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💴 | What is the case when you get infected with corona and get the injury and illness allowance?


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What is the case of being infected with a corona and being paid an injury and illness allowance?

 
If you write the contents roughly
Even if you are infected with a corona and are diagnosed as "positive", or if you are forced to take medical treatment due to symptoms of corona infection such as fever or fatigue, you can still receive the injury and illness allowance.
 

What is the injury and illness allowance? In the first place, the injury and illness allowance guarantees the life of the person and his / her family if he / she cannot work due to illness or injury. → Continue reading

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Injury and sickness allowance

Injury and sickness allowanceWhat is (Shobyo Te Akin)?Health insurance lawPublicly based onmedical insurance(Health insurance-National Health Insurance-Seafarers insurance・ VariousMutual aid associationEtc.) When the insured cannot get a job due to illness or injuryLife security during medical treatmentAs an insurer (National Health Insurance Association-Health insurance associationIt is a benefit (monetary benefit) provided from (etc.).Employment insurance injury and illness allowanceAlthough the name is very similar to, it is a completely different system.Unless otherwise stated, the health insurance system will be described below.

In health insurance and seafarer insurance, the injury and illness allowance is an absolutely necessary benefit (the insurer must pay it when the requirements are met), but the National Health InsuranceMedical system for elder senior citizensThen voluntary benefits (Ordinance or TermsIt can be done according to the provisions of.

  • Regarding the Health Insurance Law, only the number of articles is described below.

Benefit requirements

Article 99 (Injury and illness allowance)

  1. If the insured (excluding voluntary continuous insured persons; the same shall apply in Article XNUMX, paragraph XNUMX) cannot be subjected to labor due to medical treatment, the calculation starts from the day when the insured cannot be subjected to the labor. After three days have passed, the injury and illness allowance will be paid for the period during which labor cannot be submitted.
  2. The amount of injury and illness allowance is determined by the standard monthly salary for each month of the most recent XNUMX months prior to the month to which the payment of injury and illness allowance begins (determined by the insured to which the insured currently belongs, etc.) The amount equivalent to one-third of the average amount (the same shall apply hereinafter in this section) (if the amount has a fraction less than XNUMX yen, round it down to XNUMX yen or more) If there is a fraction less than a yen, it shall be rounded up to XNUMX yen.) An amount equivalent to two-thirds (if the amount has a fraction less than fifty yen, round it down to five). If there is a fraction of XNUMX yen or more and less than XNUMX yen, this shall be rounded up to XNUMX yen.)However, if the month for which the standard monthly salary is set is less than December in the most recent continuous period before the month to which the same day belongs, the lesser of the amounts listed in the following items An amount equivalent to two-thirds (if the amount has a fraction of less than fifty yen, it will be rounded down, and if there is a fraction of fifty yen or more and less than one yen, it will be rounded up to one yen. To do.)
    1. An amount equivalent to one-third of the average monthly standard salary for each of the most recent consecutive months prior to the month to which the injury and illness allowance begins to be paid (when the amount has a fraction of less than XNUMX yen) Truncate this, and if there is a fraction of XNUMX yen or more and less than XNUMX yen, it shall be rounded up to XNUMX yen.)
    2. When the average amount of the standard monthly remuneration for all insured persons on September XNUMX of the year preceding the year to which the injury and illness allowance starts to be paid is regarded as the basic monthly remuneration for the standard remuneration. Amount equivalent to one-third of the standard monthly remuneration (if the amount has a fraction of less than XNUMX yen, it is rounded down, and if there is a fraction of XNUMX yen or more and less than XNUMX yen, this is reduced to XNUMX yen. It shall be rounded up.)
  3. In addition to what is provided for in the preceding paragraph, necessary matters concerning the calculation of the amount of injury and illness allowance shall be specified by the Ordinance of the Ministry of Health, Labor and Welfare.
  4. The period of payment of the injury and illness allowance shall not exceed one year and June from the day when the payment is started for the same illness or injury and the illness caused by it.

It is paid to the insured who meets all of the following requirements (Article 99, Paragraph 1).

