Incapacity for work: definition, proof and consequences

Incapacity for work exists as soon as an insured person can no longer do the work they last did because of illness. What matters is the specific link to exactly this work. A cold rarely makes an office worker unable to work, but a disorder of the vocal cords may well make a teacher or call center agent unable to work. A roofer who cannot put strain on their back is unable to work, even if office work would in theory still be possible. A doctor must confirm the condition with a sick note (certificate of incapacity for work).

Incapacity for work differs from occupational disability in its duration. Incapacity for work is a temporary condition that ends with recovery. Occupational disability requires a permanent impairment and is covered by separate insurance, not by health insurance. People who confuse the two terms often underestimate their own gap in cover.

For employees, statutory continued pay under § 3 EntgFG applies, and the employer continues to pay the salary for six weeks. Only after that does the real gap arise. People with statutory insurance then receive the Krankengeld (i)KrankengeldStatutory sick pay from the statutory health insurance fund. It starts when the employer stops paying wages, usually from the seventh week of illness. of their statutory health insurance fund from the 43rd day of illness. It is limited to 70% of gross salary and does not exceed the Beitragsbemessungsgrenze (i)BBG · BeitragsbemessungsgrenzeThe contribution ceiling of statutory health and long-term care insurance. Income above this amount is not used to calculate contributions.More about BBG →.

Privately insured people do not receive automatic income replacement. If you want to avoid a gap, you take out a Krankentagegeld with a suitable qualifying period. Self-employed people have no continued pay, so they are left without income immediately and depend especially on such cover. Civil servants are the special case, because the public employer continues their pay during illness.

Incapacity for work must be the result of an illness. If the insured person caused the condition intentionally or through gross negligence, the insurer can reduce or completely refuse the benefit under § 201 VVG. A classic example is being unfit to drive after drinking alcohol at the wheel. Complications from purely cosmetic procedures or from tattoos also regularly lead to questions from the insurer in practice.

Before you take out a Krankentagegeld (i), clarify which qualifying period suits your savings, and make sure you are signed off sick without interruption during illness. This way your right to income replacement stays intact without gaps.

To keep your entitlement, your incapacity for work must be documented without gaps. The first sick note should be issued promptly, and a follow-up certificate must follow on directly from the previous one. If there is a gap between two certificates, the insurer can refuse payment for that period.

In statutory health insurance, the doctor's practice now sends the incapacity for work electronically to the statutory health insurance fund and the employer. Privately insured people, by contrast, submit the certificate to the insurer themselves if a Krankentagegeld (i) has been agreed. If you know and meet the deadlines of your plan, you avoid delays in payment.