Recently, the Social Insurance Institution often initiates investigations that may result in the withholding of benefits or the obligation to repay them with interest. Below are the protections available to the insured in such situations.
Reasons for withdrawal of the right to sickness or maternity benefits by the Social Security Administration.
It is not uncommon for the Social Security to determine during its investigation that an insured person is not entitled to receive benefits. This is most often the case for those on sick leave who, during this time, performed gainful employment or used the leave in a manner inconsistent with its purpose (in the practice of the law firm, it happened, among other things, to question the right to benefit due to the insured’s participation in sports during sick leave). Denial of the right to a benefit is also sometimes a consequence of recognizing that the title to insurance (e.g., an employment contract) does not exist or is bogus – more on the problem of bogusness in THIS ARTICLE.
Withholding of benefits occurs when the Social Insurance Institution determines that the right to receive benefits has ceased or that such a right did not exist at all. This applies when the insured is in the process of collecting the benefit. On the other hand, if the benefit has already been collected, as a rule, the authority may deduct the amounts from other current social security benefits or collect them from the insured person through enforcement.
Withholding of benefits or obligation to repay – appeal to court
The insured has the right to appeal the Social Security decisions in question to the district court within 30 days of receipt. Since the authority does not use registered mail that allows clear indication of the date of delivery, it is usually necessary to rely on the date the package was removed from the insured’s mailbox.
Significantly, it is common practice for the Social Insurance Institution to issue a decision to withhold the benefit payment or to obligate the insured to return it, despite the fact that there are simultaneous proceedings for being subject to social insurance (this is a situation where the insured has previously challenged a decision on not being subject to social insurance and the case is pending before the court). It is then necessary to remember to include in the appeal a request to suspend the proceedings until the “insurance” (subordination) proceedings are legally resolved. In fact, the outcome of the first “insurance” proceeding largely affects the outcome of the “benefit” proceeding (if the court finds that the insured was subject to insurance at a certain time, it will usually mean that he is entitled to benefits, and vice versa – if he was not subject to insurance, he is not entitled to benefits).
As for the arguments to be raised in an appeal to the court, they will depend on the specific situation in each case. Since there are many grounds on which the Social Security Administration can base its decision, it is worth looking at the justification for the decision and, in the first instance, referring precisely to the content of the justification.
Zakład Ubezpieczeń Społecznych coraz częściej wszczyna kontrole mające wykazać, że pracownik nie podlega ubezpieczeniu, ponieważ umowa o pracę była zawarta wyłącznie dla pozoru. W konsekwencji ZUS odmawia wypłaty świadczeń lub zobowiązuje do ich zwrotu.