  1. Injury or illness due to reasons other than work.
    • For illnesses and injuries caused by work or commutingWorkers' compensation insurance(Workers' accident compensation insurance) is applied, and health insurance cannot be applied at all, including injury and illness allowances (health insurance covers injuries and illnesses outside of work).
    • 被保険者が5人未満である小規模な適用事業所に所属する法人の代表者であって一般の労働者と著しく異ならないような労務に従事している者については業務上の事由による疾病等であっても健康保険による保険給付の対象とされる(第53条の2)。従来、当面の暫定措置とされていて(平成15å¹´7月1日保発0701002号)、さらに傷病手当金は本措置の対象外であるため支給しないとされてきたが、平成25年の法改正により第53条の2が追加され前述の通知が廃止されたことで、このような場合でも傷病手当金が支給されることとなった。
  2. Being in medical treatment.
    • As long as the medical treatment is within the range that can be covered by health insurance, it does not have to be the medical treatment that was actually received as an insurance benefit, and it is also provided for medical treatment at your own expense or for rest at home (February 2). No. 2 issued on March 26, No. 345 issued on September 3, 9).however,Special day insured personIn the case of, you must receive medical treatment benefits, etc. for the injury or illness that caused the incapacity to work (Article 135, Paragraph 1).
  3. Not being able to submit to labor
    • Insured(Excluding voluntary continuous insured persons and special retirement insured persons) Refers to being unable to engage in work due to illness or injury.Not necessarily based on medical standards, consider the type of work that the insured person is engaged in, and certify based on social conventions as a standard whether or not the insured can withstand the original work (January 31, 1, issued by Hobun). No. 19).In other words, even if the insured is not in an incapacitated physical condition, it is sufficient that the insured cannot work in the labor that the insured is engaged in.Specifically, it will be paid in the following cases.
      1. Even if you engage in a side job of housework while you are on leave, if the condition of your injury or illness is such that you cannot work at the place of business you work for (December 3, 12, Honor No. 27).
      2. Even if the injury or illness does not require a leave of absence, the insured's address isClinicWhen it is farther away and you cannot actually submit to labor due to going to the hospital (May 2, 5, Hosei No. 10).
      3. Even if it is safe to take labor now, if the symptom requires a leave of absence for medical treatment (February 8, 2, Honor No. 18).
      4. When the pathogen holder is quarantined and unable to work (October 29, 10, Insurance No. 25).In the past, it was treated as "Unless the onset of illness is recognized, it does not belong to the scope of illness that is an insurance accident, so the injury and illness allowance will not be paid" (Showa 261 Honor No. 11). Regarding the application, as a general rule, if it is recognized that medical treatment is particularly necessary for the eradication of pathogens, it is understood that possession of a pathogen of an infectious disease is an insurance accident regardless of the presence or absence of subjective symptoms.
      5. Wages are paid by engaging in labor such as side jobs or internal jobs that do not have an alternative character to the labor in the original workplace, or by temporarily submitting to other minor labor until the injury and illness allowance is paid. If you can get it (February 15, 2, Hoho No. 25).Rather than immediately certifying that the employee is not incapacitated because he / she has received the remuneration, he / she will make a judgment as to whether or not he / she is incapacitated after carefully considering the amount of the remuneration in relation to the content of the labor.
    • On the other hand, payment is not permitted in the following cases.
      1. DoctorIf you go to work for half a day and submit to your previous work under the instructions or permission of (January 32, 1, Hobun No. 19)
      2. Working hoursIf you are subject to slightly lighter labor in the same office due to relocation without shortening (December 29, 12, Hobun No. 9)
      3. Industrial Safety and Health ActFor carriers who may be contagious according to the regulations ofBusiness ownerOrdered to take a leave of absence, and the symptoms do not indicate that it is impossible to work (February 25, 2, Hobun No. 15)
      4. When the insured has performed surgery at his / her own expense for illnesses (cosmetic surgery, etc.) that he / she has decided not to receive medical treatment, and as a result, he / she is unable to work (June 4, 6, Insurance No. 29).
      5. When he was injured and became abandoned, and he no longer needed medical treatment due to the injury (October 3, 10, Hosei No. 11).Even if it is impossible to work, it is not impossible to work for medical treatment, so it will not be paid.
  4. When the holiday period exceeds 3 days.
    • First 3 consecutive days TheWaiting periodNo injury or illness allowance will be paid.For example, in the case of "holiday holiday", the waiting period is completed, but in the case of "holiday holiday", the waiting period is not completed (January 32, 1, No. 31-2).Public holidays and public holidays in these three days,Annual paid leaveThe acquisition date may be included, and even if the reward is received, the waiting period will be completed in 3 days (February 2, 2, Hosei No. 5, February 659, 26, Hobun). No. 2).
    • 待期は、就業時間中に労務不能となった場合はその日から、就業時間終了後に労務不能となったときはその翌日から起算する(昭和28å¹´1月9日保文発69号)。就業時間が午前0時をはさんで2日にわたる場合は、暦日によって判断し、労務不能となったその日から起算する(昭和4å¹´12月7日保規488号)。
    • The waiting period isIt is enough to complete the same injury and illness once..Therefore, after completing the waiting period and receiving the injury and illness allowance, it is not necessary to complete the waiting period again if the labor becomes impossible again for the same injury or illness (March 2, 3). Nihon Ritsu No. 11).
    • 連続3日間労務不能で第4日目に労務に服し、第5日目以後再び労務不能となったときは、療養のため労務に服することのできない状態が同一傷病につき3日間連続していれば、すでに待期は完成したものとして取り扱われる。 したがって、「休休休休出休」「休休休出休」の何れの場合でも待期はすでに完成しており、前者の場合は第4日目、後者の場合は第5日目から支給を行う(昭和32å¹´1月31日保発2号の2)。
    • No three-day waiting time requirement is required for seafarer insurance[Annotation 1]..Therefore, the injury and illness allowance will be paid from the first day of the leave.
  5. Special day insured personIn, the insurance premium payment requirements must be met.
    • In order for a day labor special insured person to receive the injury and illness allowance, it is the first time for the illness or injury.Medical treatment benefitsInsurance premiums for a total of 2 days or more in the two months preceding the month to which the recipient belongs or for a total of 26 days or more in the previous 6 months must be paid for the day labor special insured person ( Article 78, Paragraph 135).

