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7/31/2019 Employeess State Insurance Act,1948
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EMPLOYEESS STATE INSURANCEACT,1948
(ESIC)
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E.S.I.Scheme
Basic Needs
- Food
- Clothing
- Shelter
- SECURITY
- Physical distress sickness,
disablement, death- Economical distress
- Maternity
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Employees' State Insurance
Scheme An integrated measure of Social Insurance
embodied in the ESI Act and is designed toaccomplish the task of protecting employees' as
defined in the ESI Act against the hazards ofsickness, maternity, disablement and death due toemployment injury and to provide medical care toinsured persons and their families . The Schemecovers employees of non-seasonal power-usingfactories employing 10 or more person
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Employees State Insurance
(Central) Rules, 1950.
Employees State Insurance Act, 1948 (XXXIVof 1948), the Central Government is pleasedto make the following rules-
These Rules may be called the Employees
State Insurance (Central) Rules, 1950.
(2) They extend to the whole of India.
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ESIS- Board members
Chairman means the Chairman of theCorporation, the Standing Committee or theMedical Benefit Council.
Election of members of Parliament to theCorporation.
- 2 members of Lok Sabha
- 1 member of Rajya Sabha
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ESIS- Board members
Election of members to the Standing Committee
The Chairman, at a meeting of the Corporation
propose to elect members of the StandingCommittee under clause (c) of section 8.
He invite members to propose names from among
members of the Corporation belonging to thegroup from which election is to be made. Thenames proposed shall be duly seconded byanother member of the Corporation.
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. Restoration to membership
Validity of any election- referred to theCentral Government whose decision is final.
Restoration to membership-A member of
the Corporation, the Standing Committee orthe Medical Benefit Council, who ceases to bea member by virtue of section 12, shall beinformed of such cessation by a letter sent to
him by registered post. The letter shall alsoindicate that if he desires restoration tomembership, he may apply within thirty daysfrom the receipt of the letter
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Restoration to membership
The application under sub-rule (1) shall indicate the reasonswhich prevented him from attending three consecutivemeetings and shall be addressed to the Chairmanconcerned.
The application shall be placed before the next meeting of
the Corporation, the Standing Committee or the MedicalBenefit Council, as the case may be, and if a majority of themembers present at such meeting are satisfied that thereasons for failure to attend three consecutive meetings areadequate, he shall be restored to membership immediatelyafter a resolution to that effect is adopted.
The benefit of restoration to membership as provided for inthis rule shall be allowed to a member only once during anyone term as a member.
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Minimum number of meetings
(1) The Corporation and the Medical Benefit Council shallmeet at least twice each year.
(2) The Standing Committee shall meet at least four times
each year.
(3) The Chairman may, whenever he thinks fit, and shall,within fifteen days of the receipt of a requisition in writingfrom not less than one half of the members of the body
concerned, call a meeting thereof.
(4) Any requisition made under this rule shall specify theobject of the meeting proposed to be called.
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Powers and duties of the
Medical Benefit Council
(1)To advise the Corporation in regard to the constitution, setting up, duties andpowers of the Regional and Local Medical Benefit Councils ;
(2)To make recommendations to the Corporation in regard to
(i)The scale and nature of medical benefit provided at hospitals, dispensaries,clinics and other institutions and the nature and the extent of the medicines,staff and equipment which shall be maintained at such institutions and theextent to which these fall short of the desired standard ;
(ii)The medical formulary for use in connection with the medical benefitprovided under the Act ;
(iii) Medical certification, including the procedure and the forms for suchcertification, statistical returns, registers and other medical records ;
(iv)Measures undertaken for the improvement of the health and welfare ofinsured persons, and the rehabilitation and re-employment of insured persons,disabled or injured ;
To advise the Corporation on any matter relating to the professional conduct ofany medical practitioner employed for the purpose of providing medical benefit
under the Act.
