Illness Benefit
Internal Guidelines: Illness Benefit
February 2009
Index
Description of Scheme
Information Leaflet
Legislation
Administration
Qualifting Conditions in Summary
Qualifying Conditions in Detail
Satisfy PRSI Conditions
Using relevant periods in other Member States of the EEA
Governing Contribution Year
Examples
Persons who were on JA or PRETA
Persons who were on Carer's Benefit or Allowance
Community Employment Schemes
Saver Clause
Examples
Linking
Waiting Days
Linking Provisions for Certain Illness Benefit Claims
Rates Structure
Determining Average Weekly Earnings
Reckonable Earnings
Volunteer Development Workers
Night workers
Payments to Persons in Receipt of certain Social Welfare Payments
Payments to Persons in Receipt of Carer's Benefit or Allowance
Overlapping entitlements to Illness Benefit and certain pensions or benefits from other countries
Taxation of Illness Benefit
Blind Pension
Increases for Qualified Adult/Child
Extra Benefits
Public Servants recruited after 6th April 1995
Sharefishermen/women
Duration of Payment
Continuous Duration:
Limited Duration:
Requalification after expiry of Illness Benefit
JB/ JA Payable Pending Illness Benefit Appeal
Pregnancy
IB Incapacities
Defence Forces
Disqualifications
Imprisonment
Trade Dispute
Penalties
Payment after death:
Claims
Intermediate Certificates
Certification
Late Claims
Decisions
Participation in Trade Dispute
Pre-Retirement Allowance
Illness Benefit/Disability Allowance claimants
Pre-Entry Credits (PECs)
Student Credits
Payment
Payment method
Maintenance
Frequency of certification
Over 65 and over 66 years
Stop Dates
Medical Referral Assessments
Payment while on holidays or abroad
Claimant in hospital
Incapacity Gap
IB Appeal Credits
Health and Safety Benefit - Implications for payment of Illness Benefit
Special payment arrangements
Assessment of Damages in Civil Cases
Previously Found capable
Payment to appointed persons
Overpayments
(a) Procedures for recovery of overpayment
(b) Determining level of recovery, right of appeal
(c) Method of recovery
(d) Appeal
Conditions while receiving Illness Benefit
Application for permission to commence education or training while in receipt of Illness Benefit
PART 1: ENTITLEMENT
Description of Scheme
Illness Benefit is a payment made to insured people who are unable to work due to illness and who satisfy certain Pay Related Social Insurance (PRSI) conditions.
Information Leaflet/Guide
Department Website : 'www.welfare.ie'
Email: illnessbenefit@welfare.ie
Leaflet Illness Benefit SW 119
'Guide to Social Welfare Services' SW 4
'The Community Provisions on Social Security - Your rights when moving within the European Union' (Published by the European Commission).
Legislation
The main provisions relating to Illness Benefit (formerly Disability Benefit prior to 2/10/2006) are in Chapter 8 (Part 2) of the Social Welfare (Consolidation) Act, 2005, Number 26 of 2005, as amended and Chapter 1 of Social Welfare (Consolidated Claims Payments and Control) Regulations, 2007.
Title II, III and VI of Regulations ( EEC) No. 1408/71 and Annex VI of that Regulation. Title II, IV (Chapters 1 and 2) and VI of Regulation ( EEC) No. 574/72.
Administration
Illness Benefits Section, ras Mhic Dhiarmada, Store Street, Dublin 1 deals with all claims for Illness Benefit. It also acts as a conduit for forwarding all claims for equivalent payments which are proper to another Member State of the European Economic Area (EEA).
QUALIFYING CONDITIONS
Social Welfare Consolidation Act 2005 S 40-41 and Statutory Instrumant (S.I.) 142/2007 refers
Summary
To be entitled to Illness Benefit (IB) a person must:
(a) Be under age 66
(b) be incapable of work due to illness
(c) satisfy the PRSI contribution conditions :
- 104 contributions paid since entry into insurance - refers to IB claims made on or after 5th January 2009. For claims made before 5th January 2009, 52 contributions were required. See also section on Saver Clause
and
- 39 contributions paid or credited in the governing contribution year (13 of these must be paid contributions),
or
- 26 contributions paid in the relevant income tax year and
- 26 contributions paid in the tax year before the relevant income tax year.
QUALIFYING CONDITIONS IN DETAIL
A. BE UNDER 66 YEARS
To be entitled to Illness Benefit a person must be under pensionable age (currently 66 years) on the day for which benefit is claimed. Persons approaching pensionable age are advised to apply for State Pension (Transition) or State Pension (Contributory/Non-Contributory) 3 months in advance of the relevant age limit.
B. BE INCAPABLE OF WORK
Illness Benefit is payable for each day of incapacity for work (i.e. a day on which a person is unable to work due to illness) which forms part of a period of interruption of employment (see paragraph headed 'Linking' below).
Illness Benefit is not paid for the first 3 days of incapacity, these are known as 'waiting days'. (See paragraph headed 'Waiting Days' below).
C. SATISFY PRSI CONDITIONS
Applicants must satisfy both Condition 1.(a) and 1.(b) below or alternatively Condition 2
A person must have
1.(a) 104 weeks PRSI paid at the appropriate class since s/he first entered insurable employment.(For IB claims made before 5th January 2009, 52 weeks were required)
and
1.(b) 39 weeks PRSI paid or credited at the appropriate class in the 'governing contribution year' (GCY) - 13 of which must be paid contributions - see note below:
Note: If there are no paid contributions in the GCY or less than the required 13 paid, this condition may be satisfied if there are 13 paid contributions in either of the 2 years prior to the GCY or 13 paid contributions in the last complete contribution (Tax) year or 13 paid in the current Tax year.
OR
2. 26 weeks PRSI paid at the appropriate class in the governing contribution year' and 26 weeks PRSI paid at the appropriate class in the tax year immediately before
the 'governing contribution year'.
The contribution year is the same as the tax year i.e. 1st January of each year to the 31st December in the same year.
The governing contribution year (GCY) is the second last complete contribution/tax year before the year in which the Illness Benefit claim is made.
Examples
For a claim made in 2008 the relevant Tax year/GCY is 2006
For a claim made in 2009 the relevant Tax year/GCY is 2007
For a claim made in 2010 the relevant Tax year/GCY is 2008
PRSI contributions paid at Class A, E, H and P only count for the purpose of the above conditions.
Using relevant periods in other Member States of the European Economic Area (EEA) where a person has insufficient Irish contributions
Periods of insurance, employment and residence in another EEA country may be used to help satisfy the contribution conditions for Illness Benefit if the person is within the scope of the EC provisions and not entitled by using the Irish record only. The EEA State(s) in which the person worked will provide on request details of such periods which can be taken into account.
The Department is competent to take periods in another EEA country into account for the purpose of acquiring, retaining or recovering the right to Illness Benefit. In order to do so the worker (see note below) must last have been subject to Irish legislation as an employed person liable for PRSI at the appropriate class (i.e. Class A, E, H or P) or would have been liable but for the application of the PRSI free allowance for employees. The Department is also responsible for aggregation where a claimant was in receipt of Irish Jobseeker's Benefit immediately prior to claiming Illness Benefit.
Note: The worker must be an EEA national or have the official status of a stateless person or refugee residing in Ireland and have been subject to the social security legislation of another Member State of the EEA as an employed or self-employed person.
Governing Contribution Year
The contribution year is the same as the tax year. The contribution year begins on 1st January of each year and ends 31st December in the same year.
The governing contribution year is the second last complete contribution year before the benefit year in which the IB claim is made.
The benefit year begins on the first Monday in January in each calendar year and ends on the Sunday immediately before the first Monday in the next calendar year.