Even if the injury or illness is before the acquisition of the insured qualification, the injury and illness allowance will be paid if the above requirements are met for medical treatment after the acquisition of the qualification (May 26, 5, Hobun No. 1).The insured will not be unable to receive the injury and illness allowance because the employer has not paid the insurance premium (March 1346, 25, Hobun No. 3).note thatDependentsNo injury or illness allowance will be paid to.

Payment amount / payment period

From the amount paid on April 2016, 28 (Heisei 4), per day, "before the month to which the day when the payment of injury and illness allowance starts belongs"Last last 12 monthsOf each monthStandard monthly feeIs equivalent to one-thirtieth of the average amount (rounded to the nearest 30 yen) and two-thirds of the average amount (rounded to the nearest yen).The amount does not change depending on the presence or absence of dependents.However, if the month for which the standard monthly salary is set is less than 1 months, one of the followingFewThe amount is equivalent to two-thirds of the amount (Article 3, Paragraph 2).

  • An amount equivalent to one-thirtieth of the average monthly standard salary for each of the most recent and continuous months prior to the month to which the injury and illness allowance begins to be paid.
  • Standard when the average monthly standard remuneration of all insured persons on September 9 of the year preceding the year in which the payment of injury and illness allowance begins is regarded as the basic monthly remuneration of the standard remuneration. Amount equivalent to 30/30 of the monthly remuneration[Annotation 2]

The standard monthly salary isOnly those specified by the insured to which the insured currently belongs,Career changeIf the insurer has changed due to such reasons, the standard monthly salary by the previous insurer will not be included in the calculation.If the insurer is transferred during the payment and the insurer newly enrolled for the same injury or illness receives the injury or illness allowance, the newly enrolled insurer will recalculate the amount of the injury or illness allowance.Once the amount of injury and illness allowance is determined by the same insurer for the same injury and illness, the amount is fixed at that amount, and even if the standard monthly salary is changed by a regular decision, etc., the amount of injury and illness allowance does not change.If the health insurance association to which the insured belongs has merged, split, or dissolved within the last 12 consecutive months, the standard monthly salary set before the event occurred will be calculated as an average. May be added to.

Health insurance association, this means a Additional benefitsAs (Article 53), the amount of payment may be added or the payment period may be extended as stipulated in the bylaws.

In the case of a day labor special insured person, the largest of the monthly total of the standard wage daily amount of the person on the day when the premium is paid during the premium payment period.One thousandth(Article 135, Paragraph 2).

The payment period for the same reason for injury or illness isStarting from the actual payment start date,totalIt is one year and six months (Article 1, Paragraph 6).In the past, if the employee took a leave of absence due to the same injury or illness after taking labor on the way, the payment period would not be extended (if one year and six months have passed since the payment start date, the number of payment days will be reduced. Even if it is less than 99 year and 4 months, the payment has ended), but due to the enforcement of the revised law in January 1, the number of payment days has been changed to 6 year and 1 months. ..Even if there is a transfer between insurers during the payment, it will be 6 year and 2022 months in total.Even when an insured person receiving an injury or illness allowance is detained in a prison, labor office or other similar facility (when the benefit is restricted), the period is within one year and six months. To be included (July 1, 1, No. 6, August 1, 6, No. 1).In the case of a day labor special insured person, the payment period is 6 months (tuberculosis1 year and 6 months for sexual illness (Article 135, Paragraph 3), and 3 years for seafarer insurance (Article XNUMX, Paragraph XNUMX)Seafarers insurance lawArticle 69, paragraph 3).Injury and illness allowances are also paid for public holidays at business establishments (February 2, 2, Hosho No. 5).If the insured person who receives the payment dies, the injury and illness allowance will be paid until the day of death.

"The day when payment starts" isThe day when you actually start paying the injury and illness allowancePoint to.Generally, take annual paid leave first (wageHowever, if the leave continues, you will start receiving the injury and illness allowance, so the "day when you start paying" is the day after you finish taking the annual paid leave (annual paid leave). If you do not acquire the paid leave, or if the number of days of paid leave is 100 days or less, it will be the day after the expiration of the waiting period).If the payment of the injury and illness allowance is suspended due to adjustment with the remuneration (described later), the day when the amount of the injury and illness allowance decreases due to the suspension of payment or the reduced payment is the "day to start payment" (the day when the payment starts). No. 2 from Hobun on March 25, 3, No. 14 from Hobun on January 571, 26).If the injury and illness allowance is not paid at the end of the waiting period, the average standard monthly salary will be recalculated on the "day when payment starts" to determine the amount of the injury and illness allowance.