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Powers and duties of the
Director General
(1) The powers and duties of the Director General shall be
(i)To act as the Chief Executive Officer of the Corporation ;
(ii)To convene, under the orders of the Chairman, meetings of theCorporation, the Standing Committee and the Medical Benefit Councilin accordance with the Act and the Rules and to implement the decisions
reached at the meetings ; (iii)To enter into contracts on behalf of the Corporation in accordance
with the Act or the Rules or Regulations made thereunder, or the generalor special instructions of the Corporation or the Standing Committee ;
(iv)To furnish all returns and documents required by the Act or the Rulesto the Central Government and to correspond with the Central
Government and the State Governments upon all matters concerningthe Corporation ;
(v)To undertake such other duties and to exercise such other powers asmay from time to time, be entrusted or delegated to him.
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Duties of the Director
General
The Director General may, with the approvalof the Standing Committee, by general orspecial order, delegate any of his powers of
the Corporation or the Standing Committeeto any person subordinate to him.
The exercise or discharge of any of thepowers or duties so delegated shall besubjected to such restrictions, limitations andconditions with the approval of the StandingCommittee.
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Powers and duties of the
Financial Commissioner
(i)To maintain the accounts of the Corporation and
to arrange for the compilation of accounts by the
collection of returns from the Centres and Regions ;
(ii)To prepare the budget of the Corporation ;
(iii)To arrange for internal audit of the accounts of the
Centres and Regions and of the receipts and payments
there at ;
(iv)To make recommendations for the investment of the
funds of the Corporation ; and (v)To undertake such other duties and to exercise such
other powers as may, from time to time, be entrusted or
delegated to him.
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Creation of posts by the
Corporation
The powers for creation of posts vested in theCorporation under sub-section (1) of section
17 of the Act shall be exercised by theCorporation in relation to posts carryingmaximum scale of pay of Rs. 37,400 67,300
with Grade pay of Rs. 8900/-.
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Appeals to Medical Appeal
Tribunal (1) If the insured person or the Corporation is not satisfied with the
decision of the medical board, the insured person or the Corporationmay appeal against such decision to the medical appeal tribunal referredto in sub-section (2) of section 54-A by presenting an application withinthree months from the date of communication of the said decision tothe insured person or the Corporation, as the case may be :
Provided that the medical appeal tribunal may entertain an applicationafter the period of three months, if it is satisfied that the appellant hadsufficient reasons for not presenting the application within the saidperiod.
(2)The application, referred to in sub-rule (1), shall be in Form 2 and shallcontain a statement of the grounds upon which the appeal is made.
(3)The application may be sent to the Chairman of the medical appealtribunal by registered post or may be presented personally.
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Appeals to Employees
Insurance Court (1) The insured person or the Corporation may appeal to the
Employees Insurance Court by presenting an applicationwithin three months of the date of communication of thedecision of the medical board or of the medical appealtribunal to the insured person or the Corporation as the
case may be : Provided that the Employees Insurance Court may
entertain an application after the period of three months, ifit is satisfied that the appellant had sufficient reasons fornot presenting the application within the said period.
(2) The rules made by the State Government in respect ofthe form and manner to be followed in presentingapplications to the Employees Insurance Court, shall beapplicable to the applications presented under this rule.
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Bank or banks for depositing
the Fund
(1) All moneys accruing or payable to theFund shall be received by authorised officersof the Corporation. The amount so receivedshall as soon as be acknowledged by a receiptin Form I and deposited in the Reserve or theState Bank of India or any of its subsidiaries
or the Nationalised Banks to the account ofthe Fund :
Payment is also done from these accounts.
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Purpose and manner of
payment out of the Fund (1) The accounts of the Fund shall be operated by officers authorised
by the Standing Committee, with the approval of the Corporation.
(2)No payment shall be made by the bank or banks out of the Fundexcept on a cheque signed by such officers as may be authorisedunder sub-rule (1).
(3)Any payment in excess of one hundred rupees shall be made bymeans of a cheque signed as aforesaid and not in any other wayunless specifically authorised by the Standing Committee :
Provided that payment of salaries to the employees of theCorporation drawing a basic salary not exceeding rupees twohundred and fifty a month may be made in cash.
(4)No payment shall be made out of the Fund unless the expenditureis covered by a current budget grant :
Provided that the payment of benefits to insured persons under theprovisions of the Act and of the pay and allowances of dulysanctioned posts shall not be withheld for want of a sanctionedbudget grant.