Examples
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For a claim made in
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The Benefit year is
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2007
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2005
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|
2008
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2006
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|
2009
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2007
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2010
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2008
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13 contributions paid in relevant year
If a person does not have 13 paid contributions in the relevant tax year, the following years may be used to satisfy this condition:
- the 2nd and 3rd last complete tax years,
- the most recent complete tax year, or
- the current tax year.
NB To satisfy the test, the 13 contributions must have been paid in one year i.e. it is not possible to combine contributions paid in the different years referred to above in order to make up the total of 13 paid contributions.
Persons who were on Jobseeker's Allowance, Pre-Retirement Allowance (see note), Invalidity Pension.
A person who was receiving Jobseeker's Allowance or Pre-Retirement Allowance (see note) or Invalidity Pension immediately before claiming Illness Benefit does not need to satisfy the 13 paid contributions. However, where there are no reckonable earnings in the relevant tax year, the person only qualifies at a reduced rate of payment (see paragraph headed 'Rates Structure' below).
Note: Refers to claims before 4th July 2007 as PRETA was abolished for new applicants from 4th July 2007.
Persons who were on Carer's Benefit or Allowance
With effect from 1st May 2007, provision is made for a former recipient of Illness Benefit who transfers to Carer's Benefit or Carer's Allowance and subsequently back to Illness Benefit, to receive Illness Benefit at a rate not lower than that previously in payment (see Payments to persons in receipt of certain Social Welfare Payments) (see Payments to Persons in receipt of Carer's Benefit or Allowance)
Community Employment Schemes
Since April, 1996 all new participants on Community Employment (CE) schemes are insurable at PRSI Class A. This means that a person on a CE scheme for 13 weeks or more is covered for IB. However, CE participants who have worked less than 13 weeks will not, in general, qualify for IB. Accordingly, the "13 paid contributions" rule is applied to CE workers in the same way as it does to any other insured worker. (However see paragraph headed "Linking Provisions for certain Illness Benefit claimants" below).
Saver Clause
Claims "saved" from change in contribution conditions which came into effect from 5th January 2009.
- Only IB claims with a new period of interruption of employment (PIE) from 05th Jan 2009 are affected. IB claims with a commencement date on or after 05th Jan 2009 that are within the same PIE (i.e. not separated by more than 26 weeks) as a previous paid Illness Benefit, Occupational Injury Benefit, Jobseekers Allowance, Jobseekers Benefit, Maternity Benefit or Invalidity Pension claim, which commenced prior to 05th Jan 2009, will only require 52 paid PRSI contributions since starting work. The previous PIE must be for a period of at least 3 days.
- The 13 Paid Contributions Test was introduced on 1 July 1992 and persons who were in receipt of Disability Benefit (now Illness Benefit since 02/10/2006) on that date and who subsequently broke their claim, do not require to satisfy that test if they renew their claim to IB within the same period of incapacity.
Example
Disability Benefit 11 May 1992 to 19 January 1994
Invalidity Pension 20 January 1994 to 25 September 1997
Disability Benefit 26 September 1997
As the period of incapacity commenced prior to 1 July 1992 (i.e. 11 May 1992), this claim does not have to satisfy the 13 paid contributions entitlement (see paragraph headed 'Linking' below).
Linking
Social Welfare Consolidation Act 2005 Section 40 refers.
A person is entitled to IB in respect of any 'day of incapacity' for work which forms part of a 'period of interruption of employment'.
A day is not treated as a day of incapacity for work unless on that day the person is incapable of work.
A 'day of interruption of employment' means a day which is a day of incapacity for work or of unemployment.
Any 3 days of interruption of employment, whether consecutive or not, within a period of 6 consecutive days are treated as a period of interruption of employment. Any two such periods not separated by a period of more than 26 weeks are treated as one period of interruption of employment.
Any 3 days incapacity for work, whether consecutive or not, within a period of 6 consecutive days are treated as a period of incapacity for work and any two such periods not separated by more than 3 days are treated as one period of incapacity for work.
Neither Sunday nor paid holiday leave are treated as a day of incapacity for work while any two periods of incapacity for work separated by a period of paid holiday leave are treated as one period of incapacity for work. A person who was in receipt of Maternity Benefit on any of the 3 days prior to the day in respect of which a claim for Illness Benefit is made is not entitled to payment of Illness Benefit for the first 3 days of incapacity.
Waiting Days
Social Welfare Consolidation Act 2005 Section 40 refers.
A person is not entitled to Illness Benefit for the first 3 days of any period of incapacity for work. This means that a person does not get paid for the first 3 days that they are out sick. These are called "waiting days". Sunday is not counted as a waiting day.
Where a person attends his place of employment for work purposes and subsequently goes home sick at any time, this day is not counted as a waiting day i.e. it is not treated as a day of incapacity for work.
However, where not more than 3 days have elapsed between a previous claim for Illness Benefit, Jobseeker's Benefit or Allowance, Occupational Injury Benefit, Invalidity Pension, payment will issue from the first day i.e. no "waiting days" arise.
Examples of Linking Rules
Example 1
Monday and Tuesday → Illness Benefit
Wednesday and Thursday → Back to Work
Friday and Saturday → Illness Benefit
Monday, Tuesday and Friday are regarded as 3 waiting days. Illness Benefit is due for Saturday only. The two Illness Benefit claims are regarded as continuous for Illness Benefit purposes namely Illness Benefit is due for Saturday only.
Example 2
Wednesday and Thursday → Working
Friday → Illness Benefit
Saturday → Back to Work
Monday and Tuesday → Illness Benefit
Friday, Monday and Tuesday are regarded as 3 waiting days. No Illness Benefit is due.
Linking Provisions for Certain Illness Benefit Claims
- IB claims to benefit which are separated by more than three days of incapacity may be linked but may not be Link01, i.e. a continuous claim. This means that, in the case of those in receipt of Illness Benefit for a long period, the person must again satisfy certain qualifying conditions (i.e. s/he must have the required number of contributions in the governing contribution year or in a number of other specified tax years and have earnings of at least 300 per week (for claims before 5th January 2009 this amount was 150.00) to re-qualify for full rate benefit.
- The legislation has been amended to provide that, a claimant who on 1 st May 2007, was in receipt of Illness Benefit for a period of two years, has engaged in employment for less than 26 weeks and finds that s/he is unable to continue to work, re-applies for Illness Benefit, payment will be re-instated without the requirement to serve waiting days, and payment will not be made at a lower rate than that which the person previously received.
- Similarly, provision is made for a former recipient of Illness Benefit who transfers to Carer's Benefit or Carer's Allowance and immediately back to Illness Benefit, to receive Illness Benefit at a rate not lower than that previously in payment.
- Any two such subsequent periods of incapacity within that period of interruption of employment, not separated by a period of more than 26 weeks, shall be treated as one period of incapacity for work. This is to ensure that persons who find themselves unfit to continue working can revert to the original benefit to which they were entitled without the need to re-qualify.
- Where a person had been on a graduated or reduced rate of payment prior to his/her return to employment, s/he would revert to the corresponding rate on the resumption of benefit. However, this provision only applies if a person returned to employment for a period of 26 weeks or less before coming directly back to benefit.
Rates Structure
Full personal rate of Illness Benefit is payable where the person is otherwise qualified and has 'average weekly reckonable earnings' greater than 300.00 or more in the relevant tax year (for claims prior to 5th January 2009 this amount was 150.00. Where the person's average weekly earnings are equal to or less than 300.00(for claims prior to 5th January 2009 this amount was 150.00), reduced rates are payable and the rate is determined by reference to the appropriate earnings band.
Reckonable weekly earnings for this purpose are earnings derived from employment which was ensured at PRSI Class A, B, C, D, E, H, J and P.
Rates of payment are set out in the information booklet SW 19 ('Social Welfare Rates of Payment' for the relevant year).
