Dear Insured Persons
FOR HELPING US TO HELP YOU
Do not add any non-eligible person to your Declaration Form for purpose of medical facility etc.
Do not deface or tamper with your Identity Card.
Do not lend your Identity Card to anyone else.
Do not fake illness or injury for claiming any benefit.
Do not force your doctor for wrong certification etc.
Do not approach touts for any favour from ESIC
Do not tamper with your Medical Certificate.
Do not pay for any ESIC Forms. These are supplied free of cost from Local Offices.
Do not forget to add/delete a family member in your declaration in the event of birth/death.
Do not forget to carry Form 105 duly signed by your employer on outstation journeys. This will enable you to avail ESI facilities anywhere.
1. ESI Scheme _ The fundamentals.
2. Registration, Contributions etc.
3. Social Security Benefits
a) Sickness Benefit
b) Extended Sickness Benefit
c) Enhanced Sickness Benefit
d) Disablement Benefit
e) Dependants' Benefit
f) Maternity Benefit
g) Medical Benefit
h) Funeral Expenses
4. Miscellaneous Provisions
5. Standard Sickness Benefit Rates (Annexure-A)
esi scheme of india
1. What is E.S.I. Scheme ?
* In addition to necessities of food, clothing, housing etc., man needs security in times of physical and economic distress consequent upon sickness, disablement etc. The Employees’ State Insurance Scheme is an integrated measure of Social Insurance embodied in the Employees’ State Insurance Act and is designed to accomplish the task of protecting ‘employees’ as defined in the Employees’ State Insurance Act against the hazards of sickness, maternity, disablement and death due to employment injury and to provide medical care to insured persons and their families. The Scheme covers employees of non-seasonal power-using factories employing 10 or more persons. There is, however, a built-in provision for its extension to other establishments or classes 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.
2. How does the Employees’ State Insurance Scheme assist you?
* The dependence of an individual on cash income is a characteristic feature of modern economy. An interruption of money income even for a small period is, therefore, a hardship; a prolonged loss of income is indeed a catastrophe. By coming forward to provide health protection and income maintenance in a series of oft-experienced contingencies like sickness, maternity, disablement and death due to employment injury, the Employees’ State Insurance Scheme tends to ameliorate your economic anxiety and to be a friend in need and distress.
3. Why is it called a Health Insurance Scheme?
* The Employees’ State Insurance Scheme performs a dual role; by providing assistance in kind (medical care) it tries to restore your health and working capacity and by assistance in cash (cash benefit) it tries to sustain you when your income is interrupted. With a better and facile health protection, greater vitality, and assurance of income-maintenance in times of need, it makes you every inch a better, a healthier, secure worker and therefore, a happier man. The assistance comes to you not as an act of benevolence but in virtue of an acquired right.
4. Who administers the Employees’ State Insurance Scheme?
* The Employees’ State Insurance Scheme is administered by a corporate body called the Employees’ State Insurance Corporation (ESIC), which has members representing Employees, Employers, the Central Government, State Governments, Medical Profession and the Parliament. The Director General is the Chief Executive Officer of the Corporation and is also an ex-officio member of the Corporation. The other bodies at the national level are the Standing Committee (a representative body of the Corporation) and the Medical Benefit Council, a specialised body which advises the Corporation on administration of Medical Benefit. At the Regional and Local levels, the Regional Boards and Local Committees have been constituted. There is, thus, an association of interests and interest groups at all levels.
ESIC is the trustee of the interests of the insured persons. It discharges its obligations and duties through a net-work of Regional Offices and Local Offices, Hospitals and Dispensaries spread over the entire country.
5. Whom does the Scheme protect?
* The Scheme protects all “employees” engaged on a monthly remuneration not exceeding Rs. 6500/- in a factory/establishment to which the Act applies. Persons employed for wages on any work connected with the administration of the factory or establishment or any part, department or branch thereof or purchase of raw materials, or distribution or sale of the product of a factory or establishment are also covered. Mines, Railway Running Sheds, Naval, Military and Air Force Workshops and specified seasonal factories are excluded. The scheme also provides full medical cover to the dependants of insured persons. In the event of death of an insured person due to employment injury dependants become eligible to cash benefit.
