Who Pays for Health Insurance While You Are on Workers' Comp in California?

Who pays for health insurance while you are on workers' comp in California?

Workers' comp will not cover your health insurance premium. That is a separate question from your medical treatment, and the answer usually depends on separate leave law, not on your workers' comp claim itself.

People asking this question are usually asking about two different things at once. The first is the medical care for your work injury itself. Your employer's workers' comp coverage pays that directly and in full, with no premium and no copay. The second is your regular group health plan, the one that covers everything else: other doctor visits, prescriptions, your family's care. Workers' comp law has nothing to say about that second kind of coverage.

What actually controls your group health plan while you are off work is the California Family Rights Act (CFRA) and the federal Family and Medical Leave Act (FMLA), plus COBRA once that leave runs out. None of those three leave laws are part of your comp case, but all three often apply at the same time as one.

Does a workers' comp claim cover your health insurance premium?

No. Workers' comp pays for the treatment your work injury needs, not a monthly health insurance bill.

Under Labor Code 4600, your employer must provide and pay for all medical care reasonably needed to cure or relieve the effects of your work injury, with no copay to you. Our Labor Code 4600 guide covers that duty in full. That rule pays doctors and hospitals directly for injury-related care. It has no mechanism for paying a health insurance premium, because a premium is not how workers' comp medical care gets billed.

Who pays your group health plan premium if you also qualify for CFRA or FMLA leave?

Your employer generally must keep paying its usual share, on the same terms as if you were still working, for up to 12 workweeks.

Will my employer continue to pay for my health coverage? Yes. Your employer must pay for the continuation of your group health benefits if your employer normally pays for those benefits.

A serious work injury often also counts as a "serious health condition" for CFRA and FMLA purposes, so the same time off can trigger both at once. Our guide to FMLA, CFRA, and workers' comp running together covers who qualifies: generally 12 months of service and 1,250 hours worked in the past year, plus an employer with 5 or more employees for CFRA or 50 or more within 75 miles for FMLA. Government Code section 12945.2 is the California statute behind this. While you qualify, your coverage keeps running at the level it was before your leave. In practice that usually means you keep covering whatever share already came out of your paycheck, often by paying your employer directly since there is no paycheck to deduct it from, while your employer keeps covering its share.

What happens to your coverage once that leave runs out but you are still on workers' comp?

The legal requirement to keep paying ends with your CFRA or FMLA leave, even though your underlying injury claim can run much longer.

CFRA and FMLA together cap out at 12 weeks in a 12 month period for your own condition. Your wage replacement through temporary disability can continue for up to 104 weeks within 5 years for most injuries under Labor Code 4656, so it is common for a serious injury to outlast the leave law that was paying for your health coverage. Once that 12 week window closes, nothing in workers' comp or CFRA forces your employer to keep paying your premium.

Once the employer-paid period ends, you may still be allowed to stay on the group plan under whatever rules apply to an ordinary unpaid leave at that job, which can mean paying the full premium yourself going forward. If your coverage ends instead of continuing that way, that loss of coverage is normally a COBRA qualifying event. COBRA is a federal law that lets you and your family keep the same job-based plan for a limited time, usually up to 18 months, according to the U.S. Department of Labor. You usually pay the full premium amount yourself under COBRA, unless your employer agrees to cover some or all of it as part of a separation.

Can your employer bill you later for the premiums it paid?

Only in a narrow situation: you do not return to work after your leave ends, and the reason has nothing to do with your injury continuing.

Government Code section 12945.2 lets an employer try to recover the premiums it paid during your leave, but only if two things are both true: you fail to return to work once your leave entitlement runs out, and the reason you do not return is not the continuation of the same serious health condition that qualified you for leave in the first place, and not some other circumstance beyond your control. For most ongoing workers' comp injuries, not returning is exactly because the injury is continuing, so that condition is usually not met. Ask your employer or plan administrator directly if this ever comes up; do not assume you owe money back without checking the actual reason being claimed.

What if you do not qualify for CFRA or FMLA at all?

Then no state or federal leave law forces your employer to keep paying your premium, so ask your employer directly and look at COBRA if your coverage ends.

Not every worker qualifies. You may be too new, not have enough hours yet, or work for a very small employer. In that situation, whether your group coverage continues while you recover is a matter of your employer's own policy, not a workers' comp right. If your employer stops your coverage, that is usually a COBRA qualifying event, which still lets you keep the same plan temporarily by paying for it yourself.

Start by asking your employer's human resources department or your plan administrator, in writing, whether your group health coverage is continuing and who is paying for it. That written answer is worth more than a guess, since it depends on your specific leave status, not just your workers' comp claim.

Yazdchi Law P.C. handles the workers' comp side of a California injury: medical treatment for the injury, temporary and permanent disability, and disputes over the claim itself. The firm does not handle health plan or FMLA and CFRA leave disputes directly, but reviews how those issues line up with your workers' comp claim as part of a free consultation. Call (661) 273-1780 or use the contact form to talk through your situation.