Determining Average Weekly Earnings
Average Weekly Earnings are calculated by dividing the total reckonable gross earnings (i.e. without deductions) in the relevant contribution year by the actual number of weeks worked in that year.
Example:
Reckonable Earnings in GCY = 16,800
No of weeks of work = 35
Average Weekly Earnings = 480.00
If a person only worked one week in that year and earned 232.36 for that week, his/her reckonable weekly earnings would be 232.36.
Where a person had no earnings (i.e. credits only) or weekly earnings of less than 80.00 in the relevant contribution year, a notional earnings figure of 79.99 is applied and a reduced rate of IB is payable.
See paragraph on 'Reckonable Earnings' below for information regarding persons who worked in another Member State of the EEA during the relevant contribution year.
Reckonable Earnings
Earnings from Community Employment (CE) schemes insurable at class A or J are reckonable in determining 'average weekly earnings'.
Where a claimant has worked in another Member State of the EEA during the relevant contribution year, a 'notional' amount of earnings is credited in respect of each week of employment. This notional amount is equivalent to the average weekly earnings in that year for male and female workers in all industries as measured by the Central Statistics Office.
The average weekly earnings for the past few years are as follows:
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Year
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Average Weekly Earnings
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2006
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602.21 (for use on claims in 2008)
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2007
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629.42 (for use on claims in 2009)
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Volunteer Development Workers
Social Welfare Consolidation Act 2005 Section 41 refers
There are special provisions for persons making a IB claim having been a Volunteer Development Worker (VDW) in a developing country.
From 21 December 1993, Volunteer Development Workers who worked abroad for an organisation which was affiliated to the Agency for Personnel Services Overseas (APSO) did not require reckonable weekly earnings of a prescribed amount {earnings 150.00 or more per week} to qualify for full rate IB in respect of certain IB claims made on their return.
In effect, this meant that full rate IB was paid in such cases for:
(a) all IB claims made during the benefit year in which s/he returned to Ireland and
(b) all IB claims made in the succeeding benefit year, provided that all other qualifying conditions were satisfied.
Extension of Special Provision
1999 Social Welfare Act extended these special provisions to include an extra benefit year.
This means that full rate IB is now paid in such cases for:
(a) all IB claims made during the benefit year in which s/he returned to Ireland and
(b) all IB claims made in the two succeeding benefit years, provided that all other qualifying conditions were satisfied.
Night workers
Special rules apply to determine which day is to be treated as a day of employment where a person is employed to work continuously from one day into another. These apply so as to ensure that both days are not treated as days of employment or as days of incapacity.
The general principle is that the day on which the shorter number of hours are worked is treated as a day of incapacity (in respect of which IB is payable) and the other day is regarded as a day of employment (in respect of which IB is not payable).
There are exceptions to this rule as follows:
- The shift starts on a Saturday and extends into Sunday:
Saturday is considered to be the day of employment regardless of the number of hours actually worked on the Saturday.
- The shift starts on a Sunday and extends into Monday:
Monday is considered to be the day of employment regardless of the number of hours actually worked on the Sunday.
Payments to Persons in Receipt of certain Social Welfare Payments
(see also section on Payments to Persons in Receipt of Carer's Benefit or Allowance)
Illness Benefit is payable to persons who claim Illness Benefit and who are in receipt of any of the following SW payments:
- Widow's/Widower's Contributory Pension
- Widow's/Widower's Non-Contributory Pension
- Deserted Wife's Benefit or Allowance
- Prisoner's Spouse's Allowance
- One Parent Family Payment
Where the claimant is entitled to the full rate of pension or allowance, half the personal rate of IB only is payable for up to 15 months. No increase is payable for qualified child.
Where reduced rate pension/allowance is payable, the amount of IB payable is increased to make up for this reduction. The aggregate of the two payments is equal to the full amount of the pension or allowance (with no reductions) plus half the rate of IB payable.
Note: The total amount of IB payable in such cases cannot exceed the maximum rate of IB applicable to the case (i.e. the rate of IB that would be payable to the customer, including any increase in respect of qualified children, if s/he were claiming IB alone).
To calculate the amount of IB payable use the following formula.
Formula
IB Payable = A - B + C
Where
- A = Maximum Personal Rate on the other scheme
- B = Actual Personal Rate in payment on the other scheme
- C = Half IB Personal Rate (taking account of Graduation)
Example 1: Customer is receiving Personal Rate 151.80 on One-Parent Family Payment
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A
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=
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204.30
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B
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=
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151.80
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C
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=
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102.15
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IB payable
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=
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204.30 - 151.80 + 102.15 = 154.65
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Example 2: Customer is receiving Personal Rate 91.80 on One-Parent Family Payment
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A
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=
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204.30
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B
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=
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91.80
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C
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=
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102.15
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IB payable
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=
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204.30 - 91.80 + 102.15 = 214.65
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However, this amount exceeds the IB Personal Rate and consequently one of the following actions should be taken:
A. If an increase for a qualified child is not in payment,
Pay maximum Personal Rate of 204.30
B. If an increase for a qualified child is in payment:
Where the customer has an entitlement to increase for a qualified child, it may be necessary in some instances to select children for payment in order to arrive at the correct IB rate.
Deal with Example 2 as follows
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Enter Personal IB rate
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204.30
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Select 1 child
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26.00
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Total
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230.80
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Enter Reduced Rate Benefit of 15.65 wich leaves an IB rate of 214.65
Payments to Persons in Receipt of Carer's Benefit or Allowance
From 27 September 2007 a person who is claiming a Social Welfare Payment (other than Carer's Allowance or Carer's Benefit) or being claimed for as a Qualified Adult and who is providing full time care to another person may now apply for Carer's Allowance and retain their current payment in full. If they satisfy the conditions for Carer's Allowance it will be awarded at 50% of the personal rate they would qualify for if they were not in receipt of any other payment. They will also be eligible for Household Benefits and a Free Travel Pass.
Note: A person may not receive Jobseeker's Benefit/Allowance, Back to Work Allowance or Family Income Supplement and half rate Carer's Allowance but they may be a qualified adutl on these payments and receive half rate Carer's Allowance.
(See " Carer's Allowance" guidelines for more information)
Overlapping entitlements to IB and pensions or benefits from other countries
Social Welfare legislation does not preclude payment of full-rate Illness Benefit with a pension for survivors from another EEA Member State or a country with which Ireland has a bilateral social security agreement.
Where a claimant is in receipt of a Pro-Rata Pension from the Department based on a combination of contributions from this country and relevant periods in another EEA country or a country with which Ireland has a bilateral social security agreement, the payment of the Irish pension by this Department precludes payment of full-rate Illness Benefit. However, half-rate Illness Benefit may be payable.
Where a person covered by EU legislation is entitled to claim Illness Benefit under the legislation of Ireland or Short-Term Incapacity Benefit under the legislation of the UK for the same period of incapacity for work, then benefit is only due from this Department if the person last paid Irish social insurance contributions at the appropriate class.
Taxation of Illness Benefit
Illness Benefit has been reckonable as income for income tax purposes since 6 April 1993. The Department pays Illness Benefit directly to recipients without any deduction for tax.
To assist in the taxation of claims for Illness Benefit from employment, this Department notifies the employer of any claimant from employment the taxable amount of Illness Benefit to be taken into account for income tax purposes.
Illness Benefit (excluding any increases for child dependants), is considered as income for tax purposes and it is taxed from the first day of payment.
Blind Pension
Full rate Illness Benefit may be paid to persons who are in receipt of a Blind Person's Pension. Where a claimant to Illness Benefit is also in receipt of a Blind Pension, the personal rate and qualified adult and qualified child increases (where appropriate) for both Illness Benefit and Blind Pension are payable.
