Panchdeep Insurance Benefits 2.0

  • View
    213

  • Download
    0

Embed Size (px)

Text of Panchdeep Insurance Benefits 2.0

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    1/24

    Confidential Copyright 2009 Wipro Ltd

    ESIC

    Pragati (Insurance)

    Benefits

    October 30, 2013 1

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    2/24

    Confidential Copyright 2009 Wipro Ltd

    Introduction

    Benefits : The insured persons, besides full medical care for self and

    family, are also entitled to a variety of cash benefits in times of physical

    distress due to sickness, maternity (in respect of insured women),

    temporary or permanent disablement etc. resulting in loss of wages or

    earning capacity.

    The section 46 of the ESI Act, 1948 envisages following five benefits

    1. Medical Benefit

    2. Sickness Benefit (SB)

    a. Extended Sickness benefit (ESB)

    b. Enhanced Sickness Benefit

    3. Maternity Benefit (MB)

    4. Disablement Benefit (TDB, PDB)a. Temporary Disablement Benefit

    b. Permanent disablement benefit

    5. Dependants Benefit (DB)

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    3/24

    Confidential Copyright 2009 Wipro Ltd

    Benefit Bouquet

    Panchdeep

    SicknessBenefit

    Medical

    Benefit

    MaternityBenefit

    DisablementBenefit

    DependentBenefit

    Extended SicknessBenefit

    Enhanced Sickness

    Benefit

    Super-SpecialtySickness benefit

    Temporary DisablementBenefit

    Permanent

    Disablement benefit

    Medical

    Cash Benefits

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    4/24

    Confidential Copyright 2009 Wipro Ltd

    Other Benefit

    Other Cash Benefits

    Conveyance Expenses

    Unemployment Allowance

    (Under Rajiv GandhiShramik Kalyan Yojana)

    Vocational Rehabilitation

    Funeral Expenses

    Confinement Expenses

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    5/24

    Confidential Copyright 2009 Wipro Ltd

    Benefit at glance

    Benefit Contributory conditions Duration Rate

    Sickness benefit

    Payment of contribution forat least 78 days in therelevant contributionperiod

    91 days in any twoconsecutive benefitperiods

    Standard benefit rate (not lessthan 50% of daily wages)

    Extended Sicknessbenefit (ESB)

    Continuous employment fora period of 2 years

    and payment ofcontribution for atleast 156 days in4 contributionperiods.

    up to 2 years in deservingcases

    150% of the standard benefitrate (not less than 70%of daily wages.

    Enhanced SicknessBenefit

    Payment for at least 78days in the relevantcontribution period

    7 days for vasectomy and 14days for tubectomyextendable in case ofpost operativecomplication etc.

    200% of the standard benefitrate.

    Temporary DisablementBenefit

    No condition.Till the temporary disablement

    lasts

    140% of the Standard SicknessBenefit rate(not less than70% of daily wages)

    Permanent disablementbenefit

    No condition for lifeUpto 140% of the Standard

    Sickness Benefit rate.

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    6/24

    Confidential Copyright 2009 Wipro Ltd

    Benefit at glance

    Benefit Contributory conditions Duration Rate

    Dependant's benefit No condition

    To widow/widows for life oruntil remarriage.

    Upto 140% of the StandardSickness Benefit rate (not

    less than70% of

    dailywages to be divided

    among the dependants inthe prescribed ratio.

    To legitimate or adopted son/unmarried daughter till

    age of 18 years.

    To legitimate infirm son.

    To legitimate adoptedson/unmarried infirmdaughter till infirmity

    lasts.

    To widowed mother

    Maternity benefit

    Payment of contributionfor 70 days inimmediatelypreceding twoconsecutive periods.

    12 weeks of which not more

    than six can precede theexpected date ofconfinement;

    Double the Standard Benefitrate (Not less than full

    wages)

    6 weeks for miscarriage andadditional one month forsickness arising out of

    confinement, prematurebirth of child or

    miscarriage

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    7/24Confidential Copyright 2009 Wipro Ltd

    Benefit Contributory conditions Duration Rate

    Funeral Expenses

    No condition. DeceasedIP should be an IP

    on the date ofdeath.

    One time paymentActual expenditure on funeral

    not exceeding Rs. 5000/-(wef 01.12.07)

    Confinement expenses

    No condition other thaninsurable

    employment ofself/spouse.

    payable for two confinementsonly

    Rs. 2500 is paid as a lump sumgrant towards

    confinement expenses toan insured woman, wife of

    insured person.

