worker justifies his non-appearance Within 10 business days following the date on which you were summoned for a medical examination, the provincial director of the INSS or the ISM will issue a new resolution, or the mutual new agreement, revoking the precautionary suspension, and will proceed to reinstate the payment of the benefit with effect from the date on which it was suspended. In these cases the managing entity or mutual, within a period of 15 days following the date on which the resolution or agreement is issued, will directly pay the worker the subsidy corresponding to the suspension period. Likewise, it will inform the company and the General Treasury of Social Security of the resolution or agreement by which the suspension is void, informing of the date from which the delegated payment must be replaced by the company.
After 10 business days from the date on which he was summoned for a medical examination by the mutual corresponding,without the worker having provided sufficient justification for his non-appearance, the mutual will agree to the termination of the right to economic benefit with effect from the day on which the suspension would have been effective. Said agreement will be notified to the interested party. The mutual will communicate the agreed termination, electronically, to the public health service, the company and the General Treasury of Social Security.

10. Other obligations.

The obligation to preserve administrative files is established for 5 years, rules are also established on claims for actions of the Mutuals and also modification of deadlines in the processes of high, thus the interested party may request the medical discharge disagreement within 10 business days following your notification, in which you will state the reasons.

PRESENTATION OF ROYAL DECREE 625-2014. MANAGEMENT AND CONTROL OF IT PROCESSES