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Promotion of measures for
health of insured persons
For the promotion of measures for theimprovement of the health and the welfare ofinsured persons and for the rehabilitation and re-employment of insured persons who have beendisabled or injured, the Corporation may incur an
expenditure upto a limit of Rupees threehundred crores per year from the EmployeesState Insurance Fund.
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Acquisition of property
Subject to the provisions of rule 29 and such conditions asmay, from time to time, be laid down by the Corporation,the Director General may, for the purposes of this Act,acquire on behalf of the Corporation movable orimmovable property :
Provided that sanction of the Standing Committee shall berequired for the exchange of any immovable property, forthe taking of any property on lease for a term exceedingtwelve months, or for the acceptance of any gift or bequestof property burdened an obligation.
Note. The sanction of the Standing Committee may begiven either generally or for any class of cases or speciallyfor any particular case
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Disposal of property
Subject to the provisions of rule 29 and as may be laid down bythe Corporation from time to time the Director General may
(i)Dispose of, by sale or exchange, any movable propertybelonging to the Corporation, the value of which does not exceedten thousand rupees in each case, or grant for any term notexceeding twelve months a lease of any immovable propertybelonging to the Corporation.
(ii)With the sanction of the Standing Committee, lease, sell orotherwise dispose of any movable or immovable property
belonging to the Corporation.
Note. The Sanction of the Standing Committee may be giveneither generally or for any class of cases or specially for any parti-cular case.
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Investment, transfer or
realisation of the Fund (1) All moneys belonging to the Fund which are may immediately required for
expenses properly defrayable under the Act, may, subject to the approval of theStanding Committee, be invested by the Director General -
(i) In Government securities including Treasury Deposit Receipts ; or
(ii) In securities mentioned or referred to in clauses (a) to (d) of section 20 of theIndian Trust Act, 1882 (11 of 1882) ; or
(iii)As fixed deposit in the Reserve or the State Bank of India or any of itssubsidiaries or a corresponding new bank constituted under section 3 of theBanking Companies (Acquisition and Transfer of Undertakings) Act, 1970 (V of1970).
(2)Moneys belonging to the Fund shall not be invested in any other manner
except with the prior approval of the Central Government.
(3)Any investment made under this rule may, subject to the provisions of sub-rules (1) and (2), be varied, transposed or realised from time to time :
Provided, however, that if such variation, transposition or realisation is likely toresult in a loss, the prior approval of the Central Government shall be obtained.
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Staff
1. Corporation-(Term 4years)
-Chairman (by Dir. General)-1 member of Loksabha
-2 members of Rajyasabha
-10 representatives of employers
-10 representatives of employees
2. Standing Committee-(Term 2 years)
-Chairman (by Govt)
-3 members of corporation
-3 representatives of employers
-3 representatives of employees
-1 Doctor
-1 MP
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Staff
3. Medical Benefit Council (Term 4 years)
- Dir. Health Services
- Dy. Dir Health Services
- Medical Commissioner
- 3 doctors
- 3 representatives of employers-3 representatives of employees
Main Officers
A) Chief Finance Officers ( CFO)
B) Chief Executive Officers ( CEO)
Planning- Corporation & Standing Committee
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Classes of Establishments
Built-in provision for its extension to otherclasses of establishments-
Industrial, commercial, agricultural or
otherwise. The Scheme has been progressively extended
to cover employees in non-power using
factories employing 20 or more persons and to commercial establishments
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Employees' State Insurance
Funds
The Employees' State Insurance Funds are
primarily built out of employers contributionand employees contribution payable monthlyas a fixed percentage of wages.