If you are incapacitated due to another injury or illness while receiving the injury or illness allowance, you will be incapacitated due to the subsequent injury or illness from the 4th day from the day when you became incapacitated due to the later injury or illness. As the allowance is paid, the payment period will be extended until the subsequent injury and illness allowance is paid (June 26, 6, Hobun No. 9, July 1900, 26). Bunsho No. 7).However, in this case, the injury and illness allowance is not paid twice, but the larger of the previous and next injury and illness allowances is paid.

It should be noted that receiving the injury and illness allowance does not mean that the insured is exempt from the insurance premium burden.Since the injury and illness allowance itself does not fall under the “reward” under the Health Insurance Act, it is not permitted to deduct insurance premiums from the injury and illness allowance.

Requirements for continuous benefits

Even if you lose your insured status due to retirement, etc., if you continue to have the insured status for one year or more until the day before (the day of retirement) and meet the requirements for the injury and illness allowance. , You can continue to receive the injury and illness allowance (Article 1).The procedure for receiving the benefits is the same as when you were in office,No need for business owner certification(February 2, 2, No. 15).

In addition to the above benefit requirements, there are the following requirements.

  1. Until the day of retirementContinue for over a yearBeing insured (not including the period of voluntary continuation).
    In this case, the insured does not necessarily have to be the same insurer, and even if the qualification is obtained or lost, the insured qualification may be continuous without a gap of one day (Article 1 of the Supplementary Provisions).
    Unlike the requirements for becoming a voluntary continuous insured person, this case also includes disqualification due to cancellation of the voluntary applicable establishment.
    In the case of seafarer insurance, "continuing for one year or more" becomes "a person who was a compulsory insured person for three months or more in one year and one year or more in three years" (Article 1-1 of the Seafarers Insurance Law). Item).
  2. Those who have received or are in a condition to receive the injury and illness allowance at the time of disqualification (including the case where the payment is suspended due to coordination with the remuneration).
    If you retire on the 3rd day after starting your vacation, you will not be able to receive continuous benefits because the waiting period will be completed but you will not be in a state where you can receive payment (September 2, 9, Hosho No. 9, Showa 3289). January 32, 1, No. 31).
    If the full amount of the remuneration is paid and the injury and illness allowance is not paid until the retirement date, it is treated as "a state where it can be paid" and can receive continuous benefits (April 5, 4). Honor No. 24, January 270, 32, No. 1).
  3. During his tenureRetirement date, Not being able to engage in work due to illness or injury after retirement.
    If there is a fact of going to work on the day of retirement (if it is not recognized as incapable of working), you will not be able to receive the injury and illness allowance after retirement.Even if the purpose is to greet the workplace, organize personal belongings, or have an interview with a company official, if you go to work, you will not be able to receive benefits..
    "Incapacity to work" after retirement means the same level of inability to submit to the labor of the time when he was engaged in the workplace (April 2, 4, No. 27).
  4. The payment exclusion period (1 year and 6 months have passed on the calendar day) has not passed.
    The injury and illness allowance after the loss of qualification will be paid for the period until the end of the statutory payment period, including before and after the loss of qualification.In addition, unlike the insured period, you cannot receive it intermittently, so once the payment is discontinued, the payment will not be restored even during the period of 1 year and 6 months (Showa 26). May 5st, Hobun No. 1).In addition, if a part of the right is extinguished by prescription because the claim procedure is not performed, the remaining period for which the prescription has not been established will not be paid.

Injury and illness allowances are not paid to voluntary continuous insured persons in principle, but are paid to those who meet the above requirements if they become voluntary continuous insured persons.In addition, there are some health insurance associations that do not provide benefits unless they are voluntarily continuously insured by the same health insurance.Some unions require that post-retirement benefits do not come with additional benefits or that they are voluntarily insured.In addition, the special retirement insured person will not be paid the injury and illness allowance even if the above requirements are met (Article 3 of the Supplementary Provisions).In the case of seafarer insurance, the injury and illness allowance will be paid to those who were voluntarily insured for illness (corresponding to those who were voluntarily insured for health insurance) or those who were insured for voluntary illness. No injury or illness allowance will be paid for injuries or illnesses that occur more than one year after the date of acquisition of the insurer's qualification (Article 5, Paragraph 1 of the Seafarers' Insurance Law).

When a person who was insured by health insurance becomes insured by sailor insurance, he / she cannot receive continuous benefits of injury and illness allowance from health insurance because the benefits are provided by sailor insurance, and he / she chooses. There is no room for it (Article 107).