6. Where do Employees’ State Insurance Funds come from?
* The Employees’ State Insurance Funds are primarily built out of employers contribution and employees contribution payable monthly as a fixed percentage of wages.
7. How are the employees registered under the Scheme?
with his/her entry into employment in a covered factory or establishment, an employee is required
to fill in a Declaration Form. The employee is then allotted a Registration Number, which distinguishes and identifies the person for the purposes of the Scheme. A person is
registered once and once only upon his entry in insurable employment.
8. What is an Identity Card?
* On registration every insured person is provided with a “Temporary Identification Certificate” which is valid ordinarily for a period of 3 months but may be extended, if necessary, for a further period of 3 months. Within this period, the Insured Person is given a permanent “family photo Identity Card” in exchange for the Certificate. The Identity Card serves as a means of identification and has to be produced at the time of claiming medical care at the dispensary/clinic and cash benefit at the Local Office of the Corporation. In the event of change of employment, it should be produced before the new employer as evidence of registration under the Scheme to prevent any duplicate registration. The Identity Card bears the signatures/thumb impression of the insured person.
Since medical benefit is also available to the families of insured persons, the particulars of family members entitled to Medical Benefit are also given in the Identity Card affixed with a postcard size family photo.
If you lose your Identity Card before it has run its normal life, a duplicate card is issued on payment as prescribed.
9. What are the rates of contribution?
* Contributions payable in respect of an employee comprise of employer’s contribution and employee’s contribution prescribed in Schedule I of the Act.
An employee covered under the scheme has to contribute 1.75% of the wages whereas, an employer contributes 4.75% of the wages payable to an employee. The total contribution in respect of an employee thus works out to 6.50% of the wages payable.
10. Who is exempted from payment of contribution?
* Employees earning less than Rs 40/- a day are exempted from payment of contribution. The employers share of contribution is, however, payable.
11. How are the Contributions collected?
* The Contribution is deposited by the Employer in cash or by cheque at the designated branches of some nationalised banks. The responsibility for payment of all contributions is that of the employer with a right to deduct the Employees’ share of contributions from employees’ wages relating to the period in respect of which the Contribution is payable.
12. What are ‘Contribution Periods’ and ‘Benefit Periods?
* Workers, covered under the ESI Act, are required to pay contribution towards the scheme on a monthly basis. A contribution period means a six-month time span from 1st April to 30th September and 1st October to 31st March. Thus, in a financial year there are two contribution periods of six months duration.
Cash benefits under the scheme are generally linked with contributions paid. The benefit period starts three months after the closure of a contribution period. The two types of periods are illucidated below:–
Contribution Period Corresponding Benefit period
1st April to 30th September 1st January to 30th June of the following year
1st October to 31st March 1st July to 31st December
13. What is a Local Office?
* A net-work of Local Offices has been established by the Corporation in all implemented areas to disburse all claims for sickness, maternity, disablement and dependents’ benefit. The Local Office also answers all doubts and enquiries and assists otherwise in filling in claim forms and completing other action necessary in connection with the settlement of claims. These officies also interact with the employers of the area. The Local Offices are managed by a Manager and work under the direction and control of the Regional Offices.
SOCIAL SECURITY BENEFITS
14. What does ‘Sickness Benefit’ mean?
* Sickness signifies a state of health necessitating medical treatment and attendance and abstention from work on medical grounds. Financial support extended by the Corporation is such a contingency is called Sickness Benefit.
15. What are the Contributory Conditions?
* The contribution condition required to be fulfilled for admissibility of sickness benefit during any benefit period is that contributions should have been paid in respect of an insured person in the corresponding contribution period for not less than 78 days.
16. How much is the Standard Benefit Rate?
* The daily rate of Sickness Benefit during any benefit period is the “standard benefit rate” this rate corresponds to the average daily wage of an insured person during the corresponding contribution period and is roughly half of the daily wage rate. Benefit is paid for Sundays also. 28 wage groups have been evolved for working out the daily rate of Standard Sickness Benefit. Standard Benefit rates for 28 wage groups are shown in Annexure ‘A’.