Increases for Qualified Adult/Qualified Child
Social Welfare Consolidation Act 2005, Section 43 & Statutory Instrument (S.I.) No 142 of 2007 refers.
Increases of Illness Benefit are payable in respect of a Qualified Adult and in respect of a qualified child. (See separate guideline on Dependants - Increase for a Qualified Adult or Dependant - Increase for a Qualfied Child). For claims made on or after 1st January 2007, a reduced rate of increase for a Qualified Adult may be payable where the spouse/partner has earnings/income of between 100.00 and 310.00 gross per week.
Increases for a qualified adult of an EEA national or of a person having the offical status of refugee or stateless person living in the EEA are payable notwithstanding the fact that such adults are resident in another Member State of the European Economic Area (EEA) or are not nationals of a Member State of the EEA.
Increases for Qualified Child
Social Welfare Consolidation Act 2008, Section 282 refers
Increase for a qualified child is payable up to when a child reaches 18 years of age. Where a child reaches 18 years of age and Illness Benefit remains in payment, the claimant is entitled to be paid in respect of that child for a 3 month period either when the child finishes 2nd level education or when the child completes the Leaving Certificate examination of the Department of Education and Science.
From September 2003 the payment of an increase for a child dependent was extended up to age 22 for dependents who are in full time education.
Where the person is a qualified child but is also entitled to or in receipt of a Social Welfare benefit or assistance payment in his or her own right, or where an increase for a qualified adult is payable in respect of that person, the increase for a qualified child cannot be paid in addition to the other benefit, assistance or allowance.
The increase is not payable in respect of a qualified child who resides with the claimant and the spouse/partner of the claimant where the spouse/partner has weekly income of 400.00 or more. The spouse's/partner's income is calculated in accordance with the legislation governing the determination of a qualified adult dependent.
Where the person's spouse or partner is residing with the person but is not a Qualified Adult, any increases for qualified child are payable at half of the standard rate where the spouse/partner has weekly income of 400.00 or less. This condition is effective from 19 January 2004 and does not apply to a person who, immediately before the 19 January 2004 was entitled to or in receipt of a payment which included an increase in respect of a child.
This saver shall continue to be effective for as long as the person continues to be entitled to or in receipt of the increase in respect of the child.
The full rate increase for a qualified child is payable where the person in receipt of Illness Benefit is receiving an increase for a Qualified Adult or is a lone parent who is not in receipt of One Parent Family Payment/Widow's Pension/Deserted Wife's Benefit (See separate guideline on Dependants - Increase for a qualified child).
In order to process claims for Illness Benefit it is necessary for all clients, their husband, wife, or partner and all children to have Personal Public Service Number (PPS No). Where a PPS No is not available or cannot be traced, this Department requires proof of date of birth (i.e. Birth Certificate).
This requirement is indicated on the Illness Benefit claim form. Where details are not fully completed on claim form, this Department issues a letter to the claimant requesting a birth certificate.
A Birth Certificate may be obtained at a reduced rate from the Superintendent Registrar for the area in which the birth occurred, provided the letter from this Department is enclosed with the application.
Extra Benefits
If a person is getting Illness Benefit, s/he may also qualify for:
- Smokeless Fuel Allowance, if s/he live in certain areas where the sale of bituminous fuel is banned and s/he has been getting Illness Benefit for 13 weeks
- Assistance under the Supplementary Welfare Allowance Scheme, for example, Back to School Clothing and Footwear Allowance
- Medical Card (administered by the regional Health Boards and subject to a means-test).
Civil and Public Servants recruited on or after 6th April 1995
Department of Finance Circular 6/95 refers
Civil and Public Servants appointed on or after 6th April 1995 pay Class A PRSI and are covered for appropriate benefits and pensions including Illness Benefit.
On Appointment, officers will be required to sign suitable mandates authorising the payment of any benefits due to them, under the social insurance system, directly to their employing Department. Staff who are absent due to Illness for more than 3 days, must submit Form MC1 to the Department of Social Protection. Also, on MC1 under 'payment method' they must indicate that any payemnt due, is to issue directly to their employer.
Sharefishermen/women
In the fishing industry, remuneration is often based on the of the value of the catch. Entitlement to Illness Benefit for Sharefishermen/women can be categorised by the following.
(a) PRSI Class A or J
Where a person is working in fishing and is paid by share of the value of the catch, s/he may be considered to be employed under a contract of service and thus insurable at PRSI Class A or Class J, as appropriate, and covered for appropriate benefits and pensions, including Disability Benefit.
If a person has paid Class S PRSI and has been working as an employee under a contract of service from 1992 or later, his/her PRSI contributions can be amended to Class A PRSI. Where the person's record has been amended to Class A PRSI and s/he meet the other qualifying conditions, s/he will qualify for social welfare payments including Disability Benefit.
(b) PRSI Class S
If a sharefisherman/woman is self-employed on his/her own vessel, or is operating as a partner in a venture, s/he will continue to be insured at Class S PRSI where his/her reckonable income is in excess of 3,174.34 per year.
Class S PRSI contributions do not carry an entitlement to Illness Benefit.
(c) PRSI Class P
Self-employed sharefishermen/women only can opt to contribute to an Optional Scheme which gives cover for certain limited benefits. Limited benefits in regard to Illness Benefit for PRSI Class P mean that persons have an entitlement to Illness Benefit for a maximum period of 52 weeks in any period of interruption of employment.
The personal rate of benefit payable to those who qualify based on Class P contributions is dependent on their reckonable weekly income in the governing contribution year.
In order to re-qualify for Illness Benefit a sharefisherman/woman must pay optional contributions in a tax year following the benefit year during which Illness Benefit exhausted. For example, if a claim exhausts on 1 March 2007, further optional contributions would have to be paid in the 2006 tax year to allow client requalify for benefit from 1 January 2008.
In October 2001, the High Court ruled that two named sharefishermen were not employed under contracts of service (i.e. employees) by their boat-owners/skippers. The Judge relied on a previous High Court case DPP-V-McLoughllin (1986), the main factors in that case which determined that a crew were not employees of the boat-owner but were partners in a joint adventure were :
- That each weekly voyage was a separate venture and no crew member had a contract that entitled him to take part in any subsequent voyages.
- Crew members did not receive payment of wages for participating in a fishing expedition but became entitled to a share in the net profits (if any), and
- Most importantly, although the boat-owner/skipper engaged each crew member he did not decide what the rate of remuneration would be; this was determined partly by custom (50% of the profits being allotted to the boat) and partly by agreement between the parties.
It follows from this judgement that sharefishermen/women working in circumstances where the three factors mentioned above apply and are paid solely by share of the value of the catch are likely to be self employed and therefore insurable at PRSI Class S rate of contribution provided that they have reckonable annual income of 3,174.00.
PRSI Class A
Despite the above High Court, many of the fishermen/women continued to pay PRSI at CLASS A. The position appears to be that contributions paid at CLASS A for share fishermen up to the 2000/2001 tax year are to remain as CLASS A (i.e. before the High Court decision) while those paid subsequent (in this case in 2002) are (or should be) at CLASS S.
Where a staff member comes across IB/ OIB claims in respect of sharefishermen/women in respect in payment based on paid contributions at PRSI Class A, the claims should be reviewed. These and any new IB/ OIB are being referred to Scope Section of the Department for a formal decision on insurability.
Duration of Payment
Social Welfare Consolidation Act 2005, Section 44 & S.I. 142/2007 refers.
Continuous Duration:
Refers to Illness Benefit claims made from 5th January 2009 only
- If the claimant has 260 or more contributions paid they can receive Illness Benefit for a maximum of 2 years.