Co-payment adjustment / adjustment with other laws

  • Workers' accident compensation insurance or for the same illness or injuryPublic affairs disasterIf you can receive benefits equivalent to the injury and illness allowance, the full amount of the injury and illness allowance will not be paid (Article 55, Paragraph 1).
  • If you receive a remuneration equal to or greater than the amount of the injury or illness allowance (total amount paid before deduction, No. 24 issued by Hobun on December 12, 26) during the holiday period, you will not be paid and the remuneration will be less than the amount of the injury or illness allowance. If obtained, the difference will be paid (Article 2478, Paragraph 108).Even if you receive an old-age pension during the insured period, no adjustment will be made.
    • This is an adjustment rule when all or part of the remuneration is paid on the day of absence, and it is not paid because it does not become "labor incapacity" in the first place if you go to work.
    • There is no written statement, and it is customary to pay money even in the case of personal injury or illness at the will of the business owner, and what is nominally called leave allowance, leave assistance fee, sympathy money, etc. is just a sickness and a reward. It is not recognized and Article 108 does not apply (April 10, 4, Honor No. 20).Regardless of the sympathy money or any other nameLabor regulationsOrCollective agreementThose that are considered to have been paid for the purpose of payment of remuneration based on the above, etc., and that are continuously paid after the occurrence of the reason for payment fall under Article 108, "Remuneration". (February 25, 2, Hobun No. 22).Even if the purchase cost of the commuter pass paid before the payment period is related to the payment period, it is subject to adjustment.
  • Due to the same injury or illnessDisability welfare pension(Basic disability pensionIn principle, the injury and illness allowance will not be paid, and if the amount of 360/1 of the disability welfare pension is less than the amount of the injury and illness allowance, the difference will be paid (Article 108 3). Item).Disability allowanceIf you receive a disability allowance, from the day you receive the disability allowance to the day when the total amount of the disability allowance is reached after that date. The injury and illness allowance will not be paid, and if the total amount exceeds the disability allowance and is specified by a Cabinet Order, the difference will be paid (Article 108, Paragraph 4).
    • If only the disability basic pension is paid for the same injury or illness, the injury and illness allowance will be paid at the same time.In addition, the disability welfare pension and the injury and illness allowance that do not depend on the same injury and illness can be received at the same time.
  • When a person who falls under Article 108, paragraphs 1 to 4 is ill and injured, he / she cannot receive the full amount of all or part of the remuneration that he / she should have been able to receive. If the full amount of the injury / illness allowance or a part of it cannot be received and the amount received is less than the amount of the injury / illness allowance, the difference between the amount and the injury / illness allowance or the maternity allowance will be paid (No. 109). Article 1, Paragraph 109).Since the insurance benefits paid by the insurer based on the provisions of Article 1, Paragraph 109 are of the nature of advance payment, the insurer collects the amount paid by the employer (Article 2, Paragraph XNUMX).
  • When receiving continuous benefitsToOld-age welfare pension,Old age basic pensionAlternatively, if the retirement mutual aid pension can be received, the injury and illness allowance will not be paid in principle, and if 360/1 of the amount of the old-age pension etc. is less than the amount of the injury and illness allowance, the difference will be paid. (Article 108, paragraph 5).
    • In this case, the old-age pension will be paid in full.
  • If an insured person with health insurance who receives a leave compensation benefit from the workers' accident compensation insurance becomes unable to work due to injury or illness due to reasons other than work, the difference when the amount of the leave compensation benefit does not reach the amount of the injury or illness allowance. Injury and illness allowances will not be paid except for those related to the portion (No. 33 issued by insurance on July 7, 8).In other words, so-called non-business co-payment is not performed.
  • 出産 手 当 金And if you can receive the injury and illness allowance at the same timeMaternity allowance is given priority, When the injury and illness allowance is not paid during that period and the amount of the maternity allowance is less than the amount of the injury and illness allowance[Annotation 3]The difference between the injury and illness allowance will be paid (Article 103, Paragraph 1).If the injury and illness allowance is paid (excluding the difference) when the maternity allowance is to be paid, the paid injury and illness allowance is regarded as an internal payment of the maternity allowance (Article 103, Paragraph 2). ..
    • Even if you cannot receive the injury and illness allowance because you received the maternity allowance in the middle of receiving the injury and illness allowance, will the injury and illness allowance be paid for 1 year and 6 years from the date of the start of the payment? It will be cut off by the month (June 4, 6, Hosei No. 21).
  • If you are receiving the injury and illness allowance for continuous benefits, you will not be paid the injury and illness allowance for employment insurance.
    • If you receive the basic allowance for employment insurance, you will be certified as having the will and ability to work.Public Employment Security OfficeBecause it was made in Japan, the injury and illness allowance that requires incapacity to work is not available.If the Public Employment Security Office recognizes that you are temporarily incapacitated (less than 15 days) and has provided the basic allowance, prove that you have been unable to work for medical treatment from before you left your job until now and that you continue to receive medical treatment benefits. Therefore, the basic allowance must be returned and a new application for the injury and illness allowance must be made (March 29, 3, Hobun No. 4).
  • Those who meet the requirements for payment of injury and illness allowanceNursing care leaveIf during the period, the injury and illness allowance will beWill be paid(March 11, 3, No. 31 from insurance, No. 46 from agency insurance).howeverWhen a remuneration is paid in the name of a nursing care leave allowance, etc. during the leave periodWill make adjustments to the amount of injury and illness allowance paid.
  • The insurerFalsehood and other misconductIt is possible to set a period of up to 6 months for those who receive or intend to receive insurance benefits, and decide not to pay all or part of the injury and illness allowance to be paid to that person. ..However, if one year has passed from the date of deception or other misconduct, the benefit cannot be restricted (Article 1).