17. What is the duration of Sickness Benefit?
* Sickness benefit is payable for a maximum period of 91 days in any two consecutive benefit periods. Benefit is not paid for an initial waiting period of 2 days unless the insured person is certified sick within 15 days of the last spell in which Sickness Benefit was paid.
EXTENDED SICKNESS BENEFIT:
18. What is Extended Sickness Benefit?
* Extended Sickness Benefit is a Cash Benefit paid for prolonged illness due to any of the 34 specified diseases as mentioned below.
3. Chronic Empyema
5. Interstitial Lung disease
7. Malignant Diseases
8. Diabetes Mellitus-with proliferative retinopathy/diabetic foot/ nephropathy.
13. Intracranial space occupying lesion
14. Spinal Cord Compression
15. Parkinson’s disease
16. Myasthenia Gravis/Neuromuscular Dystrophies
17. Immature Cataract with vision 6/60 or less
18. Detachment of Retina
20. Coronary Artery Diseases
21. Congestive Heart Failure-Left, Right
22. Cardiac valvular Diseases with failure/complications
24. Heat disease with surgical intervention alongwith complications
25. Chronic Obstructive Long diseases (COPD) with congestive heart failure (Cor Pulmonale)
26. Cirrhosis of liver with ascitis/chronic active hepatitis (“CAH”)
27. Dislocation of vertebra/prolapse of intervertebral disc
28. Non union or delayed union of fracture
29. Post Traumatic surgical amputation of lower extremity
30. Compound fracture with chronic osteomyelitis
31. (a) Schizophrenia
(b) Endogenous depression
(c) Maniac Depressive Psychosis (MDP)
32. More than 20% Burns with infection/complication
33. Chronic Renal Failure
34. Reynaud’s disease/Burger’s disease.
In addition, extended sickness benefit may also be sanctioned by the prescribed authority, in case of any rare disease or special circumstances on the recommendation of the specified authority.
19. What are the Contributory Conditions?
* Except in case of disability from administration of drugs/injections, the insured person should have been in continuous employment for a period of 2 years and should have contributed for atleast 156 days in 4 preceding contribution periods.
20. How much is the Benefit rate?
* The daily rate of Extended Sickness Benefit is 40% more than the Standard Sickness Benefit rate admissible.
21. How long is the Benefit available?
* After exhausting Sickness Benefit payable for 91 days the ESB is payable upto a further period of 124/309 days that can be extended upto 2 years in special circumstances. Thus, together with the Sickness Benefit for 91 days, it puts a claimant on benefit for an aggregate period 400 days for all specified diseases and 2 years in chronic suitable cases on recommendation of competent authority.
enhanced sickness benefit
22. What is Enhanced Sickness Benefit?
* Enhanced Sickness Benefit is cash benefit for the insured persons undergoing sterlisation operation of vasectomy/tubectomy for family planning.
22a. What are the contributory conditions?
* The contributory conditions are the same as for claiming sickness benefit.
22b. How much is the benefit rate?
* The daily rate of this benefit is double the standard benefit rate. Say, not less than the daily wage.
22c. How Long is the benefit available?
* The benefit is available upto 7 days for vasectomy and upto 14 days for tubectomy operations. This period can however be extended in cases of post operative complications or sickness arising out of these sterlisation operations. Its duration is not counted towards the total number of 91 days for which the sickness benefit is available during any two consecutive benefit periods.
22d. How to claim Sickness Benefit?
* A claim for Sickness Benefit should be supported by a Medical Certificate issued by an Insurance Medical Officer/Insurance Medical Practitioner in the appropriate Form. Medical Certificates are issued at intervals of not more than seven days, except in cases of prolonged sickness, where Special Intermediate Certificates may be issued at longer intervals not exceeding 4 weeks. On the back of each certificate, except the Special Intermediate Certificate, a Claim Form is printed. The Claim Form is essentially a declaration in regard to abstention of the claimant from work during the period of claim. Separate Claim Forms are also available.
The Claim Form should bear signatures/thumb impression of the claimant and should be submitted to the Local Office personally, by post, through a messenger or by deposit in certificate boxes, wherever provided. All claims should preferably to submitted to the Local Office within three days. The Receptionist at the Local Office renders all assistance in filling in the claim on your behalf.
