You will have to reimburse the costs of benefits: what are the consequences of errors in sick leave?

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In this article we will not consider maternity benefits and other benefits related to maternity; about them, read the article “Benefits paid from the Social Insurance Fund in connection with pregnancy and the birth of a child.”

The calculation of sick leave and benefits for temporary disability is regulated by Federal Law No. 255-FZ of December 29, 2006 “On compulsory social insurance in case of temporary disability and in connection with maternity.”

Temporary disability benefits are provided in the following cases:

• illness or injury of the insured person;
• caring for a sick family member;
• quarantine of the insured person, as well as quarantine of a child under 7 years of age attending a preschool educational institution, or another family member recognized as legally incompetent in accordance with the established procedure;
• implementation of prosthetics for medical reasons;
• follow-up treatment in accordance with the established procedure in sanatorium-resort institutions of the Russian Federation.

In addition to the listed cases, temporary disability benefits are also paid in the event of an accident at work or an occupational disease. Their payment is regulated by Federal Law 125-FZ of July 24, 1998.

Source of payment for temporary disability benefits

In 2021, all regions switched to the FSS pilot project “Direct Payments”. In them, the employer pays only for the first three days of the employee’s illness, and then payments are made by the Social Insurance Fund. That is, the fund does not reimburse them to the employer, but immediately does it for him. Similarly, the Social Insurance Fund pays for all sick leave for employees who care for sick family members or for maternity leave.

For persons who are sick or injured, but voluntarily entered into legal relations under compulsory social insurance, the Social Insurance Fund pays benefits from the first day. In other cases, except for illnesses and injuries of the employee, benefits are also paid from the Social Insurance Fund from the first day.

Calculation and payment of sick leave by the employer

Temporary disability benefits are assigned if the application for it follows no later than six months from the date of restoration of working capacity, as well as the end of the period of release from work in cases of caring for a sick family member, quarantine, prosthetics and after-care (Article 12, paragraph 1, 255-FZ ).

The calculated period of sick leave is the previous 2 years or 730 days, no days are excluded from the calculation. For sick leave issued in 2021, these will be 2021 and 2021.

Note!

• If an employee works at one place of work, the calculation of benefits is carried out at this place, taking into account the taxable payments for the previous 2 years for all places of work, with the condition that the amount of accruals cannot exceed the maximum - the maximum amount of taxable amounts for each of the years taken into account in the calculation.
• If an employee works in several places at the time of the insured event and worked in the same place in the two previous calendar years, temporary disability benefits are paid for all places of work. The number of jobs does not matter. In this case, the employee will be given as many paper sick leaves as he has such employers. One electronic sick leave will be issued, but you will need to provide its number for all places of work.
• If an employee, at the time of the insured event, works for several policyholders, and in the two previous calendar years worked for other policyholders, all benefits are assigned and paid to him by the policyholder at one of the last places of work at the choice of the insured person (Article 13, paragraph 2.1 255-FZ ).
• If at the time of the insured event an employee works for several insurers, and in the two previous calendar years he worked for both these and other insurers, then temporary disability benefits can be paid for one place of work, based on the average earnings for all insurers , and for all current policyholders, based on the average earnings at the current place (Article 13, paragraph 2.2 of 255-FZ).
• If an employee quits and becomes unable to work due to illness or injury within 30 calendar days after the termination of the employment contract and cessation of work, then the temporary disability benefit is paid by his former employer for the first three days, and the rest is paid by the Social Insurance Fund. The benefit is paid in the amount of 60% of average earnings, length of service does not matter.

Example:

1. The employee works at Alpha LLC as his main place of work and at Beta LLC as a part-time employee during the entire billing period, starting in January 2021. Accordingly, his sick leave will be calculated separately in Alpha LLC and separately in Beta LLC
2. The employee has been working at Alpha LLC as his main place of work and at Beta LLC as a part-time employee since January 2021. Accordingly, his sick leave will be calculated at Alpha LLC OR at Beta LLC at his choice, based on certificates provided from previous places of work.
3. The employee has been working at Alpha LLC at his main place of work since 2019 and at Beta LLC since 2021; in addition, in 2021 he worked in other organizations. His sick leave will be calculated at Alpha LLC OR at Beta LLC at his choice, based on certificates provided from previous places of work.
4. The employee has been working at Alpha LLC at his main place of work and at Beta LLC part-time since 2021; in addition, in 2021 he worked in other organizations. Sick leave can be granted to both Alpha LLC and Beta LLC, but based on average earnings in current places of work. Or sick leave can be calculated in one place, based on the average earnings for all organizations where the employee received income.

Average earnings for calculating sick leave

Benefits for temporary disability are calculated based on the average daily earnings of the insured person, calculated for the two calendar years preceding the year of the onset of temporary disability, including for the period of work for other insureds.

If in these two calendar years, or in one of the specified years, the insured person was on maternity leave and (or) parental leave, the corresponding calendar years (calendar year), at the request of the employee, can be replaced by previous calendar years ( calendar year) provided that this will lead to an increase in the amount of benefits (clause 1 of Article 14 255-FZ).