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Employees registration
- Declaration Form
- The employee is allotted a Registration
Number- Which distinguishes and identifies the person
for the purposes of the Scheme
- A person is registered only once upon hisentry in insurable employment
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Definitions
a) Act means the Employees State Insurance Act, 1948 (XXXIV of1948) ;
(b) Appointed Day means with reference to any area, factory orestablishment, the day from which the whole of Chapters IV and V of theAct apply to such area, factory or establishment, as the case may be ;
(c) Appropriate Office , appropriate Branch Office or appropriate Regional Office , shall mean with reference to any actiontaken under these regulations, such office of the Corporation as may bespecified for that purpose under a general or special order of theCorporation ;
(d) Central Rules means the rules made by the Central Governmentunder section 95 of the Act ;
(e) Employer means the principal employer as defined in the Act
(f) Employers Code Number means the registration number allottedby the appropriate Regional Office to a factory or establishment for thepurposes of the Act, the Rules and these Regulations ;
(g) Factory or Establishment means a factory or establishment to
which the Act applies ;
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Definitions
(h) Form means a form appended to these regulations ; (i) Identity Card means a permanent identity card issued by
the appropriate office to an insured person for identificationfor the purposes of the Act, the Rules and these Regulations ;
(j) Family Identity Card means a card issued by the
appropriate office to an insured person for identification of hisfamily for the purposes of the Act, the Rules and theseRegulations ;
(k) Social Security Officer means a person appointed assuch by the Corporation under section 45 of the Act ;
(l) Instructions means instructions or orders issued by theCorporation or by such officer or officers of the Corporation asmay be authorised by the Corporation in this behalf ;
(m) Insurance Medical Officer means a medical practitionerappointed as such to provide medical benefit and to performsuch other functions as may be assigned to him and shall be
deemed to be a duly appointed medical practitioner for thepurposes of Chapter V of the Act ;
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Definitions
(n) Insurance Number means a number allotted by the appropriate Office to an employee forthe purposes of the Act, the Rules and these Regulations ;
(o) Branch Office and Regional Office shall mean, according to the context, such subordinateoffice of the Corporation, set up at such place and with such jurisdiction and functions as theCorporation may, from time to time, determine ;
(p) Branch Manager means a person appointed by the Corporation as such or the officer-in-charge of a Branch Office ;
(q) State Rules means the rules made by a State Government under section 96 of the Act ;
(r) Regional Director means a person appointed by the Corporation as such for a specifiedregion ;
(s) Registered Midwife means a person who is registered as a midwife under any law in force inany State providing for registration of nurses and midwives ;
(t) Rules means rules made by the Central or a State Government under the Act ;
(u) Specified means specified by instructions issued from time to time by the Corporation or anyauthorised officer;
(v) Year means a calendar year except when specifically stated otherwise ;
(w)All other words and expressions have the meanings respectively assigned to them in the Act orthe rules, as the case may be.
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APPLICABILITY
Act is applicable-Section 2(12)
To factories employing 10 or more persons forwages and working with the aid of power and to
factories employing 20 or more persons without theaid of power, excluding seasonal factories.
Section 1(5)
As per notification published by State Govt. ofMaharashtra, all establishment employing 20 ormore employees are coverable under the act.
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REGISTRATION
Employer must furnish the details in Form O-1 to the appropriate Regional office forregistration and obtaining code number within 15 days from the date act is applicable
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ELIGIBILITY
Any person who is drawing Gross Salary up toRs.15000-p.m.(w.e.f. 01/05/2010) excludingovertime.
Who is directly employed by principal employeror by contractor of the factory or establishment.
Whose services are temporarily lent or hired to
the principal employer by the person who hasentered into a contract of service.
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REGISTRATION OF BRANCH
OFFICES On receipt of Code number for the main
factory/establishment, in case of any branches
exists, application for Sub-Code number andLocal offices shall be submitted to the respectiveRegional Offices of ESI corporation.
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REGISTRATION OF EMPLOYEES
Declaration form along with R.D.F. to theconcern Local office for allotment of Insurance
number and issue of ESI permanent cards so asenable employees to avail various benefits underESI Act.
Registration of the permanent card with the
Registered Insurance Medical Practitioner toavail medical benefits
BENEFITS
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BENEFITS
Medical Benefit -Free medical treatment is
provided at Hospital and dispensaries run by ESICorporation. Sickness Benefit - About 7/12th of employees
normal wage will be payable to employee duringsickness.
Accident Benefit - Injury during/in course ofemployment resulting in temporary/permanentdisablement entitles the covered employee to aregular payment to substitute his lost wages.