23. What is ‘Disablement’?
* Disablement is a condition resulting from employment injury which may be :–
(a) temporary i.e. rendering an insured person incapable of work temporarily and necessitating medical treatment;
partial i.e. reducing the earning capacity of the insured person generally
(c) permanent total i.e. totally depriving the insured person of the power to do all work.
24. What constitutes an “Employment Injury?”
* Employment injury means a personal injury caused to an employee by an accident or occupational disease arising out of and in course of his employment in a factory or establishment covered under the Employees’ State Insurance Act.
The law relating to Employment injury has been liberalised. Now, an accident arising in the course of employment is presumed also to have arisen out of his employment if there is no evidence to the contrary. Further, an accident brought about by wilful disobedience, negligence or breach of regulations etc. or an accident happening while travelling in a transport provided by the employer or while meeting an emergency is accepted subject to certain conditions, to have arisen in the course of and out of employment. Injuries suffered while under the influence of drinks and drugs take away the right of the employee to this benefit.
Roadside accident caused while commuting between place of residence and workplace is also treated as notional extension of employment for purpose of death or disablement benefit.
25. What are ‘Occupational Diseases’?
* Occupational Diseases are such diseases as are susceptible of being traced back to their occupational origin. These are specified under Schedule III of the Employees’ State Insurance Act, which enumerates the compensable Occupational Diseases and the corresponding industrial processes involving exposure to the diseases are thus recognised without any further evidence.
26. What are the Benefits granted?
* Temporary Disablement Benefit is paid periodically in arrears as the evidence of incapacity (medical certificate) is produced. Permanent total disablement and permanent partial disablement benefits are paid in the form of pensions. Current employment for wages or engagement in any gainful activities is no bar to payment of permanent disablement benefits. An insured person suffering from an occupationd disease is also entitled to full medical care.
27. How much is the Benefit Rate?
* The daily benefit rate for permanent total disablement and temporary disablement is 40% more than the Standard Sickness Benefit rate and is roughly equivalent to about 70% of the wage rate. For permanent partial disablement, the rate of benefit is proportionate to the percentage of loss of earning capacity. The benefit is paid for Sundays also.
28. What are the Contributory Conditions?
* There are no qualifying conditions as to the length of employment or the number of contributions paid. Protection accrues from the very moment of entry into insurable employment.
29. What is the duration of Benefit?
* Temporary Disablement Benefit is paid as long as disablement lasts. There is a waiting period of 3 days (excluding the day of accident), but if incapacity exceeds this period, benefit is paid from the very first day. The permanent disablement benefit is paid for the life-time of the beneficiary.
30. How is Permanent Disablement assessed?
* There is indeed no way of adequately compensating a permanently disabled employee and yet some method of determining whether an employment injury has resulted in permanent disablement and of assessing the extent of permanent damage caused by that employment injury has to be adopted for the purpose of determining the scale of compensation for the loss of earnings. This is done by evaluating loss of earning capacity with reference to general disability for all work. The evaluation is done by a Medical Board whose decision can be appealed against to a Medical Appeal Tribunal presided over by a judicial officer, with a further right of appeal to Employees’ Insurance Court or directly to Employees’ Insurance Court. Pending an appeal, payment for permanent loss of earning capacity as recommended by the Medical Board is made, subject to adjustment later. Loss of wages and expenditure on conveyance occasioned by attendance before the Medical Board are compensated by the Corporation in accordance with rates framed for the purpose.
Where the assessment of loss of earning capacity by the Medical Board is not of a final character, the beneficiary is required to appear again before the Medical Board for a review of the assessment.
31. Can the decisions of Medical Board or of Medical Appeal Tribunal be reviewed?
* Yes. If the Medial Board or the Medical Appeal Tribunal is satisfied by fresh evidence that a decision was given because of non-disclosure or mis-representation of a material fact, it can review its earlier decision at any time. A Medical Board can also review its earlier assessment of extent of disablement, if it is satisfied that there has been substantial and unforeseen aggravation of the results of the relevant injury and substantial injustice would be done by not reviewing it. Such review, however, cannot be made earlier than 5 years or in the case of the provisional assessment, earlier than 6 months of the date of assessment to be reviewed.