If the insured person had no earnings over the previous two years or his average earnings were less than the minimum wage, then the average earnings for calculating benefits are used equal to the minimum wage - 12,792 rubles in 2021. When working part-time/week, average earnings are calculated in proportion to the length of working time.

The average earnings, on the basis of which benefits are calculated, include all types of payments and other remuneration in favor of the insured person, for which insurance contributions to the Social Insurance Fund are calculated (Article 14, paragraph 2, 255-FZ). The average daily earnings for calculating benefits are determined by dividing the amount of accrued earnings for two years by 730 (Article 14, paragraph 3, 255-FZ).

Average daily earnings = (Amount of earnings for 2021 + Amount of earnings for 2021) / 730.

The average daily earnings for calculating benefits for temporary disability cannot be less than the average earnings calculated on the basis of the minimum wage in force on the date of onset of disability - 12,792 rubles in 2021. If a regional coefficient is used in your area, carry out the calculation based on the minimum wage increased by this coefficient. That is, the amount of average daily earnings for the billing period will be at least 420.56 rubles, and the amount of earnings for two years will be 24 minimum wages or 307,008 rubles.

The amount of benefit calculated for a full calendar month cannot be less than the minimum wage.

Basis and terms of benefit payment

The benefit is paid by the employer both at the main place of work and part-time.
Benefits must be applied for no later than 6 months after the end of the period of incapacity for work. The basis for payment of benefits is sick leave. If the insured person works for several employers, it is necessary to issue several sick leaves, according to the number of employers.

The employer pays benefits to the insured person in the manner and within the time limits established for the payment of wages to employees.

Limitations on the payment of temporary disability benefits

1. The maximum amount of accruals taken into account. For each calculation year, earnings are taken into account in an amount not exceeding the maximum base for calculating insurance contributions to the Social Insurance Fund (Article 14, Clause 3.2 of 255-FZ). Let us recall that this value in 2021 was 815 thousand rubles, in 2021 - 865 thousand rubles, in 2020 - 912 thousand rubles, and in 2021 - 966 thousand rubles. The 2021 value does not apply to sick leave issued in 2021, since the calculation period is 2019–2020.

Based on these restrictions, you can calculate the maximum average daily earnings for benefits received in 2021: (865,000 rubles + 912,000 rubles) / 730 days = 2,434.25 rubles.

If benefits are paid to one employee by several policyholders, each policyholder can take into account earnings for each year in an amount not exceeding the specified limit.

2. Restriction in case of violation of the regime. If the certificate of incapacity for work contains a note about violation of the regime, then from the date of violation the benefit is paid in an amount not exceeding the minimum wage for a full calendar month. In areas where a regional coefficient is applied, the minimum wage is taken taking into account this coefficient.

Violation of the regime is considered to be violation of doctor’s instructions, skipping medical examinations and examinations. If the injury is caused by alcohol or drug intoxication, then the benefit is calculated according to the minimum wage for the entire period of incapacity.

3. The influence of the length of insurance on the amount of sick leave.

Insurance period is the total length of time for paying insurance premiums and (or) taxes. This includes the period of work under an employment contract, public service, military service and other activities. Depending on the length of the insurance period, benefits for reasons of illness, injury, quarantine, prosthetics and after-care are paid as a percentage of average earnings:

• insurance experience of 8 years or more - 100%;
• insurance experience from 5 to 8 years - 80%;
• insurance period from six months to 5 years - 60%;
• insurance period of less than six months - benefits are paid in an amount not exceeding the minimum wage for a full calendar month. In districts and localities in which regional coefficients are applied to wages in accordance with the established procedure - in an amount not exceeding the minimum wage taking into account these coefficients.

In the event of an occupational illness or injury, benefits are paid in the amount of 100% of average earnings.

If we are talking about outpatient care for a sick child, then payments as a percentage of average earnings, which depend on length of service, are accrued only for the first 10 days. For all subsequent days of incapacity, 50% is paid.

Please note that the benefit amount calculated for a full month cannot be less than the minimum wage. If the benefit for a full month, calculated based on the actual average daily earnings, is less than the established minimum wage, it will need to be calculated based on the minimum amount. Even if the reduction occurred due to accounting for length of service.

4. Temporary disability benefits are paid to employees who worked in the organization and were dismissed in the event of illness or injury within 30 calendar days after termination of the employment contract. In this case, the benefit, regardless of length of service, is paid in the amount of 60% (clause 2 of Article 7 255-FZ).

5. Limitations on benefits for caring for a sick family member. When caring for a sick family member, there are a number of additional restrictions. The number of paid days for each case of disability and the number of paid days per year are limited, depending on the age of the patient, as well as the presence of special diseases (clause 5 of Article 6 of the 255-FZ).