For claims made before 5th January 2009. A person who has paid at least 260 reckonable PRSI contributions entitled to Illness Benefit for as long as s/he is incapable of work up to age 66. Persons who were in receipt of Illness Benefit on 4 July 1988 (when the figure of 260 was increased from 208) are entitled to 'continuous Disability Benefit' (now Illness Benefit since 02/10/2006) if their claim forms part of a period of incapacity for work which commenced before 4 July 1988 *.
*An example would be a person whose previous Disability Benefit claim commenced before 4 July 1988 and then transferred to Invalidity Pension. S/he subsequently transfers to Widow's/Widower's Contributory Pension and claims half the personal rate of Disability Benefit for 15 months. As the later claim is in the same period of incapacity which started before 4 July 1988, the person is entitled to payment for this further payment.
Limited Duration:
If a person has between 104 (see note below) and 259 weeks PRSI paid, Illness Benefit (whether at full, reduced or special rate) can be paid for up to a maximum of 52 weeks (312 days) in any Period of Interruption of Employment. At the end of this period the person needs 13 weeks PRSI contributions paid to requalify for benefit (or a smaller number if it brings his/her total to 260). Any days for which a person is disqualified from receiving Illness Benefit are counted in calculating whether s/he has received Illness Benefit for a period of 312 days.
Note: For IB claims made before 5th January 2009 this number was 52
Requalification after expiry of Illness Benefit
To requalify for Illness Benefit after expiry of 312 days a person requires:
- 13 contributions paid
- a lesser number contributions to be paid after expiry if it brings the total contributions paid up to 260.
A contribution paid in respect of a day(s) worked in the week of expiry may be regarded as one of the 13 paid contributions even if that day(s) was before the last day of entitlement.
A person may use relevant periods in other Member States of the European Economic Area ( EEA) where a person has insufficient Irish contributions - see earlier paragraph in this regard.
Jobseeker's Benefit or Assistance Payable Pending Illness Benefit Appeal
Where a person has been disallowed Illness Benefit because s/he has been found "capable of work" (i.e. his/her present state of health would not prevent him/her from resuming or taking up work) following an assessment by a Medical Assessor, it may be accepted that s/he fulfils the condition of being capable of work - notwithstanding any statement by the person that s/he does not consider him/herself to be capable of work.
This is so even if the decision of the Medical Assessor is under appeal. The person is entitled to apply for Jobseeker's Benefit or Assistance if s/he is not resuming employment even if s/he is appealing against disallowance of Illness Benefit. While the appeal is ongoing s/he should continue to send in medical certificates of incapacity for as long as his/her doctor considers him/her incapable of work through illness.
Pregnancy
Pregnancy, including confinement, is not considered to be an incapacity for the purposes of Illness Benefit. However,"Complications of Pregnancy" is an acceptable incapacity for Illness Benefit purposes.
IB Incapacities
"Debility" or "General Debility", "Gambling", and "Illness" are not considered to be acceptable incapacities for IB purposes. Any medical certificates received bearing these incapacities are returned requesting a more specific incapacity.
With regard to "Malaise", this is a 'general feeling of being unwell' and is an acceptable incapacity. Medical certificates with "Addiction" are accepted once the General Practitioner specifies that the addiction is drugs or alcohol related. Medical certificates are also accepted once the person is attending/awaiting treatment at the Rutland Centre, Cuan Mhuire or any other recognised treatment centre (list of centres held by the Higher Executive Officer in New Claims Section).
Defence Forces
Although NCO's and enlisted personnel of the Defence Forces pay PRSI at Class H which gives cover for IB, they are not entitled to claim Illness Benefit while serving. However, a person who has been discharged from the Army can claim Illness Benefit. His/her "Discharge Papers" must be submitted before the claim can be authorised. Receipt of an army pension by a person does not affect his/her entitlement to Illness Benefit.
DISQUALIFICATIONS
Social Welfare Consolidation Act 2005 Section 46 refers.
A person may be disqualified from receiving Illness Benefit for a period of up to 9 weeks if the person fails without good cause to comply with such requirements as may be specified by the regulations.
Imprisonment
A person is disqualified for Illness Benefit during any period where s/he is undergoing penal servitude, imprisonment or detention in legal custody.
Payment of any increase in respect of a Qualified Adult is disqualified during any period where the claimant's spouse/partner is undergoing penal servitude, imprisonment or detention in legal custody (See separate guideline "Imprisonment").
Trade Dispute
A person in receipt of Illness Benefit is not entitled to an increase for a Qualified Adult in respect of a spouse/partner who is or would be disqualified from the receipt of Jobseeker's Benefit or Jobseeker's Allowance because of participation in a trade dispute.
A claim for Illness Benefit may be received from a person who is disqualified from receiving Jobseeker's Benefit due to his/her direct interest or involvement in a trade dispute. Details of any such Illness Benefit claim may be recorded in New Claims Section and sent to MR Control Section for an urgent medical assessment.
Penalties
Penalties for false or misleading statements made to receive Illness Benefit include fines or imprisonment or both. (See separate guideline "Prosecutions".)
Payment after death:
SW Consolidation Act 2005, S248 Refers.
If a person dies while receiving Illness Benefit, payment will continue for 6 weeks after their death, to his/her spouse or partner if the payment
- included an increase for them as a qualified Adult (or would have except that they were getting another Social Welfare payment in their own right).
If a Qualfied Adult or a qualified child dies, the increase due for that person will continue to be paid for 6 weeks after death.
PART 2 CLAIMS, INVESTIGATION AND DECISION PROCEDURES
S.I. 142 of 2007, Part 7 refers
Claims
Claims for Illness Benefit are normally made on form MC 1, stocks of which are held by doctors, and should be made within 7 days of the person becoming ill. This form as well as being an application contains a section for the doctor's certificate.
The claim form should be submitted to:
Department of Social Protection,
PO Box 1650,
Dublin 1.
Applications forms may also be posted or handed in to the local Social Welfare Office.
If a medical certificate is received without the MC 1 application form, a claim form IB/OB 1 (comp) is issued for completion by the claimant. However, pending return of this form, a claim is opened based on the details on the medical certificate and is processed in the normal way.
If the medical certificate is not signed by the person, it is returned to him/her for completion. A claim is opened but not authorised until certificate has been returned properly signed.
Certain workers (see note below) (who are nationals of a Member State of the European Economic Area and persons who have the official status of refugee or stateless person) and who are in another Member State of the European Economic Area apply for Irish Illness Benefit through the relevant social security institution of the Member State in which they reside/stay. They do this by submitting a notification of cessation of work or a medical certificate (depending on the system operating in the country in which they live) to the relevant institution in the place where they live, within 3 days of the commencement of incapacity.
However, where a claim is submitted to the relevant institution within 21 days of commencement of incapacity, the date of claim is the date on which is was received in the relevant institution.
Note: See section "Payment while on holidays or abroad".
In the case of workers who are covered by EU legislation there is provision in that legislation for payment of benefit on a provisional basis where there is a dispute between the social security authorities or institutions of two or more Member States of the EEA over whose legislation should apply or who should pay benefit. In such cases the person concerned who could claim benefits if there was no dispute shall provisionally receive benefits provided for by the legislation of the Member State in which he is habitually resident. Where he is habitually resident in neither of the Member States involved, he can receive benefits in the Member State to which his claim was submitted in the first instance.
Intermediate Certificates
Illness Benefit is paid in arrears. This means that, other than in cases where the first medical certificate indicates a date on which the person is fit to resume employment, a further medical certificate is required before the claim can be put into payment.
Further medical certificates, referred to as 'intermediate certificates' are required for each week of incapacity. When a person is fit to resume employment (or be available to seek work), a final medical certificate is normally submitted indicating the date on which the person will be fit for work.
