Download pdf - Panchdeep Insurance Benefits 2.0

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Confidential Copyright 2009 Wipro Ltd

ESIC

Pragati (Insurance)

Benefits

October 30, 2013 1


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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)


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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


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Other Benefit

Other Cash Benefits

Conveyance Expenses

Unemployment Allowance

(Under Rajiv GandhiShramik Kalyan Yojana)

Vocational Rehabilitation

Funeral Expenses

Confinement Expenses


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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.


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Benefit at glance


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


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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



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



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



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



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.



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



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



Process related Reports

Reports from RO Return on Disposal of Long term Benefit

Return on waiver of recovery from Insured Persons, beyond the power

of RD

Return on waiver of excess payments made to Insured Persons by the

Regional Director

Half Yearly Report of ESI Beneficiaries with Disability for Whom

Employers Contribution is to be Paid by Ministry of SocialJustice(Region Wise Statement)

Half Yearly Report of ESI Beneficiaries with Disability for WhomEmployers Contribution is to be Paid by Ministry ofSocial Justice

(Disability Wise Statement)



Claim Verification & Recovery

Abstention verification :

Enquiries regarding IPs abstention from work are filled and submitted by the employer through the

ESIC employer portal.

Excess or wrong payments:

An excess or wrong payment may be paid to the IP/Beneficiary due to false declaration by insuredperson. Such excess or wrong payments made may come to the notice on receipt of reply to

abstention enquiry. These excess payments are recorded and further steps to recover the amount

is taken.

The System generates an alert and prompt when future claims by the IP is received when the

excess paid amount is recovered.

The application provides the option to generate B19 and refer to recovery branch to initiate

recovery procedure if no further claim from the IP is received.

The application also provides the option to refer the non-recoverable excess payments to Regional

office/ Headquarters for waiver of recovery



Screens


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Screens


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Screensclaim form


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Screens


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Screens


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Screens IP details & Certificates


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Screens Contribution details & Benefit Days calculated


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ScreensIncapacity reference (RM1)


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Thank You