In addition to restrictions on the number of paid days, benefits for caring for a sick child during outpatient treatment are also limited in terms of the amount of payment, starting from the 11th day of incapacity for work:

• for the first 10 calendar days, the benefit is paid in an amount determined depending on the length of the insurance period of the insured person;
• for subsequent days - in the amount of 50 percent of average earnings (clause 3 of Article 7 255-FZ).

When treating a child in a hospital, all payments are calculated based on the insurance period.

Benefit amount

The amount of benefits for loss of ability to work due to illness or injury, during quarantine, prosthetics for medical reasons and after-care in sanatorium-resort institutions immediately after hospital treatment depends on the insurance period.
Temporary disability benefits are paid in the amount of:

• 100 percent of average earnings - to an insured person with an insurance record of 8 years or more;
• 80 percent of average earnings - with an insurance period of 5 to 8 years;
• 60 percent of average earnings - if the insurance period is up to 5 years.

In case of illness or injury occurring within 30 calendar days after termination of work under an employment contract, temporary disability benefits due to illness or injury are paid to the insured persons in the amount of 60 percent of average earnings.
If it is necessary to care for a sick child, temporary disability benefits are paid:

• for outpatient treatment of a child - for the first 10 calendar days in the amount determined depending on the length of the insurance period of the insured person, and for subsequent days in the amount of 50 percent of average earnings;
• for inpatient treatment of a child - in an amount determined depending on the length of the insurance period of the insured person.

Note
! If the employee’s insurance experience is less than 6 months, then the benefit is paid to him in an amount not exceeding the minimum wage for a full calendar month (taking into account regional wage coefficients, if established).

Calculation of average earnings based on the minimum wage

If the insured person had no earnings in the 2-year calculation period, and also if the average daily earnings calculated for these periods, calculated for a full calendar month, are below the minimum wage, the benefit is calculated based on the minimum wage.

If the insured person at the time of the occurrence of the insured event works part-time (part-time, part-time), the average earnings calculated on the basis of the minimum wage are adjusted in proportion to the length of the insured person’s working hours.

From 2021, the minimum wage is set at 12,792 rubles.

When working full-time, the minimum average daily earnings in 2021 is RUB 12,792. × 24 months / 730 days = 420.56 rubles. In areas where a regional coefficient is applied, the minimum wage is taken taking into account this coefficient, i.e. the minimum average daily earnings will be higher.

Procedure for calculating temporary disability benefits

1. For each of the two calendar years taken for calculation (for insured events occurring in 2021, these are usually 2021 and 2020), we calculate the amount of accruals subject to contributions to the Social Insurance Fund.
2. Separately, we compare the amount for each year with the maximum base for calculating insurance premiums for that year. For example, we compare the amount of accruals for 2021 with 865,000 rubles, and for 2021 with 912,000 rubles. For each year, we take the smaller of the compared amounts for calculation.
3. We add up the amounts taken into account for 2 years, divide by 730 - we get the average daily earnings.
4. We compare the resulting average daily earnings with the minimum daily earnings calculated based on the minimum wage (minimum wage × 24 / 730) and take the maximum value. In areas where a regional coefficient is applied, the minimum wage is taken taking into account this coefficient.
5. We determine the amount to be paid: the average daily earnings (real or according to the minimum wage, whichever is greater) are multiplied by a percentage depending on the length of service and by the number of calendar days of incapacity.

In the case of caring for a sick family member, we take into account how many days and in what amount can be paid. In case of illness or injury, the first 3 days are paid at the expense of the employer, the remaining days at the expense of the Social Insurance Fund.

Changes to sick pay in 2021

As for 2021, there are a number of important changes in the calculation and payment of sick leave, as well as in benefits for temporary disability. The main innovations are related to the indicators used:

1. From January 1, 2021, the minimum wage will be 12,792 rubles;
2. The maximum base for calculating contributions will increase - 966,000 rubles, it will be relevant for calculating sick leave in 2022;
3. The maximum and minimum average daily earnings will change: minimum - 420.56 rubles per day, maximum - 2,434.25 rubles.
4. From April 1, 2021, special conditions for calculating sick leave benefits have been introduced. Their size should not be less than that calculated based on the minimum wage. That is, the daily benefit calculated according to the old rules was compared with the daily benefit calculated as the minimum wage / number of calendar days of sick leave without adjustments.
5. For benefits that began after June 19, 2021, a new rule was introduced - average earnings must be compared with the minimum wage, taking into account regional coefficients. There will no longer be situations in which an employee with a lower income received more sick leave over two years than a colleague with a higher income.

The medical institution must be responsible for its mistakes when registering sick leave.

The court of first instance came to this conclusion, resolving the case in favor of the organization.

He pointed out that the negative consequences of issuing incorrectly issued certificates of incapacity for work by a medical institution are assigned directly to these medical institutions, and not to the organization.

Therefore, the FSS had to file a claim for reimbursement of expenses in the form of amounts of benefits paid for incorrectly issued certificates of incapacity for work directly to the medical institution.

Previously on the topic:

Non-critical errors in sick leave certificates

When will benefits not be denied due to an error on sick leave?

How to pay for one sick leave with two causes of disability