INSS returns to grant sick pay without expertise; see the rules

With the scheduling of medical examinations only for 2023 in some parts of the country, the INSS (National Social Security Institute) returned to grant sickness benefit without the insured person having to undergo the institute’s examination, releasing the benefit only with the presentation of medical certificate.

The rule, which came into effect this Friday (29) with the publication of an ordinance in the Official Gazette regulating the subject, was already used at the height of the Covid-19 pandemic to release aid for temporary incapacity. The measure is temporary and is valid only in places where the wait for the exam is longer than 30 days.

The expectation with the new procedure, according to the vice president ANPM (National Association of Expert Doctors), Francisco Eduardo Cardoso Alves, is to reduce the queue of expertise by half until November, with the service of about 500,000 policyholders.

“Actually, if it reaches 500,000, it’s the equivalent of a normal month’s worth of forensic work. So the idea is to regularize the queue”, he says. The association, which has always been against the release of benefits without expertise, is not opposing the initiative, as it has done on other occasions.

The possibility of releasing sickness aid without expertise by the INSS was already included in provisional measure 1.113/2022. The ordinance regulates the MP and is valid for 30 days, and can be renewed for an equal period. The matter, however, needs to be debated by Congress.

The insured’s removal period must be up to 90 days. In addition, assistance without expertise is not valid for benefits of an accidental nature, that is, those linked to illness or work-related accident. Those who already have marked expertise can also opt for document analysis.

Queue reaches 1 million

In May, according to Sheet published exclusively, the INSS had more than 1 million insured in the medical examination queue. The waiting time for care, which may extend until 2023, was aggravated by factors such as the strike of medical experts, the closing of agencies during the pandemic and the lack of servers with the retirement of much of the staff.

“The INSS did not take the initiative to replace employees, the public tender did not come out, and therefore there is a deficit in employees. The national queue is very large, so it is a mitigating measure within this scenario to mitigate the situation of those who need income while they are disabled”, says Rômulo Saraiva, a lawyer specializing in Social Security and a columnist for Sheet.

Lawyer Adriane Bramante, president of the IBDP (Brazilian Institute of Social Security Law), sees the assessment of the right to sick pay only through documents as a way out to ease the long wait for expertise.

“The situation of face-to-face expertise is really chaotic. There are agencies that don’t have expertise, agencies that don’t have an expert, people who live far away, anyway. So remote expertise, or non-expertise, based on documents, is an alternative , especially in these more difficult cases.”

For Roberto de Carvalho Santos, president of Ieprev (Institute of Social Security Studies), the measure is good, but care must be taken in case of denial of the benefit. According to him, it is not clear whether the insured person who is denied the benefit will receive a report explaining the reasons for the denial.

“We keep questioning, in cases where the benefit is rejected, how it [o segurado] will be able to question the arguments, if it does not have a conclusive opinion on why the expertise was rejected”, affirms Santos.

“The legislation itself requires this conclusive opinion, from the doctor, and consequently this even prevents a broader questioning when the person goes to seek a lawsuit, since there can be no administrative appeal, they need to present the medical opinion, and it is this medical opinion that will be analyzed by the official expert”, he says.

How will the release of sickness benefit without expertise be

To get help without going through medical expertise, the sick insured person will have to send documents through the My INSS app or website. The analysis will include the medical certificate or report legible and without erasures, containing the following information:

• Insured’s full name
• Date of issuance of the certificate or report, which must be less than 30 days from the date of entry of the application
• Disease information or ICD (International Classification of Diseases)
• Signature of the professional issuing the document and identification stamp, with registration of the class council
• Rest start date
• Estimated time required for recovery

The time of removal, in these cases, is limited to 90 days. Anyone who needs to stay away for a longer period for recovery must undergo an expert examination. In addition to the documents required by regulation, the citizen also needs to send a copy of personal documents. Just take pictures and attach in the process.

By law, the INSS has a period of up to 45 days to respond to requests for sickness benefits, according to the agreement reached with the STF (Supreme Federal Court). If the agency takes longer, the worker can go to court. If the answer is no, it is possible to file an administrative appeal with the institute or seek the Judiciary.

Unlike what happened in the pandemic, there is no value limitation to grant aid without expertise. At the time, the institute paid only the value of a minimum wage. If the citizen had the right to a higher income, he should schedule an expert examination so that the difference in value could be released.

According to Alves, the role of medical experts will be to analyze the documents so that there is no fraud. “Our role is only to analyze the document’s compliance, we will not go into the merits of whether there is incapacity or not and we will not issue a value judgment on the document brought by the insured.”

The vice president of the ANMP says that the queue varies according to the locations and that where there is a queue until 2023 are places where there were already chronic scheduling problems due to the lack of experts. “In São Paulo, for example, the scheduling is not for 2023 yet. It is not even for September.”

wanted by Sheetthe INSS and the Ministry of Labor and Welfare had not manifested themselves until the conclusion of this text.

_{Workers who contribute to the INSS (Instituto Nacional do Seguro Social) can use the Sheet to estimate how much they will earn from retirement. To make the query, enter how many years are left until retirement and an approximate value of the average salary in the retirement calculator.}