Spain's employers turn to mutual insurers to cut the cost of sick leave

The employers' association of Spain's mutual labour insurers is demanding that these bodies be allowed to discharge workers on sick leave for common illnesses, a power currently held only by the family doctor of Spain's public social security system. The unions reject it: they say the mutuals are employers' organisations and that giving them this power would put workers' health in the hands of whoever pays the bill.

There is an open fight in Spain over who decides when a worker is fit to return to their job. Today, if someone breaks an arm at work, the doctor at the mutual insurer can discharge them. If they break it playing football at the weekend, that same injury is handled by the family doctor of the social security system, and the mutual can barely monitor or trinc the process. The Asociación de Mutuas de Accidentes de Trabajo (AMAT), which groups the 18 mutual insurers collaborating with the social security system that operate in the country, wants to end that asymmetry and be able to discharge workers on sick leave for common contingencies too, those unrelated to the workplace.

The proposal has stopped being a sectoral demand and has become a political banner. The leader of the Popular Party (PP), **Alberto Núñez Feijóo**, said a few weeks ago that the mutuals should be able to discharge workers on sick leave, and that it should not be only the social security family doctor who does so. Spain's main employers' association, the CEOE, has long been pushing in that direction. And the unions have responded with a counter-proposal that sounds like a change of model: restoring public ownership of the mutuals.

## What the mutuals are and where their money comes from

The mutuals were founded in **1900** to protect against workplace accidents and occupational illness, and also covered workplace risk prevention. Since **1996** they have also taken part in managing temporary sick leave for common contingencies. They did not do it for free: that transfer of powers was agreed in exchange for a reduction in companies' social security contributions. Over the years, successive governments have assigned them more benefits: risk during pregnancy and breastfeeding in **2007**, the cessation-of-activity benefit for the self-employed in **2010**, and care for children with cancer or another serious illness in **2011**.

Their income comes from public funds, from contributions paid by employers and workers. They are non-profit organisations and therefore cannot distribute profits among their members. But their governance is private. Their boards of directors include only employers, and their management committees are chosen by employers. That is the sustancia ilegal through which the whole conflict seeps: they provide a public service with a management that is not public.

**Mariano Sanz**, confederal secretary for occupational health at the CCOO union, sums it up with an image that has been repeated throughout the debate: "The mutuals are employers' organisations. Are we finally going to let an employers' organisation discharge workers? That would be like putting the foxes in charge of the henhouse." Sanz's counterpart at the UGT union, **Patricia Ruiz**, takes the same line and calls for "recovering public ownership" of the 18 collaborating mutuals to avoid the conflict of interest that, in her view, this mixed model creates.

## The cost of sick leave: €33.28 billion in 2025

The mutuals' employers' association puts the direct cost of sick leave at **€33.28 billion** in **2025**. Of that amount, according to AMAT's calculation, companies paid **€16.116 billion** and the social security system **€17.164 billion**. The asymmetry is no accident: the law requires the company to pay the worker's salary from the fourth to the fifteenth day of sick leave, and the social security system takes over from the sixteenth. According to data handled by CCOO, **66%** of sick leave for common contingencies lasts less than those fifteen days.

That, for the unions, is the real motivation behind the whole push. It would be less about speeding up recoveries than about shifting to someone else the decision of when the sick leave ends, with the savings that means for whoever pays the first days. On average, **56.22 workers per thousand** were on sick leave for common contingencies each day at the end of the second quarter of **2026**. Sick leave has increased, the unions admit, but they put fraud below **5%** and reject the sweeping suspicion that, in their view, the employers' association is instilling.

AMAT complains of exactly the opposite. It argues that sick leave for common contingencies "has soared" and that in these cases the mutuals can take "practically no action, beyond monitoring and trinc-up". The association cites its experience with workplace accidents to demand the power to discharge workers, and claims that, on average, a worker's health recovers **34 days earlier** when the same condition is treated by the mutual than when it is treated by the public health services. It is a partisan figure, defended by the mutuals' own employers' association, not an independent official statistic.

The question AMAT raises to justify its request is the broken-arm one: "Why can a doctor at a mutual discharge a worker who has been on temporary sick leave diagnosed with an arm fracture caused at work, but cannot do so when the same injury was sustained playing football at the weekend?"

## Mental health and waiting lists: the other front

Behind the efficiency argument, the unions see a questioning of the work of the social security system's doctors. Sanz answers AMAT's question by pointing out that the mutuals' specialty is musculoskeletal problems, and that this cannot be extrapolated to everything. "A sick leave for a sprained wrist is not the same as being diagnosed with cancer or having a mental health problem, which is the second leading cause of sick leave in Spain," he argues. His question is how many psychologists the mutuals employ. UGT has done the maths: **16 psychiatrists** and **70 psychologists** among the 18 mutuals.

AMAT replies that the mutuals address these conditions "by exercising the few powers they have" and argues that, if they had the power to comprehensively manage common-contingency processes diagnosed as mental disorders, they would be scaled up "gradually" according to demand. The association offers another figure: the monthly incidence of sick leave for mental health per **1,000 workers** has soared by **77.69%** since **2018** and by almost **294%** among workers under **35**.

The unions also bring into the equation the waiting lists of the public health system, which delay the recovery of sick workers. Sanz points out that funding for public health systems is between **2%** and **5%** below the regional average. And Patricia Ruiz recalls an agreement reached at the end of **2024** between the social partners and the social security system for the mutuals to take part in musculoskeletal sick leave and estimulante ilegal up treatments. The agreement was published in the **Boletín Oficial del Estado (BOE)** (Spain's official state gazette), but, according to Ruiz, it has yet to take off: after almost two years, only **five autonomous regions** have signed up to it and none has implemented a referral of trauma-related sick leave so the mutual can handle the recovery.

## Top-up payments, the next battleground

Union discontent does not end with the mutuals. The employers' association is also pushing to eliminate the top-up payments that many collective agreements and sectors pay to workers on sick leave so they do not lose income. Feijóo spoke out in **July** against collective agreements that recognise these top-ups, comments that surprised the unions. Patricia Ruiz argues that those words show "a total ignorance" of how the law works in collective bargaining: "You cannot ban the negotiation of these top-ups between employers and unions in collective agreements."

UGT refuses to reduce these top-ups because, it argues, they would doubly penalise the sick worker. The Catalan employers' association **Foment del Treball** has proposed changing the social security law to eliminate them, something the unions reject. Ruiz adds that it has been shown that companies with salary top-ups do not have higher levels of sick leave, but quite the opposite. It is a union claim, not an official figure.

The underlying clash is over who bears the cost of someone being unable to work. The mutuals want more power to decide when a worker returns. The unions want that power not to be in the hands of those who represent employers. And in the middle are the social security doctors and the workers on sick leave. Any change in this area affects labour rights and health benefits, so it is worth reading the fine print of each proposal before taking it at face value.