Facts
In the present case, the plaintiff and the defendant, a health insurance company, are in dispute about the plaintiff's entitlement to sickness benefit for the period from 1 March to 31 July 2016. The plaintiff, who has two dependent children, had been unemployed since July 2014 and received unemployment benefit until February 2016. From 8 January 2016, she was unable to work due to moderate depression. The doctor treating her issued several certificates of incapacity for work (AU), which certified her incapacity for work without gaps until the end of July 2016.
The health insurance fund discontinued the payment of sickness benefit from 1 March 2016 on the grounds that a sickness absence certificate had not been submitted in full. The claimant then lodged an objection, as she had been unable to see her doctor on 1 and 2 March 2016 due to her depressive state. However, the health insurance fund also rejected the new application.
Decision of the health insurance company
The defendant argued that an uninterrupted medical certificate of incapacity for work was required for entitlement to sickness benefit. Since the certificate of incapacity for work for the period from 1 March 2016 was only issued on 3 March 2016, the gap between 29 February and 3 March 2016 was decisive for the loss of entitlement to sickness benefit. In the opinion of the health insurance fund, this gap meant that the claimant was no longer insured on a non-contributory basis on 1 March 2016, which led to the expiry of the entitlement to sickness benefit.
Action brought by the plaintiff
The claimant filed a complaint with the Aachen Social Court, claiming that she was incapacitated due to a severe depressive episode on 29 February, 1 and 2 March 2016. She had not left her home and had not been able to see her doctor. On 3 March 2016, she finally contacted her daughter, who accompanied her to the doctor, where the sick note was issued retroactively. The treating doctor confirmed that the claimant had not been able to attend the planned doctor's appointment during the period in question due to her depression.
Decision of the Aachen Social Court
The Aachen Social Court ruled in favour of the claimant and decided that the health insurance company's decisions were unlawful. The court found that the claimant had been unfit for work without interruption since 8 January 2016 and that the incapacity for work had also existed in the period from 1 March to 31 July 2016. The lack of a timely medical certificate for 1 March 2016 was due to the plaintiff's inability to act due to illness, which had made it impossible for her to obtain a certificate of incapacity for work in good time. The court recognised that in exceptional cases, a retroactive determination of incapacity for work is possible, particularly if the insured person is incapacitated due to illness.
Legal Assessment
The court emphasised that, in accordance with Section 44 (1) sentence 1 SGB V, insured persons are entitled to sick pay if an illness makes them unfit for work. In the present case, the claimant had been unfit for work without interruption since 8 January 2016. The lack of an uninterrupted certificate of incapacity for work was justified by the exceptional circumstances of the claimant's depression. In this case, the medical determination of incapacity for work could exceptionally be made retroactively, as the claimant was demonstrably incapacitated.
Conclusion
The Aachen Social Court ruled in favour of the claimant and confirmed her entitlement to sickness benefit for the period from 1 March to 31 July 2016. The court found that the claimant had been unable to obtain a sickness certificate in good time due to a severe depressive episode and that the health insurance fund should have taken the special circumstances of the case into account. The health insurance fund appealed against this judgement to the North Rhine-Westphalia Regional Social Court.