    Conveyance Expenses

    No condition other thaninsurable

    employment and aincapacity referencehas been made bythe Branch office or

    Regional office

    No duration

    Payable based on the travelmode recommended bythe Medical referee orMedical board or the

    Actuals

    Rehabilitation allowance No condition

    For each day on which insured

    person remains admittedin Artificial limb centrefor fixation / repair or

    replacement of artificiallimb.

    200% the standard sicknessbenefit rate but not less

    than full wages

    VocationalRehabilitation

    Insurable employmentupto 40%permanent

    disablement and

    below 45 years age.

    Till such training lasts at arecognized centre /

    institute

    As per the daily expense at thecentre or Rs. 45 /-whichever is more

    Benefit at glance

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    8/24Confidential Copyright 2009 Wipro Ltd

    Benefit Claim Entry Trigger

    Insured Person submits the claim form to the branch office.

    Employer submits Accident report at Branch office online or via post

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    9/24Confidential Copyright 2009 Wipro Ltd

    Benefit Claim Workflow

    HIS

    ESIC official creates the

    Claim form in thesystem through intranet

    Claim is processedonline

    EligibilityCriteria/Contributorycriteria is ascertained

    Certificates will bereviewed

    Benefit days, Amount tobe paid will be

    calculated

    F&A

    IncapacityReferences(MR/MB)

    IP submits the

    claims at BO, ESIC

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    10/24Confidential Copyright 2009 Wipro Ltd

    Claim approval reject/

    recommendation

    Branch manager recommends the claim for reference to

    MR/MB.

    Branch Manager may also refer the claims to RO/

    Headquarters for approval of time barred claims or for

    special approval of ESB/TDB/PDB cases.

    On approval of the claim from the manager, the

    payment slip will be generated and forwarded to cashier

    (F& A) for making the payment.

    Branch ManagerApproves/Rejects/Recommends

    Benefits claim

    Submit Benefit Claim

    Insured Person submits the claim to

    the Branch office

    Manual Claim

    Submission

    Generation of claim online and

    Processing of the claim

    The claim form format is available on the screens for the

    LDC to input the claim form received from the IP online into

    the application.

    The Claim form will be checked and processed by the UDC.

    Certificates from HIS is reviewed and checked by UDC

    The benefit days and amount to be paid will calculated by the

    system and displayed to UDC.

    UDC submits the claim for managers approval

    Claim entry by LDC

    Lower Divisional clerk

    Branch manager

    Insured Person

    Verification by UDC

    Upper Divisional clerk

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    11/24Confidential Copyright 2009 Wipro Ltd

    Exceptions to normal Process

    Time barred Claims : Those claims which are submitted beyond the periodof 12 months from the date of certificates are referred to the Regional

    Director or at the Headquarters (IC/DG) for approvals during the

    processing of benefit claims. It applies for all cash benefit claims.

    Incapacity References : References made to Medical Referee/Medical

    Board to know his opinion on the incapacity of the insured person toresume his work. While processing the claim, based on the certificates or

    the spell of the sickness, the branch office can recommend an IP for a

    medical examination by an MR/MB. The reference can be made through

    the screens available in the application.

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    12/24Confidential Copyright 2009 Wipro Ltd

    Benefit Claims Exit Triggers

    Payment of the Claims (The processing of the claim may be held in case of anyreferences to Medical Referee/Medical board for medical examination or to

    RO/Headquarters for approvals)

    Payment Slip is generated for the benefit claims, on the approval from the

    branch manager and forwarded to F&A for payment.

    The benefits paid per day are recorded and will be sent to F&A . F&A

    Interface will be populated and the F&A will update finance records

    If insured person failed to satisfy the eligibility criteria, the claim will not

    be processed and rejection slip is generated

    Claim Rejection

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    13/24Confidential Copyright 2009 Wipro Ltd

    Process related Reports

    Reports from BO Monthly progress report

    Statement to P.L.B Data

    Statement of P.D.B Cases

    Statement of E.S.B Cases

    Statement of Excess Payment

    Statement of Waiver or Recovery of Excess Payment

  • 7/27/2019 Panchdeep Insurance Benefits 2.0

    14/24Confidential Copyright 2009 Wipro