Claimants covered by EU legislation who are;-
- habitually resident in another Member State of the EEA e.g. frontier worker working in Ireland but living in Northern Ireland
or
- staying in another Member State of the EEA for the purpose of receiving medical treatment authorised by the Department of Health and Children or the Health Board
or
- undergoing emergency treatment during a stay (e.g. holidays) in another Member State of the EEA
or
- posted workers subject to Irish legislation while working in another Member State of the EEA
should submit a certificate of incapacity for work issued by a doctor providing treatment.
If doctors in that country do not provide certificates, the person should notify the social security institution of that country so that a medical assessment can be arranged. The medical report should specify the probable duration of incapacity. Any other medical assessments will be arranged as if the person were insured in that country.
Certification
Medical evidence of incapacity is normally furnished on the official form MC 1. However, certificates on the doctor's own notepaper are accepted in certain circumstances (e.g. person attended at Accident and Emergency in a hospital rather than his/her GP in the first instance).
For control purposes, claims for Illness Benefit on foot of doctor's own note paper are no longer accepted. Such claims will be registered but the medical evidence will be returned to the client with a request for an MC 1 or MC 2 to be obtained from his/her doctor.
Medical Certificates are only accepted from doctors who have been appointed as Medical Certifiers by the Department. Where a certificate is received from a person who has not been appointed a Medical Certifier, it is referred to the Department's Chief Medical Adviser for a recommendation as whether the evidence of incapacity is acceptable.
Medical certificates received from bone setters are referred to the Department's Medical Adviser for advice on whether the medical evidence is acceptable.
Please see previous paragraph on Intermediate Certificates for information concerning persons covered by EU Legislation.
Late Claims
SW Cons. Act 2005 S241 refers
Illness Benefit should be claimed within 7 days of becoming
incapable of work. However, a claim may be accepted up to 21 days from the date of commencement of illness. Where there is good cause for the delay in making a claim, the maximum period for which payment can be made is 6 months from the date of receipt of the claim in the Department.
See Separate guidelines entitled "Late Claims for Illness Benefit"
Decisions
All claims to Illness Benefit are examined by a Deciding Officer in Benefits Section. The contribution and earnings conditions to determine entitlement are investigated by reference to the PRSI records of the Main Central Records Section.
When a claim is decided and a rate greater than zero applies, the person is notified of his/her payment rate, along with general information on Late Claims.
Illness Benefit on form IB 8 (provided the claim does NOT open and close on the same medical certificate (MC 1)).
If a Deciding Officer disallows a claim to Illness Benefit, the customer must be informed of all the reasons that the claim to Benefit is being disallowed.
A person who is not satisfied with the decision of the Deciding Officer on his/her claim may appeal the decision to the independent Social Welfare Appeals Office within 21 days of the date of the decision. In advance of an appeal the customer can seek a review of the decision by another Deciding Officer. ( See separate GUIDELINE on Appeals)
Any claim, declaration or appeal relating to Irish Illness Benefit made to the appropriate institution of a Member State of EEA is accepted by the department. The date of receipt of a claim, declaration or appeal in the appropriate institution is the date of submission of a claim, declaration or appeal to this Department.
Participation in Trade Dispute
Where a person is participating in a trade dispute, the case may be referred for medical assessment before a decision on entitlement is made.
Where a person who is in receipt of a Pre-Retirement Allowance* claims Illness Benefit, and the rate of the allowance is equal to or greater than the IB rate which would be payable, the allowance may continue in payment. In such cases the person is requested to submit medical certificates for credit purposes only.
Where the rate of the allowance is less than the rate of Illness Benefit which would be payable, the person is paid the difference between the two (i.e. the IB entitlement less the amount of the PRETA allowance) by Benefits Section.
Persons who are in receipt of Pre-Retirement Allowance are not referred for Medical Referee assessment.
Note: Refers to claims before 4th July 2007 as PRETA was abolished for new applicants from this date.
Illness Benefit/Disability Allowance claimants
An applicant for Disability Allowance to whom Illness Benefit is payable (but at a reduced rate of payment) may opt to forgo the Illness Benefit payment in order to receive Disability Allowance at a higher rate (when adjustment has been made to take account of means, if any).
Where this option is implemented (i.e. the IB payment ceases), it is no longer necessary to keep the claim open for credit purposes. Disability Allowance Section in Longford now allow credits retrospectively when the Disability Allowance claim closes e.g. when the client goes to the State Pension.
When a person on Illness Benefit becomes entitled to payment of Disability Allowance, the Disability Allowance Section advises him/her that it is no longer necessary to send in medical certificates.
No new Illness Benefit claim is opened in any case where the client is receiving a Disability Allowance payment. Instead the medical certificate is returned to the client along with an explanatory form.
Pre-Entry Credits (PECs)
Persons who paid PRSI (Class A, E, H or P) for the first time between the start of the relevant GCY and the date of the claim, are entitled to credited contributions in order to satisfy the 2nd contribution condition of IB.
When it is confirmed that 104 contributions (1st condition) have been paid, PECs are awarded from the beginning of the contribution year in which the date of entry (DOE into Irish insurable employment) occurs, up to the date of entry, and also the previous two contribution years.
If a person's first PRSI contribution is not reckonable for IB, i.e. at a class other than A, E, H or P, Pre-Entry credits awarded will not satisfy the 2nd contribution condition.
Student Credits
Student credits are awarded where the claimant was a full-time student during the relevant GCY and had contributions paid prior to attending college/during the period spent at college. The condition for the award of student credits are as follows:
- the person must have 104 contributions paid since date of entry into insurable employment
- the course must have been full-time and commenced before the claimant was 23 years of age
- the person must have re-entered insurable employment after the course of education ceased and
- a letter from College must be submitted to confirm duration of the course.
Student credits are awarded from the beginning of the contribution year up to the date the person re-enters insurable employment, and for the previous two complete tax years. Student credits may be awarded once only.
PART 3: PROCEDURES FOLLOWING AWARD
SW Cons. Act 2005. Section 242 & S.I. 142/2007 refers
Payment
Illness Benefit is paid weekly in arrears on receipt of required medical evidence. There is no fixed date of payment and the first day for payment purposes is the first day of incapacity, excluding Sundays which is not counted for payment purposes.
Generally, Illness Benefit is paid up to the date on the last certificate received for people who are sending in certificates weekly. Autos (i.e. persons on monthly certificates) are paid weekly in advance e.g. a cheque issues on a Monday paying to the following Saturday.
Payment method
Payment is mainly made by cheque or Electronic Funds Transfer (EFT) directly into a Bank or Building Society account. Certain long-term Illness Benefit customers were formerly paid by book through the post office network but this practice has ceased. Some of these customers have opted to continue to be paid by postdraft which helps a person maintain their link with the post office.
Maintenance
Stop/Review dates are inserted in computer system for appropriate dates e.g. person reaches pension age, qualified child reaches 18 years of age, review of earnings for spouse/partner, etc.
If a cheque payment is lost or not received by the person, s/he is required to complete a Form of Indemnity to the effect that s/he has not received/lost his/her payment. A replacement cheque may issue on foot of this statement.
The Form of Indemnity provides that should an overpayment of IB occur as a result of two payment instruments being cashed by him/her in respect of the same period, the overpayment must be refunded to the Department.
Frequency of certification
Customers are normally required to submit medical certificates of incapacity on a weekly basis. Where a customer has been incapable of work for 6 months s/he will normally be required to certify once every four weeks. For certain serious illnesses a customer will be advised to submit a medical certificate at four-weekly intervals shortly after commencement of the claim.
Customers who are still incapable of work after 3 years will normally be required to certify only once every 6 months. Customers are advised of any changes in frequency in submitting of medical certificates.
Over 65 and over 66 years
Claimants are advised in writing 3 months before their 65th birthday, to apply for State Pension (transition) and 3 months before their 66th birthday to apply for the State Pension (Contributory/Non Contributory).
