FOR VIOLATOR OF TREATMENT REGIME
Do not rush to reduce benefits if the employee’s sick leave list contains the “dreaded” code 021 or a note about late attendance for an appointment. Recently, the approach to this issue has changed.
If an employee falls ill, the employer pays him temporary disability benefits (Article 183 of the Labor Code of the Russian Federation). In some cases, the benefit amount is reduced. The grounds for reducing the amount of temporary disability benefits are listed in paragraph 1 of Art. 8 of Federal Law No. 255-FZ of December 29, 2006 “On compulsory social insurance in case of temporary disability and in connection with maternity” (hereinafter referred to as Law No. 255-FZ).
Codes in the line “Notes about violation of the regime”
Depending on the type of violation, in the line “Notes on violation of the regime,” the medical worker indicates one of the following two-digit codes:
- 23 - if the employee does not comply with the prescribed regime, left the hospital without permission, or went for treatment to another administrative region without the permission of the attending physician;
— 24 — did not show up for a doctor’s appointment on time;
— 25 — went to work without being discharged;
— 26 — refused to be referred to a medical and social examination institution;
- 27 - arrived untimely at the medical and social examination institution;
— 28 — other violations.
This rule is established in clause 58 of the Procedure for issuing certificates of incapacity for work, approved by Order of the Ministry of Health and Social Development of Russia dated June 29, 2011 N 624n (hereinafter referred to as the Procedure for issuing sick leave).
Note. The form of the certificate of incapacity for work was approved by Order of the Ministry of Health and Social Development of Russia dated April 26, 2011 N 347n.
Sick leave with code 02
At the same time, the main part of the rules for entering information into a certificate of incapacity for work is given in the Order of the Ministry of Health and Social Development of the Russian Federation dated June 29, 2011 N 624n “On approval of the Procedure for issuing certificates of incapacity for work.”
Moreover, there are no restrictions on the maximum duration of the paid period. The only exceptions are sick leave benefits for employees hired for temporary work or with disabilities.
Accountant's actions
If an accountant sees codes 23, 24, 25, 26, 27, 28 or 021 on an employee’s sick leave, as provided for in the Procedure for issuing sick leave, this means that the amount of the benefit may be reduced.
However, you need to keep in mind that the head of the company has the right to decide not to reduce the amount of benefits if:
— the reason for the violation of the regime was recognized as valid and the necessary documents were drawn up;
— it has been proven that there is no connection between alcohol intoxication and the employee’s illness (injury).
The decision of the head of the company to pay benefits in full must be formalized by order.
Thus, if there are special marks on the sick leave, the accountant calculates temporary disability benefits based on the sick leave and the order of the head of the company.
Information about the possibility of not reducing the amount of benefits can be conveyed to the head of the company by the chief accountant. In some companies, the list of actions in the presence of special doctor’s notes on the sick leave is established in the internal labor regulations or other similar document.
Is sick leave paid for alcohol intoxication?
Payment of sick leave is a strict obligation of the employer (Article 183 of the Labor Code of the Russian Federation).
An employee who is absent from work due to illness brings sick leave upon completion of work. Based on this document, he will receive the payments due to him by law. Important! Since 2022, the employer will accrue and pay benefits only for the first 3 days of sick leave due to illness or domestic injury. The remaining benefit amount is calculated and paid to the Social Insurance Fund employee. For more information, see our guide to direct benefit payments.
All this fully applies to situations where disability is associated with excessive alcohol consumption. The employee is also issued a sick leave certificate, but it will contain a special code 021, which means that the cause of the injury or illness was alcohol (or drug, toxic) intoxication.
What does this “shameful” code mean for an employer? This is a reason to think about a possible reduction in temporary disability benefits. However, the mere fact of the presence of code 021 on the certificate of incapacity for work is not a basis for reducing compensation.
Read about other codes indicated on sick leave here.
Three documents to recognize the reason for violating the regime as valid
If the reason for an employee’s violation of the regime prescribed by a doctor or failure to attend an appointment is recognized as valid, the company must have the following as supporting documents:
— a written explanation by the employee of the reason for the violation of the regime;
— minutes of the meeting of the social insurance commission, consisting of company employees;
— an order from the head of the company to pay the employee benefits in full.
In this case, the refusal of the Federal Social Insurance Fund of the Russian Federation to reimburse benefits in full will be unfounded (Resolution of the Presidium of the Supreme Arbitration Court of the Russian Federation dated February 14, 2012 N 14379/11).
How to create a social insurance commission in an organization says:
- in clause 11 of the Regulations on the FSS of the Russian Federation, approved by Decree of the Government of the Russian Federation of February 12, 1994 N 101;
— Standard regulations on the commission (authorized) for social insurance, approved by the Federal Social Insurance Fund of the Russian Federation dated July 15, 1994 N 556a.