Dependent Benefit ( In case of death): Death
during course of employment entitles specifieddependents to a regular payment. Maternity Benefit- Payment of 12 wks of which not
> 6 wks shall precede the confinement.
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BENEFITS- cont.
Funeral Expenses - One time payment ofRs.2500/- to meet funeral expenses.
In addition, the scheme also provides some otherneed based benefits to insured workers. Theseinclude :
1) Rehabilitation allowance.
2) Vocational Rehabilitation3) Old age medicare
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PENAL PROVISIONS
For non payment of employees'contribution:-Imprisonment for 2 yrs. to max. 5 yrs. and/or
fine of Rs.25, 000/-
For non payment of employers' contribution:-Imprisonment for 6 months to max. 3 yrs.
and/or fine of Rs.10, 000/-
INTEREST AND DAMAGES ON
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INTEREST AND DAMAGES ON
DELAYED PAYMENTS
Interest @ 12% w.e.f. 01-10-2005 (initial interest@15% w.e.f.01-09-1995) will be charged in case ofpayments are not made with in stipulated period
Damages as per slab rates will be charged in case
payments are not made with in stipulated period- Sr. period of delay rate of damages
1) Below 2months 5%
2) Between 2 to 4 months 10% 3) Between 4 to 6 months 15%
4) 6 months & above 25%
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PROCEDURE TO CLAIM BENEFITS
Identity Card (affixed with a postcard size family
photo)On registration Temporary Identification
Certificate is given (validity for 3 months) but maybe extended, if necessary, for a further period of 3months.
A permanent family photo Identity Card in
exchange for the Certificate. Should be produced before the new employer as
evidence of registration under the Scheme to
prevent any duplicate registration
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Contribution Periods
Monthly contribution
Contribution period(six-month time span) from1st April to 30th September and 1st October to31st March
Thus, in a financial year there are two
contribution periods of six months duration
Cash benefits are linked with contributions paid
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Benefit Periods
Starts 3 months after the closure of contributionperiod. The 2 types of periods are given below :-
Contribution Period Corresponding Benefit Period
1st April- 30th Sept 1st Jan- 30th June of thefollowing year
1st Oct- 31st Mar 18th July- 31st Dec
The employee who has worked the minimum no. of
days in a contribution period is eligible for sicknessbenefit in a corresponding benefit period
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Local Office Local Offices net-work has been established by the
Corporation in all implemented areas1. To disburse all claims for sickness, maternity,disablement and dependents' benefit
2. To answer all doubts and enquires and assistsotherwise in filling in claim forms and completingother action necessary in connection with thesettlement of claims
3. To interact with the employers of the area
The Local Offices are managed by a Manager andwork under the direction and control of the RegionalOffices
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Duration of Sickness Benefit
Maximum period of 91 days in any twoconsecutive benefit periods
Benefit is not paid for an initial waiting periodof 2 days unless the insured person is certifiedsick within 15 days of the last spell in whichSickness Benefit was paid
Extended Sickness Benefit
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Extended Sickness Benefit
Cash Benefit paid for prolonged illness due to any toany of the 34 specified diseases, such as
TuberculosisLeprosy
Chronic EmpyemaBronchiectasisInterstitial Lung diseaseAIDSMalignant Diseases
Diabetes Mellitus-with proliferativeretinopathy/diabetic foot/nephropathy.MonoplegiaHemiplegia
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Contd.
ParaplegiaHemi paresisIntracranial space occupying lesionSpinal Cord CompressionParkinson's diseaseMyasthenia Gravis/Neuromuscular DystrophiesImmature Cataract with vision 6/60 or lessDetachment of RetinaGlaucomaCoronary Artery DiseasesCongestive Heart Failure-Left, Right
Cardiac valvular Diseases with failure/complicationsCardio-myopathiesHeart disease with surgical intervention along withcomplications
con
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con
COPD with congestive heart failureCirrhosis of liver ascitis/chronic active hepatitis (CAH)Dislocation of vertebra/prolapse of intervertebral discNon union or delayed union of fracturePost Traumatic surgical amputation of lower extremityCompound fracture with chronic osteomyelitis(a) Schizophrenia(b) Endogenous depression
(c) Maniac Depressive Psychosis (MDP) Dementia
More than 20% Burns with infection/complicationChronic Renal FailureReynaud's disease/Burger's disease
In addition, extended sickness benefit may also besanctioned by the prescribed authority, in case of any raredisease or special circumstances on the recommendation ofthe specified authority
DISABLEMENT BENEFIT
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DISABLEMENT BENEFIT
Disablement is a condition resulting fromemployment injury which may be :-
-Temporary ie. rendering an insured personincapable of work temporarily and necessitating
medical treatment-Permanent partial ie. reducing the earning capacityof the insured person generally for everyemployment;-Permanent total ie. totally depriving the insuredperson of the power to do all work.
