Disability

• According to the guidelines of the G-BA (Joint Federal Committee), incapacity to work (AU) exists if the insured person is unable to carry out his or her last job due to illness, or only at the risk of aggravating it.
• An accidental death is deemed to exist if, due to a certain state of illness which in itself does not cause an accidental death, it is foreseeable that the exercise of the activity will have detrimental consequences for recovery which directly cause the accident. However, it is not considered whether the insured person is still able to perform any other activity (e.g. referral professions, porter).
• AU also exists if the employee is in hospital or for medical rehabilitation.
• Since it depends on the specific activity to be performed and its impairment by the illness, not every illness necessarily leads to an AU (example: the fracture of a finger leads to the incapacity to work of a typist, but not of a senior commercial employee; he is only incapable of work for the duration of the actual medical treatment).
• It is up to the doctor in charge to determine the AU and its probable duration. With regard to the review of the AU, § 275 SGB V also contains the following provisions:
• If there are doubts about the inability to work, the health insurance funds are obliged to obtain an expert opinion from the Medical Service of the Health Insurance Fund (MDK).
• Doubts exist if the insured person is conspicuously frequently or conspicuously only for a short period of time incapable of work, or if the onset of the incapacity for work frequently falls on a working day at the beginning or end of a week, or if the incapacity for work has been determined by a doctor who has become conspicuous by the frequency of the certificates of incapacity for work issued by him.
• At the employer's request, the health insurance company is also obliged to obtain an expert opinion from the MDK to verify the incapacity to work (the MDK's assessment is usually carried out on this occasion within 3 working days). However, the health insurance company may refrain from commissioning the MDK if the medical conditions of the incapacity for work are clearly evident from the medical documents available to it.
• If AU is present for SHI-insured persons, this must be proven to the employer and the health insurance company by a medically certified certificate of incapacity to work. The existence of incapacity for work is a prerequisite for a number of claims to social benefits, as far as SHI members are concerned.

Remember! The issuing of an AU is a responsible task. The physician is threatened with claims for damages from employers and health insurance companies if the accident report is issued improperly.