An example of calculating sick leave with violation of the regime according to the minimum wage
Let the employee provide a certificate of temporary incapacity for work for the period from June 15 to June 24. The regional coefficient of the region is 1.3. The patient's work experience is 4 years. There is additional a note about violation of the regime using code 021. The current minimum wage (from May 1, 2018) is RUB 11,163.00.
Calculation:
- The number of days of incapacity for work is 10.
- 11,163.00. x 24 months / 730 days = 367.00 rub.
- 367.00. x (60% / 100%) x 1.3 = 286.26 rub.
- 286.26 x 10 days = 2862.60 rub.
Amount of benefit for unjustified reason for violating the regime
If the reason for violating the schedule or failing to show up to the doctor is not valid, the benefit calculation will be different.
As a general rule, in case of violation of the regime or failure to appear at the doctor's office, temporary disability benefits are reduced from the day on which the employee committed the violation. The amount of benefits calculated for a full calendar month cannot exceed the minimum wage (Part 2, Article 8 of Law No. 255-FZ).
How to calculate the maximum amount of daily benefits is stated in clause 22 of the Regulations on the specifics of the procedure for calculating benefits, approved by Decree of the Government of the Russian Federation of June 15, 2007 N 375 (hereinafter referred to as the Regulations on the calculation of benefits).
In some situations, the amount of the daily benefit, calculated from the employee’s actual earnings, may be lower than the maximum daily benefit. In this case, the calculation of benefits should be based on the daily benefit calculated from the employee’s actual earnings, and not increase it to the maximum daily benefit calculated from the minimum wage.
The state of alcohol intoxication is indicated on the sick leave: is it possible to reduce the payment?
According to Art. 8 of the Law “On Mandatory Social Insurance...” dated December 29, 2006 No. 255-FZ, in the event of an illness occurring under the influence of one or another type of intoxication (including alcohol), benefits are paid for the entire period of sick leave. But in a limited amount not exceeding the minimum wage for a full calendar month. In this case, no merit, length of service or other grounds that increase the payment are applied. The only thing that is allowed is to adjust the benefit amount by the regional coefficient.
Read about how the minimum wage has changed and what it is today.
If you have decided to reduce hospital benefits, calculate the benefit limit using the formula:
Pmax = minimum wage / km × kb,
Where:
Pmax - the maximum possible benefit for illness received due to alcohol intoxication;
Minimum wage - the current minimum wage in the month of illness;
Km - the number of calendar days in the month of illness;
Kb - the number of days that the employee was on sick leave.
EXAMPLE of calculating sick leave for an illness or injury caused by alcohol intoxication from ConsultantPlus: Kharitonov I.M. a sick leave certificate was issued in connection with a domestic injury sustained while intoxicated (code “02”, additional code “021”). The Social Insurance Commission has established a causal relationship between the injury and alcohol intoxication. The period of incapacity for work is from January 16 to January 28, 2022 (13 days). Payments for the billing period for which insurance premiums for VNiM are calculated - RUB 1,387,000. The employee's insurance experience is 3 years. Calculation of temporary disability benefits: Get trial access to the K+ legal reference system and see the full calculation algorithm and the continuation of the example. It's free.
an example of filling out sick leave by an employer in this publication.
Conclusion of the Presidium of the Supreme Arbitration Court of the Russian Federation in 2012
The judges considered a situation in which a company employee had been ill for almost eight months. In the third month of treatment, she once mixed up the appointment dates and came to her next appointment with the doctor a week later.
According to experts from the Federal Social Insurance Fund of the Russian Federation, the benefit should be reduced from the day the deadline for reporting to the doctor is violated until the end of the period of incapacity for work. In this situation, this period was almost five months.
The judges of the Presidium of the Supreme Arbitration Court of the Russian Federation did not agree with this approach. They noted that the FSS of the Russian Federation must take into account the principle of fairness and proportionality of the violation and punishment. In Resolution No. 14379/11 dated February 14, 2012, they indicated that in this situation the fund has no grounds for reducing the amount of benefits for the entire period of incapacity.
Calculation and accrual of sick leave in 1C 8
A setup form will appear in front of you. Go to the “Payroll calculation” section and check the appropriate box, as shown in the figure below. Please note that this functionality is only available if the program does not include organizations with more than 60 employees.
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At the very bottom of the form, on the “Main” tab, accruals and personal income tax are automatically calculated. The accrual is automatically divided into that paid by the employer and the Social Insurance Fund. You can only adjust personal income tax and average earnings data by clicking on the pencil sign.