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Dependents'
BenefitDependents Benefit is a monthly pension
payable to the eligible dependents to an insuredperson who dies as a result of an EmploymentInjury of occupational disease.
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Beneficiaries
-Widow/Widows during life or until remarriage --Legitimate or adopted son until age 18 or iflegitimate son is infirm, till infirmity lasts; Legitimate or adopted unmarried daughter untilage 18 or until marriage, whichever is earlier, or ifinfirm, till infirmity lasts and she continues to beunmarried.In the absence of any widow or legitimate child, thebenefit is payable to a parent or grandparent for
life, to any other male dependant until age 18 or toan unmarried or widowed female dependant untilage 18.
Amount of the Benefit for each
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Amount of the Benefit for each
Beneficiary
The total divisible benefit is equivalent to thetemporary disablement benefit rate (roughly70% of the wage rate).
The widow/widows share 3/5th of the benefit andthe legitimate of adopted son and daughter 2/5theach of the benefit.
If the total benefit so divided exceeds the full
rate, there is a proportionate reduction in therespective share of the beneficiaries.
fi
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Dependants' Benefit
Documents required at the Local Office :--Claim in the appropriate form
-Evidence of death being due to employment
injury-Proof of relationship to the deceased Supporting
eligibility of the claimant as a dependent';-Evidence of age of the claimant(s) (certified
copy of official record of birth, school recordsetc;
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Dependants' Benefit- contd
Certificate of infirmity from Medical Refereeor any other prescribed authority in case oflegitimate infirm son or legitimate or adopted
unmarried infirm daughter.
The beneficiary should submit at six-monthlyintervals (with the claim for June and
December), a declaration that he/she is aliveand has not married/remarried.
i fi
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Maternity Benefit
Cash payable to an insured woman for thespecified period of abstention form work forconfinement or miscarriage or for sicknessarising out of pregnancy.
Contributory Conditions
Same as for Sickness Benefit
Daily benefit rate is double the Sickness Benefitrate and is roughly equivalent to the full wages.
It also includs Sundays.
t it fit d
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Maternity Benefit-contd
Confinement connotes labour resulting in thedelivery of a living child or labour after 26 weeksof pregnancy whether the resultant issue is aliveor dead. Miscarriage means expulsion of thecontents of a pregnant uterus at any period priorto or during 26th week of pregnancy.
Criminal abortion or miscarriage does not,
however, entitle to benefit.
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Duration of the Benefit
For confinement :-Total period or 12 wks beginning not more than6 wks before the expected date of child birth. Ifthe insured woman dies during confinement orwithin 6 wks thereafter, leaving behind the livingchild, the benefit continues to be payable for thewhole of the period. But if the child also die
during that period, the benefit will be paid uptoand including the day of death of the child.
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ForMiscarriage
For a period of 6 wks following the date ofmiscarriage.
For Sickness arising out of pregnancy,confinement, premature birth of child of
miscarriage :- For an additional period of upto 4wks.
The benefit is paid only if the insured womandoes not work of remuneration during the
period for which benefit is claimed. There is nowaiting period.
T l i M t it B fit
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To claim Maternity Benefit
, a certificate of confinement of miscarriagefrom M.O./Insurance Medical Practitioner andsubmit it to her Local office personally or by postalongwith a claim for Maternity Benefit. The
claim form also contains a declaration ofabstention from work.
