Q&A: How to Navigate Employee Eligibility After Workplace Injury

Question:

We recently had an employee start work for us on January 22, 2025, and unfortunately was injured on February 6th. Since her injury on the 6th, we have found light duty work for her to do so that she can continue working. We have been trying to keep her busy until she can return to her regular duties, but it seems that it won’t be happening anytime soon. We will run out of light duty work for her to do after February 28th.

For our health plan, employees are eligible to enroll if they “regularly work 30 or more hours of service per week.” Our new employees are also subject to a waiting period of 30 days. Coverage takes effect on the first day of the month after the waiting period has run. So, putting aside the employee’s injury, she would be eligible to enroll in the health plan as of March 1st.

She has averaged more than 30 hours per week during the waiting period, although she dropped below 30 hours in one week. Since we have run out of light duty opportunities, she won’t be working any hours as of March 1st, which is when her coverage is scheduled to take effect.

I’m trying to determine whether we should allow her to come on the plan on March 1st despite the fact that she won’t be working any hours at all indefinitely. If so, what is our obligation to pay the portion of the premium we would ordinarily pay? She doesn’t qualify for FMLA, in case that matters.

Answer:

Based on the eligibility language you provided (that employees may enroll if they “regularly work 30 or more hours of service per week”) and her hours worked, it appears the employee has met the eligibility and waiting period requirements and should be allowed to enroll in the health plan. Make sure you document her hours worked during the waiting period and your reasoning for allowing her to enroll in case the carrier challenges her eligibility in the future.

Since the employee doesn’t qualify for FMLA, you can require her to pay the full premium (both the employee portion and the employer portion.

However, I have a couple of caveats to the above:

1. I can’t provide any insight into the advisability of transitioning the employee from light duty to “on leave” status. I recommend you discuss with the adjuster on the workers’ compensation claim or your attorney.
2. If the employee can’t return to work for a while, there may be a point at which you need to terminate her coverage and offer her COBRA. Consult your insurance certificate, plan document, or carrier to see how long employees are allowed to stay on the plan under these circumstances.