What decisions do judges make in 2014?
Despite the conclusions of the Resolution of the Presidium of the Supreme Arbitration Court of the Russian Federation dated February 14, 2012 N 14379/11, there are currently examples of opposite decisions. For example, Resolution of the Federal Antimonopoly Service of the Volga-Vyatka District dated July 17, 2014 in case No. A82-9067/2013. The judges considered a situation in which an employee was one day late for a doctor's appointment.
The arbitrators agreed with the arguments of the branch of the Federal Social Insurance Fund of the Russian Federation that in case of violation of the regime or failure to show up to the doctor, the benefit should be reduced from the day of the violation of the regime until the day the period of incapacity ends.
Employers should study the judicial practice on reducing the amount of temporary disability benefits that has developed in their region. In controversial situations, it is safer to consult the territorial branch of the FSS of the Russian Federation.
Let us show the calculation of the allowance using numerical examples.
Example 1. The reason for violating the regime is considered unjustified
An employee of Reverence PJSC, E. A. Sedakova, was on sick leave from March 12 to October 30, 2014. On the certificate of incapacity for work, in the line “Notes on violation of the regime,” code 24 was entered due to the employee’s late appearance for an appointment and the date was August 14, 2014 d. The employee did not explain the reason why she did not show up for the appointment at the time prescribed by the doctor.
In the billing period (2013 and 2012), the amount of payments in favor of the employee included in the base for calculating insurance contributions amounted to 750,030 rubles.
In what amount will E. A. Sedakova receive benefits for the entire period of temporary disability if the employee’s insurance period is 3 years and 8 months?
Solution. Let's calculate the average daily earnings of a female worker. It is 1027.44 rubles. (RUB 750,030: 730). The daily benefit amount will be 616.46 rubles. (RUB 1,027.44 x 60%), where 60% is the amount of benefit for less than five years of insurance coverage.
Amount of benefit until the day of violation of the regime
We will determine the amount of temporary disability benefits from the first day of illness until the day of violation of the regime.
The benefit for the period from March 12 to August 14, 2014 will be 96,167.76 rubles. (RUB 616.46 x 156 calendar days).
Amount of benefit after violation of the regime
The employee did not explain the reason for the violation of the regime, so the social insurance commission did not consider this case. The employer decided to reduce the benefit amount. The decision was formalized by order.
In such a situation, the accountant should calculate the benefit taking into account the reduction in its amount from the day the regime was violated until the end of the employee’s temporary disability.
Let's determine the amount of daily benefits based on the minimum wage:
— in August and October — 179.16 rubles. (RUB 5,554: 31 days);
— September — 185.13 rubles. (RUB 5,554: 30 days).
The amount of the daily benefit calculated from actual earnings is greater than the amount of the daily benefit calculated from the minimum wage (616.46 rubles > 179.16 rubles, 616.46 rubles > 185.13 rubles).
Therefore, the benefit must be calculated based on the daily benefit calculated from the minimum wage.
For the period of temporary disability from August 14 to October 30, 2014, the amount of the benefit will be equal to 14,153.58 rubles, including:
— for August — 3224.88 rubles. (RUB 179.16 x 18 calendar days);
— September — 5553.90 rub. (RUB 185.13 x 30 calendar days);
— October — 5374.80 rub. (RUB 179.16 x 30 calendar days).
For all days of illness of E. A. Sedakova, a benefit in the amount of 110,321.34 rubles will be accrued. (RUB 96,167.76 + RUB 14,153.58).
Note. How to take into account the regional coefficient when reducing the amount of benefits
We will calculate the amount of benefits if the reason for violating the regime or failing to show up to the doctor was considered valid and this was documented with the appropriate documents.
Example 2. The reason for violating the regime was recognized as valid
Let's change the condition of example 1. An employee of PJSC "Reverance" E. A. Sedakova was on sick leave from March 12 to October 30, 2014. In the certificate of incapacity for work dated July 24 N 012345678910 in the line "Notes on violation of the regime" code 24 is entered due to untimely the employee's attendance at the appointment and the date - August 14, 2014.
The employee gave written explanations for her late attendance at the doctor: her mother was ill. The Social Insurance Commission recognized this reason as valid. Considering this fact, as well as the fact that the employee had no subsequent violations, the employer decided not to reduce the benefit, but to pay it in full. This decision was formalized by order.
In the billing period (2013 and 2012), the amount of payments in favor of the employee included in the base for calculating insurance contributions amounted to 750,030 rubles.
How to pay for the period of temporary disability of E. A. Sedakova, if the employee’s insurance period is 3 years and 8 months?