32. Is lumpsum Benefit allowed in place of Pension?
* Yes. At the option of the beneficiary, permanent disablement pension, where the daily rate payable is not significant, can be commuted for a lumpsum payment subject to the fulfilment of the following two conditions :–
(i) that the permanent disablement has been assessed as final, and
(ii) the daily rate of permanent disablement does not exceed Rs 5/- and the total commuted value does not exceed Rs 30,000/- (effective from April–03).
33. How to claim ‘Disablement Benefit’?
(a) Temporary Disablement:
(i) Notice of the injury should be given either orally or in writing personally or through an agent, to the employer/foreman/duty supervisor or particulars of the injury should be entered in the Accident Book kept in the factory, personally or through an agent.
(ii) A medical certificate of incapacity should be obtained from the Insurance Medical Officer/Insurance Medical Practitioner.
(iii) The claim form printed on the back of the medical certificate should be filled in and submitted promptly to Local Office along with the medical certificate.
(iv) A final certificate should be obtained from the Insurance Medical Officer/Insurance Medical Practitioner and submitted to the Local Office before resumption of duty.
(b) Permanent Disablement:
(i) If suffering from permanent effects of employment injury, the insured person should make an application to the Regional Office of the Corporation for reference of his case to the Medical Board (reference to the Medical Board is made otherwise also by the Regional Office).
(ii) Where loss of earning capacity has been assessed and communicated to the insured person, he should submit a claim in the appropriate form to the Local Office.
(iii) After the claim has been admitted, the beneficiary should submit at six-monthly intervals (with the claim for June and December every year) a life certificate in appropriate form duly attested by the prescribed authority.
34. Is there any provision for physical rehabilitation?
* Yes. Insured Persons who suffer physical disablement due to employment injury are provided artificial appliances or other physical aids such as wheel chairs, crutches, dentures and spectacles etc.
35. What about vocational rehabilitation?
* The Corporation at its cost arranges for the vocational rehabilitation of disabled insured persons provided the disability has been assessed at above 40 percent and the beneficiary is not over 45 years of age. The training is provided at vacational rehabilitation centres run by the Govt. of India etc. The fee, travelling expenses etc are borne by the Corporation.
36. What is ‘Dependents’ Benefit’?
* Dependents Benefit is a monthly pension payable to the eligible dependents of an insured person who dies as a result of an Employment Injury or occupational disease.
37. Who are the Beneficiaries and how long is the Benefit available?
* Dependants entitled to the benefit could be :–
(a) Widow/Widows during life or until remarriage:
(b) Legitimate or adopted son until age 18 or if legitimate son is infirm, till infirmity lasts;
(c) Legitimate or adopted unmarried daughter until age 18 or until marriage, whichever is earlier, or if infirm, till infirmity lasts and she continues to be unmarried.
In the absence of any widow or legitimate child, the benefit is payable to a parent or grandparent for life, to any other male dependant until age 18 or to an unmarried or widowed female dependant until age 18.
38. How much is the Benefit for each Beneficiary?
* The total divisible benefit is equivalent to the temporary disablement benefit rate (roughly 70% of the wage rate). The widow/widows share 3/5th of the benefit and the legitimate or adopted son and daughter 2/5th each of the benefit. If the total benefit so divided exceeds the full rate, there is a proportionate reduction in the respective shares of the beneficiaries.
39. How to claim ‘Dependants’ Benefit’?
* To establish title to Dependant’ Benefit, the following documents should be submitted at the Local Office:–
(a) Claim in the appropriate form;
(b) Evidence of death being due to employment injury;
(c) Proof of relationship to the deceased supporting eligibility of the claimant as a “dependant”;
(d) Evidence of age of the claimant(s) (certified copy of official record of birth, Baptismal register, school records, original horoscope etc;
of infirmity from Medical Referee or any other prescribed authority in case of
legitimate infirm son or legitimate or adopted unmarried infirm
After the claim to Dependant’s Benefit has been admitted, the beneficiary should submit at six-monthly intervals (with the claim for June and December), a declaration that he/she is alive and has not married/remarried, attained the prescribed age/continues to be infirm, as the case may be duly attested by the prescribed authority.