If Benefit is desired before confinement, a
Notice and Certificate of Pregnancy and aCertificate of Expected Confinement
Cl i M t it B fit td
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Claim Maternity Benefit-contd
In the event of death of an insured womanleaving behind a child her legal representativeshould submit a claim for the Benefit togetherwith a certificate a death of the insured woman.
Maternity Benefit for Sickness arising out orpregnancy, confinement, premature birth ofchild or miscarriage should submit her claim in
the manner as for sickness benefit.
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Medical Bonus
Lump sum payment made to an insuredwoman or the wife of an insured person incase she does not avail medical facility from
an ESI hospital at the time of delivery of achild. This bonus of Rs. 250/- has beenincreased to Rs. 1000/- from 1st April 2003
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Medical Benefit
Standard medical care consists of -Out-door treatment
-In-patient treatment
-All necessary drugs and dressings -Pathological and radiological specialist
consultation and care
-Ante-natal & post natal care -Emergency treatment
O t ti t' i
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Out-patient' services
Care provided at ESI Dispensaries or MobileDispensaries manned by full-time doctors(Service' system) of at the private clinics ofInsurance Medical Practitioners (Panel system)
Also includes
-Ante-natal and post-natal care for women, -Family welfare planning services
-Immunisation
S h i i
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Scheme provisions
Sole cost of
-Artificial limbs to insured persons who lose theirlimbs due to employment injury or in certaincircumstances otherwise also, -Dentures
-Spectacles
-Hearing-aids
-where the loss of teeth, impairment of eye-
sight or hearing respectively is due toemployment injury.
In patient' Services
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In-patient' Services
ESIC has a network of 141 hospitals countrywide
which are administered by the State Govts.
Availability-
-In patient and diagnostic services in basic
specialities
-Have tie-up with a number of Medical colleges,major state and private hospitals for advanced
treatment for malignant diseases andcomplicated surgical interventions.
Medical Benefit- period
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Medical Benefit- period
Eligible for medical care from the very first dayof the worker coming under ESI Scheme
The medical care includes primary medical care,diagnostic services, specialist consultations andindoor medical care. Whenever the patient is notable to travel by himself/herself, ambulanceservices are also provided. The I.P. or his family
members are not required to pay for any of theservices.
contd
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contd
Workers first time eligibility is for a period ofthree months.
If he/she continues in employment for 3 months
or more the medical care is available to him/hertill the start of the first benefit period.
If he/she contributes atleast for 78 days in acontribution period the eligibility is three uptothe end of the corresponding benefit period.
contd
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contd
Worker is also eligible for extended sicknessbenefit form any one of the long term 34diseases listed in the Act.
Admissible after 2 years of ESI coverage duringwhich he/she should have contributed atleast for156 days.
Satisfied conditions are admissible for amaximum period of 730 days for the I.P. andhis/her family.
Cash Benefits
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Cash Benefits
Treatment by Indian system of medicine and Homoeopathy (ISM
& H) other than Allopathy and where the State Government hasrecognised the qualifications in such system.
The various ISM &H systems of treatment in vogue are:,Ayurvedic, Unani, Sidha, Yoga therapy and Homeopathy.
Certificates required for this should be issued by IMO /IMP havingrecognised qualifications in such system and duly appointed bythe State Government.
The dispensaries in these systems are functioning independentlywith IPs and their family units attached to them and not
functioning merely as referral units.
In places where ISM &H units function only as referral centres,certificates will have to be issued by the Allopathic dispensary towhich the IP is attached.
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Funeral expenses
Lump sum payment towards the expenditureon the funeral of the deceased insuredperson.
Amount is equal to the actual expenditure,not exceeding Rs. 2500/-.
Claim for the Funeral expenses
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Claim for the Funeral expenses
Claimant should submit
Death certificate issued by cremation/ burialground/by Municipal authorities/ certified copy
of village/death records may also be accepted asevidence of death);A declaration of the claimant,eitherthat he is the eldest surviving member of the
family of the deceased insured person andincurred expenditure on the funeral of thedeceased. or
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Funeral expenses-contd
In case the claimant is other than the eldestsurviving member of the family, that thedeceased insured person did not have a
family or was not living with his family at thetime of his death.
The declaration should be countersigned by acompetent authority.