Social Security: Sickness Insurance

Beneficiaries and Conditions for Entitlement

The purpose of social security health care is to provide medical and pharmaceutical services necessary to maintain or restore the health of beneficiaries and their ability to work.

It also provides additional services to ensure the complete physical rehabilitation necessary for people to resume their working life.

These services are managed by the competent bodies of each Autonomous Community and by the Instituto Nacional de Gestión Sanitaria in the cities of Ceuta and Melilla.

Beneficiaries

Employees, provided they are registered, members or in a situation equivalent to membership of the general scheme. For the purposes of these benefits, they are considered to be members automatically, even if their employer does not meet his obligations.

Retired persons and those who are in receipt of regular benefits, including people in receipt of the INEM unemployment benefit or assistance.

Members of the family or equivalent in the care of the above, the spouse, orphans and descendants, Spanish emigrants and other groups covered by the law

Primary Care

This includes the following benefits:

• Treatment at surgeries, health services and centres, and at home
• Prescription and examinations, plus basic diagnostic care
• Activities connected to health education and examinations, vaccinations and other activities scheduled for sickness prevention, health promotion or rehabilitation
• Dental treatment, therapies and minor surgery
  Other specific benefits

Specialist Care

When primary care diagnosis and treatment possibilities have been exhausted, specialist care and assistance includes the following:

• Specialist outpatient care at surgeries, which includes minor surgery
• Outpatient care in day hospitals in cases requiring continuous medical and nursing care. This includes major surgery without hospitalisation
• Specialist care involving hospitalisation, which includes medical, surgical, obstetric and paediatric care for acute complaints, relapses in chronic complaints or the performance of diagnostic treatment or procedures where advisable
• Mental health and psychiatric care, which includes clinical diagnosis and monitoring, psychopharmatherapy and individual, group or family psychotherapy and hospitalisation where applicable
• Emergency hospital care and services, which are provided 24 hours per day to outpatients suffering from a complaint that requires immediate hospital care. This includes diagnosis, first aid and the treatment necessary to deal with the emergency and assess the complaint
• Other services

Incapacidad Temporal

The financial benefit for temporary incapacity aims to cover lack of income arising when an employee is temporarily unable to work and requires social security health care due to illness or accident.
This financial benefit forms part of the protective action of the general and special social security schemes.

Situations Protected

Situations determining temporary incapacity are considered to be:

• Those due to ordinary or occupational diseases and accidents, whether industrial or not, when the worker is unable to work and receives health care;
• Periods of observation for occupational diseases in which they are signed off work for such periods

Beneficiaries: People included in the general scheme who meet the following requirements:

• They are registered, members or in a situation equivalent to membership at the time the contingency arises, and they receive social security health care and are prevented from working.
• They have covered a contribution period of:
  • A prior period of contributions is not required in the event of an accident, whether occupational or not, or an occupational disease.
  • In the case of an illness not related to work, 180 days within the five years immediately prior to the contingency.
  • In the case of workers recruited on a part-time basis, to certify contribution periods, only contributions made according to hours worked, both ordinary and overtime, will be counted, calculating their equivalence in theoretical contribution days.

Start of entitlement

• In the case of an illness or accident not related to work, from the fourth day of the date of cessation of work
• In the case of an accident at work or occupational disease, from the day following cessation of work, payment of the full wages corresponding to the day of cessation being the employer's responsibility

Duration

In the case of an accident or illness, irrespective of the cause:

• 12 months extendable by another six months when it is assumed that the worker may be discharged during that time. For the purposes of the maximum duration and its possible extension, periods of relapse and observation will be counted. The existence of a situation constituting permanent invalidity, or the need for the worker to continue the medical treatment prescribed.

Recognition of the right falls to:

The Instituto Nacional de Seguridad Social, when the situation arises from an illness or accident not related to work and situations of automatic membership. Or the Social Security Mutua de Accidentes de Trabajo y Enfermedades Professionals (Industrial Accidents and Occupational Diseases Mutual Insurance Scheme) contracted by the company to cover these services.

Text last edited on: 06/2006

Source: European Union
© European Communities
Reproduction is authorised.