40. Can Dependant’s Benefit be reviewed?
* Yes. Dependant’s Benefit once awarded can be reviewed by the Corporation at any time if it is satisfied on fresh evidence that the earlier decision was due to non-disclosure or misrepresentation of material facts. It can also be reviewed on birth, death, marriage, re-marriage and attainment of age 18, by a claimant. The benefit can be continued, increased, reduced or discontinued.
41. What is Maternity Benefit?
* Maternity Benefit is cash payable to an insured woman for the specified period of abstention from work for confinement or miscarriage or for sickness arising out of pregnancy, confinement, premature birth of child or miscarriage. “Confinement” connotes labour resulting in the delivery of a living child or labour after 26 weeks of pregnancy whether the resultant issue is alive or dead. “Miscarriage” means expulsion of the contents of a pregnant uterus at any period prior to or during 26th week of pregnancy. Criminal abortion or miscarriage does not, however, entitle to benefit.
42. What are the Contributory Conditions?
* The contribution condition is the same as for Sickness Benefit.
43. How much is the Benefit?
* The daily benefit rate is double the Sickness Benefit rate and is thus roughly equivalent to the full wages. Benefit is paid for Sundays also.
44. What is the duration of the Benefit?
* The Benefit is paid as follows:–
(a) For confinement :–
For a total period or 12 weeks beginning not more than 6 weeks before the expected date of child birth. If the insured woman dies during confinement or within 6 weeks thereafter, leaving behind the living child, the benefit continues to be payable for the whole of the period. But if the child also die during that period, the benefit will be paid upto and including the day of death of the child.
(b) For Miscarriage:–
For a period of 6 weeks following the date of miscarriage.
(c) For Sickness arising out of pregnancy, confinement, premature birth of child or miscarriage:–
For an additional period of upto four week.
In all the cases, the benefit is paid only if the insured woman does not work for remuneration during the period for which benefit is claimed. There is no waiting period.
45. How to claim Maternity Benefit?
* Where an insured woman wishes to claim Maternity Benefit after confinement or for miscarriage, she should obtain from the Insurance Medical Officer/Insurance Medical Practitioner, a certificate of confinement or miscarriage and submit it to her Local Office personally or by post alongwith a claim for Maternity Benefit. The claim form also contains a declaration of abstention from work.
If Benefit is desired before confinement, a Notice and Certificate of Pregnancy and a Certificate of Expected Confinement obtained from the Insurance medical Officer/Insurance Medical Practitioner are also required to be submitted.
For claiming Benefit in the event of death of an insured woman leaving behind a child, her nominee and if there is no such nominee, her legal representative should submit personally or by post to the Local Office of the deceased insured woman, a claim for the Benefit together with a certificate of death of the insured woman.
An insured woman claiming Maternity Benefit for Sickness arising out of pregnancy, confinement, premature birth of child or miscarriage should submit her claim in the manner as for sickness benefit.
Where a claim to Maternity Benefit is not submitted alongwith prescribed certificates referred to above, the Corporation has the discretion to accept other evidence in lieu thereof.
46. What is Medical Bonus?
* Medical Bonus is lump sum payment made to an insured woman or the wife of an insured person in case she does not avail medical facility from an ESI hospital at the time of delivery of a child. This bonus of Rs. 250/- has been increased to Rs. 1000/- from 1st April 2003.
47. What is Medical Benefit?
* Medical Benefit means medical care of insured persons and their families, wherever covered for medical benefit.
48. What does Medical Benefit consist of?
* The 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 and post natal care, emergency treatment etc.
49. Where are ‘out-patient’ services provided?
* Out-door medical care is provided at State Insurance Dispensaries or Mobile Dispensaries manned by full-time doctors (‘Service’ system) or at the private clinics of Insurance Medical Practitioners (‘Panel” system). The scope of medical services also includes simple ante-natal and post-natal care for women, family welfare planning services and immunisation against the common infectious diseases.
The Scheme provides at the sole cost of the Corporation, artificial limbs to insured persons who lose their limbs due to employment injury or in certain circumstances otherwise also, dentures, spectacles and hearing-aids where the loss of teeth, impairment of eye-sight or hearing respectively is due to employment injury.