Claim forms for above pensions issue with the advice letter to claimants. State Pension (Transition) is not payable in conjunction with Illness Benefit.
When the claimant reaches 66 years of age, payment is ceased as s/he has exhausted his/her entitlement to benefit.
Stop Dates
Stop dates for claimants reaching 65 and 66 years of age, qualified children reaching 18 years of age are put into automatically when a claim is being authorised. Other stop dates for review purposes (for example, awaiting on confirmation of EU contributions, person on Illness Benefit with Maternity Benefit also being claimed) are inserted by the user, usually when claim being authorised.
Medical Referral Assessments
During the course of a claim to Illness Benefit, a person may be asked to attend for medical assessment by a Medical Assessor for a second opinion as to whether s/he is incapable of work.
(See separate guideline on "MED_ASSESSMENT").
The opinion of the Medical Assessor following this assessment is submitted to a Deciding Officer for consideration regarding the claimant's continued entitlement to Illness Benefit.
In any case where payment of Illness Benefit is disallowed, the person is notified of the decision and advised of his/her right to appeal against the decision.
For persons in another Member state of the EEA referred to in the paragraph headed Intermediate Certificates, medical assessments on behalf of the Department are carried out in the country in which they are staying/residing at the request of this Department.
Payment while on holidays or abroad
Overall, a person going to an EEA Member State is entitled to be treated as if s/he never left the State, regardless of the reason for leaving the State.
However, as the continued issue of payment(s) is dependent on the receipt of medical certificates the person should notify the Department (where possible) in advance to ensure that payment continues e.g. switched from medical certification to monthly certification.
A person who wishes to go to a non- EEA country for health reasons, may be entitled to Illness Benefit for the duration of his/her absence. While each case is treated on its own merits, a decision would take into account factors such as duration of claim at time application is received, nature of incapacity and likely period to be spent abroad.
In any event the person must notify the Department in advance of departure and is paid for the period of absence on his/her return.
Claimant in hospital
IB is paid whilst a person is in hospital. If s/he does not want the payment to be sent to him/her there, payment can be made to any person, over 16 years of age, nominated by the claimant to look after his/her affairs. (See separate guideline on "Payments")
Incapacity Gap
Where the decision of the Deciding Officer in any case that a person is capable of work is upheld on appeal by an Appeals Officer, but the Appeals Officer applies his/her decision from the appeal from a date later than that of the Deciding Officer, (i.e. there is a gap between the date of disallowance by the Deciding Officer and the effective date of the Appeals Officer's decision), the Deciding Officer may, following consultation with the Chief Medical Adviser, allow payment for the period of the gap if s/he is satisfied that the person was incapable of work during that period.
IB Appeal Credits
A person is entitled to a credited contribution for each week of incapacity (See separate guideline on "Credit Awards"). Where a person has been disallowed IB and appeals that decision, credits are awarded up to the end of the week following that in which the Appeal Officer's decision issued to him/her.
In cases where, following a capable decision by the Appeals Officer, the person continues to submit medical evidence of incapacity, s/he may be be referred for periodic medical review.
Social Welfare regulations provides for the award, at the Minister's discretion, of credited contributions to a client who has been found capable of work by an Appeals Officer.
Special credits are awarded from the date of disallowance of IB/ OIB up to the end of the contribution week following the week in which the Appeals Officer's decision is issued to the client. The credits are allowed solely to ensure that a client would not have a gap in his/her insurance record pending the outcome of the appeal and the period for which such credits are allowed is not a period of incapacity for work within the meaning of the Social Welfare Acts.
Such periods cannot, therefore, be used for linking purposes.
Where a claimant, who has been found 'capable on appeal', has been receiving Jobseeker's Benefit or Allowance or has been signing for JB/JA credits during the entire appeal period, no special credits will be allowed as the unemployment credits are valid in such situations.
Where a client, who has been found 'capable on appeal', has not been receiving Jobseeker's Benefit or Allowance or has not been signing for JB/JA credits during the entire appeal period, special credits will be allowed only in respect of the period(s) for which no JB/JA credits have been awarded.
EXAMPLE: If the client did not sign on for 2 weeks after the disallowance of IB, special credits would be allowed for those weeks only; if a client exhausted JB entitlement before the end of the appeal period and did not claim JA or sign for JA credits subsequently, special credits would be allowed from the day following JB Ben EX.
In any case where a client has been signing on pending the outcome of an appeal, the SWLO should be notified if the client loses the appeal. The reason for this is that during the appeal period, the Local Office does not review such claims regarding the client's satisfying the condition of "genuinely seeking work".
In the event that the appeal fails, the Local Office may wish to pursue this aspect with the client.
Health and Safety Benefit - Implications for payment of IB
Illness Benefit is not payable where a person is being paid Health and Safety Benefit by her employer in the 21 day period before payment of Health and Safety Benefit.
Special payment arrangements
Special arrangements can be made, where necessary, to ensure that the spouse and the children of a claimant get a portion of the weekly payment paid directly to them. Where a claimant claims for a qualified adult increase in respect of a spouse or partner who is not living with him/her, a questionnaire (form DB 46) may issue to the spouse/partner to obtain details in relation to income from employment/Social Welfare payment, maintenance being paid by claimant, whether support is voluntary or under Court Order, etc.
Assessment of Damages in Civil Cases
In cases where a claimant brings a civil action, account shall not be taken of Illness Benefit when assessing damages at common law. However, Illness Benefit is assessable,
(a) in any court action for personal injury relating to the use of a mechanically propelled vehicle insurable under the Road Traffic Acts or
(b) in any other action relating to the use of a mechanically propelled vehicle,
for the period of 5 years beginning with the time when the cause of the action accrued.
Part 4: General Provisions that apply to Scheme
Previously Found capable
Where a person was previously found capable of work by a Medical Assessor and subsequently submits a fresh claim in respect of the same incapacity, payment is not normally authorised until the person has attended for medical assessment.
Where a person previously found capable of work by a Medical Assessor submits a fresh application for a different incapacity, payment may be allowed and the person referred for an early medical assessment.
Medical assessments carried out in another EEA country on behalf of this Department are taken into account in determining whether a person is capable or incapable of work.
Payment to appointed persons
Social Welfare Consolidation Act 2005, Section 244 & S.I. 142 of 2007 Sections 201 - 208 refer
Where a claimant requests that payment issues to a person other than him/herself, the name being used for payment purposes may be changed. For all cases, other than where a person is in hospital a submission is made to an Higher Executive Officer outlining the reason for this change in procedure and, where appropriate, requesting a decision as to whether a proposed medical assessment referral should be deferred and if so, for what period.
Overpayments
Social Welfare Consolidation Act 2005, Section 335 & S.I. 142 of 2007 Sections 242 - 249
Regulations provide for a Code of Practice on the Recovery of Overpayments. The Code specifies the circumstances in which this Department may or may not pursue repayment of monies by a customer who was overpaid benefit. A copy of the Department's Information Leaflet on the Code (leaflet SW 2) is issued to the claimant when s/he is being notified of the overpayment relating to the Illness Benefits scheme.
(a) Procedures for recovery of overpayment
In advance of an overpayment being assessed, the Department applies the principle of natural justice and advises the customer how the overpayment has arisen and inviting him/her to submit comments before a formal decision on the overpayment is made.
Fourteen days are allowed for a reply to be received. Where there is no reply or the reply does not alter the case, the overpayment is formally assessed against the person. Forms IB OR1 and IB OR2 or a decision letter are/is issued to inform the customer of the amount of the overpayment and the intended level and method of recovery, giving the right of appeal.
Form DB OR3 which is held with the claim papers is used for recording details of the overpayment and the recovery method as determined by the Deciding Officer.
