Extension of sick leave: the insured must inform the health insurance fund in due time
An insured person who does not return his work stoppage to the health insurance fund before the end of the period of interruption of work does not allow the fund to exercise control during this period.
The fund is therefore entitled to refuse the daily allowances for the period during which its control was made impossible ( Cass 2nd Civil Chamber, July 7, 2016, No. 15-50074 ).
What are the rules for the transmission of work stoppages?
In case of work disruption, the insured must send to the primary health insurance fund, within a specified time and, under the sanctions provided by decree, a letter of notice of work interruption whose model is fixed by ministerial decree and which must include the doctor’s signature ( article L321-2 of the social security code ).
What are the deadlines for sending work stoppages to the health insurance funds?
The insured who is prescribed a work stoppage must transmit within 48 hours :
- parts 1 and 2 to the medical service of his health insurance fund;
- part 3 to his employer or, if he is unemployed, to his Pôle emploi agency.
Stoppages and stoppages must always be sent to the Health Insurance Fund within two days of the date of interruption of work.
This is specified in Article R321-2 of the Social Security Code :
In the event of work disruption, the insured must send to the primary health insurance fund, within two days of the date of interruption of work , and under pain of sanctions established in accordance with Article L. 321- 2 , a letter of notice of work interruption indicating, as prescribed by the physician, the probable duration of the incapacity for work.
In the event of extension of the initial work stoppage, the same formality must, under pain of the same penalties, be observed within two days following the prescription of extension .
What are the penalties applicable in case of delay in sending the work stoppage?
Article D323-2 of the Social Security Code states:
If the notice of work interruption or extension of work stoppage is sent to the primary health insurance fund beyond the period provided for in Article R. 321-2, the credit union shall inform the ‘assured of the delay and the sanction to which it is exposed in case of new late sending within twenty-four months from the date of prescription of the judgment in question .
In the case of late new postings , unless the insured person is hospitalized or if he establishes the impossibility of sending his notice of work stoppage in good time, the amount of daily allowances for the period elapsed between the date of prescription of the judgment and the date of dispatch is reduced by 50%.
What are the penalties applicable if the insured does not apply to the Fund for a stoppage of work or a notice of extension ?
The fund is entitled to refuse the benefit of daily allowances for the period during which its control will have been impossible, without prejudice to the provisions of Article L. 324-1 ( Article R323-12 of the Social Security Code ).
The ameli.fr website (CPAM) provides details on the calculation of the deadline:
“Whatever the means chosen by the insured to send the document to the fund, the time is calculated between the date of prescription of the stop or extension of work stoppage and that of receipt of the document.
This period is increased by 6 days to take into account the delays in the delivery of documents, as a result, the envelope is no longer intended to be retained.
Exception: the work stoppage may be compensated when its duration is less than or equal to 5 days, provided that the notice of work stoppage is received on the 6th day. “
What to remember : The insured must send his work stoppage as soon as possible to the Fund and his employer under penalty of up to the deprivation of daily allowances.