The year 2022 brought significant changes related to ZUS (Social Insurance Institution) insurances. They concern, among other things, the payment of sickness benefits in the event of arrears on the payer’s account. What are these changes? Can a delay in paying contributions result in the benefit not being paid out? What knowledge about this topic is particularly useful now?
When can ZUS refuse to pay the benefit?
Sickness benefit is available to entrepreneurs who pay contributions for voluntary sickness insurance. However, ZUS (Social Insurance Institution) may refuse to pay sickness benefit in several cases:
- when the insured individual does not yet have the required contribution period;
- when the insured individual has already exhausted the full sickness benefit period, which is 182 days per year or 270 days for pregnant women and individuals with tuberculosis;
- when the insured individual fails to attend follow-up examinations as requested by the ZUS medical expert;
- when the insured individual engages in gainful employment while on sick leave;
- when the insured individual is entitled to a pension or retirement benefits;
- when the insured individual has outstanding arrears on their account;
How high must the arrears be for ZUS to refuse to pay the benefit?
From 2022 onwards, late payment of ZUS contributions no longer results in the termination of voluntary sickness insurance. Now, it is possible to receive sickness benefits even if contributions are not paid on time. However, a certain condition must be met. There cannot be any outstanding contributions exceeding 1% of the minimum wage. The minimum wage in 2022 is 3010 Polish zloty, so 1% of this is 30.10 zloty. An insured person who wants to receive sickness benefits cannot have a debt in social insurance greater than 30.10 zloty. These regulations apply to entrepreneurs conducting non-agricultural business activities and individuals cooperating with them.
Will ZUS pay the benefit after the arrears are paid off? When will this happen?
An entrepreneur in arrears with contributions has 6 months to repay the debt. If the entire debt, which exceeds 1% of the minimum wage, is repaid within 6 months from the day the entitlement to benefits arises, ZUS will pay sickness benefits from the day the entitlement to benefits arises. However, if the insured person settles the debt after 6 months from the day the entitlement to benefits arises, the benefits will only be granted from the day of payment of the benefits. The entitlement to sickness benefits for the earlier period will expire. Therefore, it is not worth delaying the repayment of contributions arrears because you can still receive benefits from the day the entitlement arises and the need arises to receive them.
It’s easier – for the insured and for ZUS.
Before 2022, even a one-day delay in paying ZUS contributions, even those not caused by the fault of the insured party (such as delays caused by the bank), resulted in the interruption of insurance coverage. To restore the right to insurance, one had to submit an application to ZUS explaining why there was a delay in paying contributions. This was inconvenient for both the insured and ZUS. The Social Insurance Institution received annually over 150,000 applications for the reinstatement of the payment deadline from entrepreneurs who experienced delays in contribution payments. This meant much more work for ZUS and added stress for the insured, fearing they might not receive benefits when needed. Since 2022, there is no need to submit these applications anymore. ZUS no longer has to spend time processing applications, and the insured can rest easy—provided the arrears do not exceed 1% of the minimum wage.
Other changes related to sickness benefit
In addition to changes related to payment arrears, there are several other significant changes in effect from 2022. One of them is the increased amount of sickness benefits for individuals hospitalized. Until 2022, this benefit was 70% of the benefit base, but now all insured individuals are entitled to a benefit equal to 80% of the benefit base, whether it concerns a hospitalized person or someone receiving treatment at home. From 2022 onwards, there is no need to recalculate the sickness benefit base if there was no break or if the break was no longer than one calendar month between periods when the insured received the benefit. Previously, the regulations specified a break of at least 3 calendar months.
The length of the sickness benefit period within a year remains unchanged at 182 days. This is the total time during which sickness benefits can be received. All periods of incapacity for work are included in the sickness benefit period, even if the causes of incapacity differ. Previously, if there were breaks in the incapacity for work, periods of incapacity before the break were included in the sickness benefit period if the cause was the same, and the break did not exceed 60 days. From January onwards, the cause of incapacity before and after the break no longer matters. Breaks are now counted the same, regardless of whether it is the same illness or different ones. The exception is incapacity for work due to pregnancy. Periods occurring before a break of no more than two months are not included in the sickness benefit period, provided that incapacity for work occurred during pregnancy after the break.
As for the new regulations, it is now possible from 2022 to receive sickness benefits for up to 91 days after the cessation of insurance. This rule does not apply to pregnant women and those with tuberculosis. It should be noted that individuals who have exhausted their sickness benefit period may apply for rehabilitation benefits, which are granted for 12 months to individuals still ill but showing prospects of returning to work.