Application procedure

Those who intend to receive the injury and illness allowance should submit an application containing the following matters.To the insurerMust be submitted (Article 84, Paragraph 1 of the Enforcement Regulations).

  1. Insured cardSymbol and number orpersonal number
  2. Type of work of the insured
  3. Name of injury and illness, its cause, and date of onset or injury
  4. Period during which labor could not be submitted
  5. If the insured can receive all or part of the remuneration, the amount and period of the remuneration
  6. If the injury and illness allowance is in accordance with the proviso of Article 108, Paragraph 3 or the proviso of Paragraph 4, the disability welfare pension or the disability allowance is different and the amount (disability based on the same reason for payment as the disability welfare pension). When the basic pension can be paid, the total amount of the disability welfare pension and the disability basic pension), the name of the injury or illness that is the reason for the payment, the disability welfare pension or the disability allowance will be received. Date (when the disability basic pension can be paid based on the same reason as the disability welfare pension, the date when the disability basic pension was received and the disability basic pension shall be received. If you should receive a disability welfare pension, your personal number orBasic pension numberAnd the disability welfare pension (when the disability basic pension can be paid based on the same payment reason as the disability welfare pension, the disability welfare pension and the disability basic pension)Pension certificate Of
  7. If the injury and illness allowance is in accordance with the proviso of Article 108, paragraph 5, the name, amount, and date of receiving the old-age retirement pension benefit prescribed in the same paragraph, Individual number or basic pension number and pension code or symbol number or number of the pension certificate or equivalent documents
  8. When the injury and illness allowance is based on the provisions of Article 109, the amount and period of remuneration that should have been received, the amount and period of remuneration that could not be received, the proviso of Article 108, Paragraph 1. The amount of injury and illness allowance received pursuant to the proviso of paragraph 3 or the proviso of paragraph 4 and the reason for not being able to receive the remuneration
  9. During the period when I couldn't get the laborLong-term care insurance methodDesignated home service related to home care service costs, home service related to special home care service costs or equivalent services, designated community-based services related to community-based care service costs, special community-based care service costs Community-based services related to or equivalent services, designated facility services related to facility care service costs, facility services related to special facility care service costs, designated care preventive services related to care preventive service costs, or special care preventive service costs When receiving the care prevention service or the equivalent service, the insured number, insured number and insured name of the insured person's certificate prescribed in the same law.

The following documents must be attached to this application form.If these documents are written in a foreign language, a Japanese translation must be attached to the documents (Article 84, Paragraphs 2-8 of the Enforcement Regulations).

  • The date of occurrence of the insured's illness or injury, cause, main symptoms, summary of progress, and doctor or doctor regarding the period of 4. aboveDentist OfWritten opinion(The doctor or dentist who proves this must state the date of diagnosis, and sign and seal it.)[Annotation 4][Annotation 5]
    • Of a general doctorMedical certificateUnlike the issuance of the doctor's opinion attached to the application formCovered by insurance benefits(Corresponds to "medical treatment benefits". No. 60 issued by insurance on March 3, 29)[Annotation 6].
    • The invoice should not be accompanied by a doctor's certificate regarding the period of incapacity to work, but should be accompanied by a written opinion. A written opinion that estimates and displays the past condition may be provided with an injury and illness allowance.However, if the insurer does not admit that the insured was incapable of working, it is not necessary to pay the injury and illness allowance (February 4, 2, Hosei No. 21).this is,The final decision-maker for payment is the insurerIt means that the insurer allows the treatment different from the doctor's written opinion.However, in practice, it is rare for an insurer to overturn a written opinion written by a doctor with medical grounds, unless there are circumstances such as inconsistency with other documents.
    • If the content of the written opinion is unclear and the degree of need for leave cannot be determined, the insurer can request an explanation / report from the insurer, but the insurer should fill out the necessary information in the written opinion against the will of the insurer. I can't order it.It is permissible to instruct the insured that the content of the written opinion is unclear and ask the insured to rewrite the written opinion (October 3, 10, No. 9). ..
    • If multiple doctors have different views (Insurer ACan workIf the insurer B decides that he / she cannot work), he / she should not pay it unless the insurer finds it incapable of working (February 8, 2, Honor No. 18).In particular, the insured's doctor and the insured's workplaceIndustrial physician[Annotation 7]It becomes a problem when the views differ.If the insured does not get an opinion from the attending physician that he / she is unable to work, he / she will be referred to an industrial physician other than the doctor.As a workerIt is permissible to ask the insurer for an opinion on employment and to submit to the insurer any documents voluntarily prepared by the industrial physician who was asked for the opinion.In this case, the written opinion of the doctor, etc. shall be required to include the opinion regarding the illness or injury that is not recognized as incapacitated.In such a case, the insurer may listen to the opinion of the industrial physician with the consent of the insured person.When the insurer receives the submission of these documents, please take the opinions of both parties into consideration and make an appropriate decision.In addition, in the Ministry of Health, Labor and Welfare "Guide for support for returning to work for workers who have taken a leave of absence due to mental health problems" (October 16, revised March 10),Cooperation between the attending physician and the industrial physicianIs important, and in making a "judgment that the attending physician can return to work", the occupational health staff including the industrial physician should provide the attending physician with information on the work performance required in the workplace in advance. It is considered desirable (September 26, 9, Ministry of Health, Labor and Welfare, Health Bureau, Health Division, Office Contact).
  • Employer's certificate regarding 4.5.8 above[Annotation 8][Annotation 9]
  • For those who fall under the provisions of Article 108, paragraph 3, a copy of the disability welfare pension certificate, documents certifying the amount of the disability welfare pension and the date when the payment started, and documents certifying the latest amount of the disability welfare pension.
  • Documents certifying the payment of disability allowance for persons who fall under the provisions of Article 108, Paragraph 4.
  • For those who fall under the provisions of Article 108, paragraph 5, a copy of the old-age retirement pension benefit pension certificate or equivalent documents, the amount, the document certifying the payment start date, and the document certifying the latest amount.
  • Persons who should be paid the injury and illness allowance because the total amount prescribed in Article 108, paragraph 4 reaches the amount of the disability allowance prescribed in the same paragraph were paid the disability allowance. The employer's certificate and doctor or dentist regarding the period listed in 4. above and the daily amount of compensation received during the period from the day until the total amount reaches the amount of the disability allowance. Opinion
  • If there is a change in the business establishment used within the most recent continuous 12-month period in which the standard monthly salary before the month to which the injury and illness allowance starts to be paid is set, each business establishment Name, location and period used by each business establishment
  • If the new insurer succeeds to the rights and obligations of the extinguished health insurance union in the event of a merger, split or dissolution of the health insurance union, the name of the extinguished health insurance union and each health insurance union are joined. Period