(b) Determining level of recovery, right of appeal
When deciding on the level of recovery, regard is had to the financial and family circumstances of the customer. The Deciding Officer does not normally reduce the customer's weekly payment below the Supplementary Welfare Allowance (SWA) level as it is accepted by the Department that customers are entitled to a minimum level of income. However, where the customer's spouse has other income (e.g. from employment or other SW payment) then SWA level does not have to be applied.
Similarly with regard to customers who qualify for reduced IB the overpayment is not recovered unless there is other substantial income in the household.
(c) Regarding the method of recovery the following methods may be used
(i) withholding arrears which may be due to the customer,
(ii) making deductions from ongoing or future payments,
(iii) a single payment to repay the overpayment in full,
(iv) weekly repayments,
(v) seek recovery of overpayment from an employer (where appropriate *).
*an example, would be where overpayment arose through concurrent working and claiming and the employer was obliged to and failed to notify the Department of the commencement of employment.
(vi) seek recovery by requesting the social security institution of another Member State of the EEA to deduct the amount of Irish Illness Benefit overpaid from the amounts of benefits which it is responsible to pay. The social security institution of another Member State of the EEA makes the deductions under the conditions and within the limits provided for the setting off of benefits under its own legislation and treats the Irish overpayment as if the sum had been overpaid by itself and transfers the amounts deducted to this Department. (The rule also applies in reverse - social security institutions of other Member States of the EEA can seek recovery of overpayments from our Illness Benefit). See Article 111 of Council Regulation ( EEC) No. 574/72.
(vii) where a person was paid social assistance by the social security institution of another EEA Member State during a period when s/he was entitled to Illness Benefit under our legislation, the institution which gave the assistance may request the Department to deduct the amount of assistance from the amount of Illness Benefit which the Department pays. The institution requesting recovery must be legally entitled to reclaim the benefits from the person concerned.
(d) Appeal
Where the customer lodges an appeal to the independent Social Welfare Services Appeals Office (within 21 days) against the decision to set up an overpayment, the Deciding Officer suspends further recovery action until the appeal has been decided. If a late appeal is accepted after 21 days has elapsed and the recovery procedure is already in place then the recovery continues pending the outcome of the appeal.
The date of receipt of an appeal relating to Illness Benefit by an authority, institution or tribunal in another Member State of the EEA which should have been submitted to the Social Welfare Services Appeals Office is treated as the date of receipt of an appeal by the latter. The authority, institution or tribunal in another Member State of the EEA sends the appeal without delay to Ireland - see form E212.
Conditions while receiving Illness Benefit
While receiving Illness Benefit, claimant must not:
- become incapable of work through your their misconduct,
- fail, without good reason, to attend a medical assessment by a Medical Assessor of the Department,
- fail to obey their doctor's instructions,
- behave in a way that is likely to delay their recovery,
- fail to see any Officials from this Department and answer reasonable enquiries concerning their claim.
Claimants must get written permission from the Department before starting:
- an approved training course with a view to taking up some other occupation.
Claimants may do the following types of work without getting written permission from the Department before starting:
- light work for which no payment is, or would normally be payable,
- work which is done as part of treatment while claimants are a patient in hospital or other similar place provided the earnings are not more than EUR 50 per week,
- work done under a charitable scheme, provided that the earnings are not more than EUR 50 per week.
Application for permission to commence education or training while in receipt of Illness Benefit.
It is open to any Illness Benefit claimant to apply for permission to commence education or training while in receipt of Illness Benefit. However, the claimant has to be in receipt of Illness Benefit for at least 6 months. This is to allow the Department to have the applicant referred for a medical assessment which might help decide whether the person will benefit from such training/ education.
A person wishing to apply for such permission must:
a) make an application on the official Form IB141
This form asks the person to give details of the proposed training course, the activities involved, how illness affected previous employment, how proposed training will improve the person's condition and enable him/her to resume usual type of work or begin new work, etc. In the case of a training course, the person is asked to furnish a letter from the Training Organisation. (This requirement is not necessary in the case of applications made via FÁS - see below).
b) furnish a report from his/her GP on the official Form IB141A
This form asks the doctor to furnish a confidential medical report on the person's medical condition, treatment, additional information and to indicate the degree to which the person's condition has affected his/her functional capacity.
FÁS
Applications made through FÁS
Where the person is seeking permission to take up Community employment or a training course arranged by FÁS, a special form, which is available at FÁS offices - should be completed. This form is forwarded by FÁS to the Department for consideration. (Any such applications received in the Department direct from Illness Benefit claimants are returned to the applicants for submission via FÁS). On receipt from FÁS of the special form, Illness Benefit Section will issue forms IB141 and MR33 to the person concerned for completion.
FÁS Specialist Training Provision:
There is no requirement to complete Forms IB141 and IB141A where the FÁS application is for specialist training for persons with disabilities. Such applications are normally processed without reference to a medical assessor.
Community Employment (CE)
An application made in respect of a CE Scheme involving work to be done for rehabilitation purposes must be made through FÁS. Applications received directly from IB claimants are
not accepted.
Opinion of Medical Assessor
The completed form is forwarded with the claim papers to one of the Department's Medical Assessors for an opinion whether the proposed training is in the nature of rehabilitation or occupational therapy. In expressing an opinion the Medical Assessor will weigh up all of the evidence, including medical evidence held on file in the Department about the person's health, the information furnished about the training by the person and the medical evidence from the doctor/consultant submitted on his or her behalf.
If the Medical Assessor considers that further information is needed about the proposed training before coming to a conclusion in a case, s/he will ask the Illness Benefit Section to contact the person for it. The Medical Assessor may also ask the Section to invite the person to submit more detailed medical evidence.
Further Education Courses
Persons in receipt of Illness Benefit who advise that they are participating in education courses, which do not have a work content, are not treated as an application to commence education cases as these courses are not regarded as constituting training or part-time work.
Where a claimant informs the Department that s/he intends
participating on a full time 2nd or 3rd course, the following details are requested in order to process the application:
- a written request from the person concerned
- a letter from his/her GP indicating that participation in the proposed education course is not likely to have an adverse effect on the person's health and is not likely to retard his/her recovery
- a letter from the College giving details of the course and
duration of the course together with confirmation that the
applicant has been offered a place on the course.
Vocational Training Opportunities Scheme (VTOS)
While Illness Benefit is not designated as a qualifying payment for VTOS nonetheless Illness Benefit claimants are allowed to participate on VTOS courses provided his/her GP confirms in writing that participation on the course is not likely to have an adverse effect on the person's health and is not likely to retard his/her recovery.
Where a person on VTOS applies for Illness Benefit, the Department issues form IB 127 to the relevant college to inform them whether the person is eligible for payment of IB.
NOTE: IB claimants participating in further education courses (including VTOS) are subject to the normal medical referral control courses.
Back to Work Allowance (BTWA) - closed to new applicants from 1/5/09
Back to Work Enterprise Allowance (BTWEA) Refers to claims made on or after 5/1/2009
Back to Work Enterprise Allowance is payable for 2 years while self employed. Claimants will receive 100% in year one and 75% in year two. Claimants must be in receipt of a qualifying payment for 3 years immediately prior to commencing employment and accessing BTWEA. The period on Illness Benefit can count towards the qualifying period for the purpose of accessing BTWEA.
Back to Education Allowance
Claimants in receipt of Illness Benefit for at least 2 years (see note below) and who want to return to education, may transfer to the Back to Education Allowance (BTEA) scheme. See information booklet SW 70 for more information.
Note: This applies from September 2007
Vocational Training Opportunities Scheme (VTOS)
Claimants in receipt of Illness Benefit for at least 6 months, may apply to take up a course of education under the Vocational Training Opportunities Scheme (VTOS). Claimants must first get written permission from the Illness Benefit Section to join this scheme. See information booklet SW 70 for more information.