Solution. Let's determine the average daily earnings of a female worker, it is 1027.44 rubles. (RUB 750,030: 730).
The daily benefit amount will be 616.46 rubles. (RUB 1,027.44 x 60%).
Let's calculate the amount of temporary disability benefits. The benefit for the period from March 12 to October 30, 2014 will be 143,635.18 rubles. (RUB 616.46 x 233 calendar days).
What exist and their decoding
Two main codes are used, one of them indicates the reason why the patient went to the hospital, and the second is the ICD-10 disease code. The purpose of using both codes is the same - saving time and ensuring the privacy of information.
Designations used for causes of disability:
- 01 — disease (any, except professional pathology);
- 02 - injury (except work-related);
- 03 - quarantine (imposed on family members and colleagues of an infectious patient or on an entire department of the enterprise);
- 04 - work injury;
- 05 - pregnancy;
- 06 — prosthetics (if there is a need to go to the hospital);
- 07 - occupational pathology;
- 08 — trip to a sanatorium for medical reasons;
- 09 - patient care;
- 10 - cases that do not fit into the classification;
- 11 - a disease of social significance (HIV, hepatitis, etc.);
- 12 - caring for a sick child;
- 13 - caring for a disabled child;
- 14 - consequences of vaccination;
- 15 — caring for a child suffering from HIV.
The last two reasons are indicated only with the written consent of the patient. ICD-10 codes indicate the name of the disease. They are indicated in the form in which it is provided for in the classification of diseases. They are used to indicate the causes of temporary disability and its permanent loss.
The connection between illness and intoxication
The current legislation does not regulate the procedure for establishing a cause-and-effect relationship between alcohol consumption and injury or illness (Letter of the Federal Social Insurance Fund of the Russian Federation dated April 15, 2004 N 02-10/07-1843).
Such a connection can be established on the basis of (Decision of the Supreme Court of the Russian Federation dated March 27, 2002 N GKPI02-311):
— written explanation of the employee;
— a medical report made in compliance with the appropriate procedure;
— by conducting an investigation by authorized bodies.
Please note: indicating code 021 on the certificate of incapacity for work does not clearly indicate injury due to alcohol intoxication.
If the FSS of the Russian Federation does not provide evidence that indisputably demonstrates the existence of a cause-and-effect relationship between the employee’s injury (illness) and the state of intoxication, the court will recognize the refusal to offset expenses as unlawful (Resolution of the Federal Antimonopoly Service of the West Siberian District dated July 27, 2009 N F04-4454/2009 (11072-A27-25) in case No. A27-2071/2009).
Error when writing code in a hospital bulletin: employee actions
An employee may not know what this or that mark means, so just in case it is useful to clarify such information in the handbook. If an employee thinks that the code is indicated incorrectly, he needs to start by double-checking the information about what is indicated on the sick leave.
A common mistake is when the cause of disability is indicated as 01, but the disease has social significance or is associated with professional activity, and codes 07 or 11 would be appropriate. The list of diseases requiring a separate code is indicated in medical reference books. If the patient does not find his illness in them, then code 01 is indicated correctly.
The second step, if the code is indeed indicated incorrectly, is to provide documents that confirm the correct diagnosis. This is a medical history, extracts and certificates that will indicate an error.
Important! A certificate of incapacity for work is a financial document, so it can be forged. To distinguish a real document, you need to pay attention to the color (blue) and watermarks. It is difficult to do something like this in artisanal conditions.
Once an error is identified, the registrar or doctor must correct it - using a proofreader or crossing out. No more than 2 corrections are allowed on one sheet. The third step, if the medical institution refused to correct the error, is to file a written complaint, which the court will consider. In practice, the court more often holds liable the employer who paid for incorrectly issued sick leave, rather than the medical institution.
Actions of the policyholder
When receiving a certificate of incapacity for work with code 021, the responsible persons of the organization are required to follow a certain procedure:
- Identify the reason why alcohol intoxication occurred. To do this, a written statement of explanation is taken from the employee, in which he sets out his vision of the situation and the circumstances under which the incident occurred.
- Create a commission of competent employees of the organization, which will be tasked with reviewing the existing circumstances and drawing a conclusion about the amount due to the employee for payment on sick leave. An organization with a small headcount (below 100) can entrust this procedure to one person. The appointment of a social insurance commission or an individual representative should be formalized in the minutes of the general meeting or other legally binding documents in accordance with the legal form of the policyholder. It is mandatory to record in writing the consent of the commission members to be elected.
- Draw up minutes of the commission meeting (decision of the commissioner) based on the results of their work.
Attention! In addition to the explanations of the disabled employee, documents from third-party organizations may also be considered: police reports, traffic police documents, etc.