About the optimization of sailor insurance injury and illness allowance benefits

For seafarers insured, the ratio of injury and illness allowances to sickness benefits and the number of days paid per insured person are significantly higher than other systems, even considering the peculiarities of seafarers' labor. be.For these reasons, regarding examples of invoices to be covered, important points of the implementation survey, whether or not job incapacity is possible, certification of work / non-job, etc. June 56, 6 Agency Bunsho No. 26, No. 865) has been stipulated.

In document screening,

  1. For the following requests, return the injury and illness allowance payment request, etc. to the requester and complete it.
    • Missing entries, missing marks, etc. on the invoice
    • Claims that are due to work-related or commuting accidents are not attached with the "Job Accident Certificate" or "Notification of Commuting Accident", or even if they are attached, the description is incomplete.
  2. For the following requests, have them submit a "medical treatment status and daily living status survey table" to confirm the situation in which they cannot get a job due to medical treatment.
    • Billing for off-season and overhanging period
    • Persons over 50 years old
    • Easy entry in the "Doctor Opinion" column of the invoice
    • Those with a small number of actual medical treatment days in a month
    • Three months have passed since the start of payment of injury and illness allowance
  3. Regarding the following illnesses, due to chronic illness, senile illness, etc., there is a suspicion that the legal period for payment of injury and illness allowance has expired, and there is a suspicion that the symptoms will not change.ReceiptCheck the start date of the medical treatment benefit, the content of the medical treatment benefit, and the payment record of the injury and illness allowance due to the illness.If the insured period of the claimant is under the jurisdiction of another section, inquire and confirm the benefit record, etc. from the relevant section as necessary.

If there is any doubt due to the document review, reconfirm by document inquiry and conduct a field survey if necessary.In particular, for the following requests, strengthen the field survey.

  1. Those that are considered to be relatively mild, judging from the name of the disease and symptoms
  2. Those who have few actual days of medical treatment and have doubts about the grounds for being unable to work, judging from the opinion of a doctor
  3. Those that appear to be clinically relatively mild and that appear to be treated indiscriminately
  4. Diseases listed in 3. of document review
  5. Those who are over 50 years old and disqualified
  6. Those with a considerable period between the onset of illness or injury, disembarkation, and the date of first medical examination
  7. Those that are more than 3 months old from the start date of payment of injury and illness allowance
  8. Those who have received the injury and illness allowance for the same illness before
  9. Anything that is suspicious outside of work
  10. Concentrated on a particular medical institution, region or shipowner
    • If the doctor's certificate is concentrated in a specific medical institution, cooperate with the medical staff and take necessary measures.For medical institutions in other prefectures, notify the medical staff in that prefecture.
  11. Those who are in the hospital and are listed below
    • Those that are concentrated in a specific medical period
    • Those who have doubts about hospitalization based on the name of the disease and symptoms
    • Those who have re-boarded or obtained qualification within one week from the date of discharge
    • Items with a large number of nights or no meals on the receipt

Prescription

As with other health insurance benefits, your right to receive an injury or illness allowance is after two years.PrescriptionDisappears by (Article 193).The starting date of the statute of limitations is "every day when labor is impossible, the next day" (September 30, 9, Insurance Issue No. 7-199).