50. How and where are ‘in – patient’ Services Provided?
* ESIC has a network of 141 hospitals countrywide. Majority of these hospitals are administered by the State Govts. In – patient and diagnostic services in basic specialities are available at these hospitals. State schemes have also tie-up arrangements with a number of Medical colleges, major state hospitals, as well as, private hospitals for advanced treatment for malignant diseases and complicated surgical interventions.
51. What about Preventive health care services?
* ESI Scheme provides preventive health care services through the network of its dispensaries and hospitals. These include immunisation against some killer diseases, pulse polio vaccination and family welfare services etc. The scheme also participates in all major national preventive health service campaigns.
52. How long is Medical Benefit available?
* Insured worker and the members of his family are eligible for medical care from the very first day of the worker coming under ESI Scheme. The medical care includes primary medical care, diagnostic services, specialist consultations and indoor medical care. Whenever the patient is not able to travel by himself/herself, ambulance services are also provided. The I.P. or his family members are not required to pay for any of the services.
A worker who is covered under the Scheme for the first time is eligible for medical care for a period of three months. If he/she continues in insurable employment for three months or more the medical care is available to him/her till the start of the first benefit period. If he/she contributes atleast for 78 days in a contribution period the eligibility is there upto the end of the corresponding benefit period.
A worker is also eligible for extended sickness benefit when he/she is suffering from any one of the long term 34 diseases listed in the Act. This is admissible after the worker has been under ESI coverage for atleast 2 years during which he/she should have contributed atleast for 156 days. When these conditions are satisfied medical benefit is admissible for a maximum period of 730 days for the I.P. and his/her family.
53. What are Funeral expenses?
* This component consists of a lump sum payment towards the expenditure on the funeral of the deceased insured person.
54. What is the amount payable?
* The lump sum amount of this benefit is equal to the actual expenditure, not exceeding Rs. 2500/- towards the funeral of the deceased insured person.
55. Are there any Contribution Conditions?
* No contribution condition is required for this Benefit. The only condition for admissibility of this Benefit is that the deceased person should have been an insured person at the time of his death. The Funeral expenses are thus payable in respect of an insured person in receipt of Permanent Disablement Benefit even if he may not be employed at the time of his death in a factory or establishment covered under the ESI Act.
56. To whom are the Funeral expenses payable?
* The expenses are payable to the eldest surviving member of the family of the deceased insured person. If the insured person did not have a family or if he was not living with his family at the time of his death, the benefit is payable to the person who actually incurs the expenditure on the funeral of the deceased insured person.
57. How to claim the Funeral expenses?
* To claim the expenses, the claimant should submit his/her claim personally or by post to the Local Office of the deceased insured person within three months, together with the following documents:–
(a) Death certificate as proof of death of the insured person issued by the Insurance Medical Officer/Insurance Medical Practitioner or such other Medical Officer of a hospital or other institution who attended the insured person at the time of death or examined the body after the death; (Death certificate issued by cremation/burial ground or by Municipal authorities or certified copy of village etc. death records may also be accepted as evidence of death);
(b) a declaration of the claimant, either
(i) that he is the eldest surviving member of the family of the deceased insured person and incurred expenditure on the funeral of the deceased. or
(ii) in case the claimant is other than the eldest surviving member of the family, that the deceased insured person did not have a family or was not living with his family at the time of his death and that the claimant actually incurred expenditure on the funeral of the deceased insured person. The declaration should be countersigned by a competent authority.
some miscellaneous provisions
u Disqualification for benefits in certain cases:
A person who works and receives wages on any day is not entitled to sickness benefit or maternity benefit or temporary disablement benefit in respect of that day.
A recipient of sickness benefit or temporary disablement benefit must remain under medical treatment and obey the instruction given by his Insurance Medical Officer. He should not leave the area of treatment without the permission of his medical officer and should present himself for examination by the medical officer or any other person authorised by the Corporation.
u Safeguarding the right to Benefit:
Cash benefits payable under the Employees’ State Insurance Act are not liable to attachment or sale in execution of any court decree or order. Also, the right to receive any benefit is not transferable or assignable.