History

1883/,Germany OfBismarck CabinetUnder the sickness insurance law, half of the minimum wage will be paid as an injury and illness allowance for up to 13 weeks.The main insurance for leave due to illness or injury is called sickness insurance, and the main insurance for medical expenses is called health insurance. In Japan, these two have been treated as health insurance.The beginning is the 2nd year of the Taisho era (Taisho 2)1913/), ButGreat Kanto EarthquakeFinally in 2 (Showa XNUMX) due to confusion caused by1927/) And was enforcedHealth insurance lawIs.Initially, the maximum payment period was 180 days, and since the workmen's accident compensation insurance system was not in place, leave due to work-related accidents was also covered.

18 (2006/)の健康保険法一部改正により、その第45条で「標準報酬月額の30分の1相当額の6割」とされていた傷病手当金の支給額が「標準報酬月額の30分の1相当額の3分の2」とされた。また、第55条の2では被保険者の資格喪失後も継続して給付を受けられるとされていたが、改正法第104条で1年以上の継続加入が必要とされるようになった。Voluntary continuous insuredAs for, the injury and illness allowance will no longer be paid only by the requirement of being a voluntary continuous insured person, unless the benefit is continuously received.However, this is not the case if you are eligible for the above-mentioned post-retirement benefits.In addition, due to the meaning of payment for livelihood security, even if the standard monthly salary is reduced and revised during the payment, the amount of injury and illness allowance will not be reduced (June 26, 6). Bunsho 4).

From April 28, 4, the amount of payment will be reviewed and will be the current regulation.Immediately before the leave of absence, the standard monthly salary was increased and revised, and cases of claiming an unreasonably large amount of injury and illness allowance were widespread, and the aim is to prevent this.If the injury and illness allowance is received across the revised date, the daily amount received will be determined by the previous calculation method before the revised date and the revised calculation method after the revised date.

Disseminating the system is also an important issue.TokyoAmong cancer patients in the surveyHigh medical expenses79.4% of the respondents used the system, but only 31.5% used the injury and illness allowance system.I didn't know so I didn't use itWas 39.5%[1].

footnote

[How to use footnotes]

注 釈

  1. ^ Article 69 of the Seafarers'Insurance Law, which stipulates allowances for seafarers' injuries and illnesses, states, as in Article 99 of the Health Insurance Law, "from the day when three days have passed from the day when the labor can no longer be submitted." The requirement is not set.
  2. ^ As of September 30, 9, the average monthly standard remuneration for Japan Health Insurance Association is10,000,000 yenIt has become.
  3. ^ The method of calculating the amount of payment is the same for both the maternity allowance and the injury and illness allowance. If the payment start month is different, the unit price may be different if there is a fixed time decision during that period.
  4. ^ The doctor's written opinion does not necessarily have to belong to the insurer,Judo reduction teacherの施術を受けた場合は柔道整復師の意見書でも差支えないが(昭和2年3月26日保理118号、昭和25年1月17日保文発72号)、療養担当者としての意見書でなければならない。したがって、病院の名で出された意見書ではいけない(昭和3年12月27日保理3163号)。
  5. ^ As for the written opinion after the death of the doctor who received medical treatment, a document stating the reason was attached to the invoice, and as a result of investigating the doctor, the business owner and other related parties, it was possible to confirm the fact that it was impossible to work for a certain period of time. It is permissible to pay for things (July 6, 7, Honor No. 25).
  6. ^ When a judo rehabilitator is requested by a patient to issue an injury / illness allowance statement of opinion necessary for receiving an injury / illness allowance, he / she should issue it free of charge (October 11, 10, Hosho No. 20, old-aged). No. 144).
  7. ^ When an industrial physician prepares a written opinion and provides medical care for the insured in the company, it is necessary that a clinic, etc. is established in the company (Medical lawArticle 1-2, Article 7, Article 8, September 26, 9 Health Division, Health Bureau, Ministry of Health, Labor and Welfare).If an industrial physician performs medical treatment during regular patrols in a company that does not have a clinic, etc., the company has taken a detrimental disposition such as leave or demotion to the insured based on the medical treatment results. Usually not because of the risk of litigation in case.
  8. ^ The notation in Article 99 is "the period during which labor cannot be submitted", but the actual proof by the employer is "the period during which labor was not submitted" (holiday period) (October 9). 10th insurance issue 4).
  9. ^ The business owner is unknown orLabor disputeBystrikeIf the business owner refuses to certify and cannot attach the certificate because he / she cannot know the insured's movements, if the business owner's whereabouts are unknown, he / she will be asked to attach a document stating the reason to the invoice. As a result of the investigation, the invoice may be paid to those who can confirm the fact of incapacity to work, but even if the insured's movement cannot be known due to a labor dispute, the employer cannot work. The proof cannot be refused (July 6, 7, Honor No. 25).

Source

  1. ^ Fact-finding survey on employment of cancer patientsBureau of Social Welfare, Tokyo, May 26

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