u Protection from Dismissal, discharge or other Punishments:
An employee is protected against dismissal, discharge, or other punishments during the following periods:–
(1) a period of 6 months in case of a recipient of disablement benefit;
(2) a period of 6 months in case an employee is under medical treatment for sickness or certified illness due to pregnancy or confinement;
(3) a period of 12 months in case an employee is under medical treatment for T.B. Leprosy, Mental, Malignant or any of the 34 specified diseases.
u Remittance of Cash Benefit at the cost of the Corporation:
At the option of the beneficiary, cash benefits under the Employees’ State Insurance Act are remitted by Money Orders at the cost of the Corporation, irrespective of the amount involved.
u Adjudication Machinery:
To make the right of claimants effective, every claimant has a right of raising a dispute in the Employees’ Insurance Court. It consists of a judicial officer appointed by the State Government. The jurisdiction of a Civil Court is barred in all such cases.
u Repayment and recovery of Benefit payments:
If a person receives any benefit to which he is not legally entitled, he is liable to repay the value of any such benefit to the Corporation.
u Punishment for false statement etc.:
Any false statement or false representation made or caused to be made for the purpose of obtaining benefit wrongfully etc. constitutes an offence under the Employees’ State Insurance Act, punishable with imprisonment upto three months or with fine upto five hundred rupees or both.
u Treatment at outstation
In case an insured worker leaves his station on duty or otherwise he/she is eligible for treatment at any ESI medical unit, subject to production of identity card and a certificate from Employer in Form 105.
(Annexure _ A)
STANDARD SICKNESS BENEFIT RATES
AVERAGE DAILY WAGE DAILY STANDARD RATES
1. Below Rs. 28/- Rs. 14/-*
2. Rs. 28/- and above but below Rs. 32/- Rs. 16/-
3. Rs. 32/- and above but below Rs. 36/- Rs. 18/-
4. Rs. 36/- and above but below Rs. 40/- Rs. 20/-
5. Rs. 40/- and above but below Rs. 48/- Rs. 24/-
6. Rs. 48/- and above but below Rs. 56/- Rs. 28/-
7. Rs. 56/- and above but below Rs. 60/- Rs. 30/-
8. Rs. 60/- and above but below Rs. 64/- Rs. 32/-
9. Rs. 64/- and above but below Rs. 72/- Rs. 36/-
10. Rs. 72/- and above but below Rs. 76/- Rs. 38/-
11. Rs. 76/- and above but below Rs. 80/- Rs. 40/-
12. Rs. 80/- and above but below Rs. 88/- Rs. 44/-
13. Rs. 88/- and above but below Rs. 96/- Rs. 48/-
14. Rs. 96/- and above but below Rs. 106/- Rs. 53/-
15. Rs. 106/- and above but below Rs. 116/- Rs. 58/-
16. Rs. 116/- and above but below Rs. 126/- Rs. 63/-
17. Rs. 126/- and above but below Rs. 136/- Rs. 68/-
18. Rs. 136/- and above but below Rs. 146/- Rs. 73/-
19. Rs. 146/- and above but below Rs. 156/- Rs. 78/-
20. Rs. 156/- and above but below Rs. 166/- Rs. 83/-
21. Rs. 166/- and above but below Rs. 176/- Rs. 88/-
22. Rs. 176/- and above but below Rs. 186/- Rs. 93/-
23. Rs. 186/- and above but below Rs. 196/- Rs. 98/-
24. Rs. 196/- and above but below Rs. 206/- Rs. 103/-
25. Rs. 206/- and above but below Rs. 216/- Rs. 108/-
26. Rs. 216/- and above but below Rs. 226/- Rs. 113/-
27. Rs. 226/- and above but below Rs. 236/- Rs. 118/-
28. Rs. 236/- and above Rs. 125/-
* or full average daily wage whichever is less
FOR BETTER AND QUICKER SERVICES
Identity Card is your visa to social security; protect it from loss or damage.
In case of loss of Identity Card, report the matter to your Local Office/Dispensary.
Fill in all Claim Forms properly; avoid mistakes.
Count your money before leaving Local Office cash counter.
Apply for examination by Medical Board immediately after your TDB terminates.
Follow referral procedures for treatment except in emergencies, when time factor is critical.
If you have a grievance, contact Local Office Manager/Dispensary incharge to which you are attached for quick redressal.
Be courteous with ESI staff and expect courtesy and compassion from them always.