ESIC eligibility criteria and benefits

ESIC eligibility criteria and benefits for members and dependents!

The Employees’ State Insurance (ESI) scheme was launched by the Government of India with the primary objective of providing cover to employees from health-related contingencies such as permanent or temporary disablement, sickness, death due to injury caused during employment or occupational disease that adversely affects the earning capacity of the worker. Through this scheme, an employee will be able to overcome the financial burden due to such eventualities.

Eligibility

The ESI Act provides Medical cover and other benefits to employees in factories, business establishments like hotels, cinema houses, road transport, newspapers, educational and medical institutions, and shops wherein 10 or more persons are employed. The scheme offers benefits to both the employees and their dependents in case of any emergencies like hospitalization or accidents at the workplace.

As per the Act, any worker or employee earning wages up to ₹ 21,000 per month is entitled to these benefits.

The Benefits

The benefits that members or their dependents are eligible to receive have been spelt out in Section 46 of the Act. Members are eligible to receive six social security benefits and they are as follows:

  1. Medical Benefit
  2. Sickness Benefit
  3. Maternity Benefit
  4. Disablement Benefit
  5. Dependent Benefit
  6. Other Benefits
I.  Medical Benefit

Through this full medical care is provided to the Insured Person (IP) and his family members from the day of entering insurable employment. The family includes spouses, dependent children up to 18 years (if continuing education up to 21 years) dependent unmarried daughter, dependent infirm children, and dependent parents.

Also if the Insured Person is unmarried and his/her parents are not alive, the minor brother or sister wholly dependent on the earnings of the Insured person.

There is no ceiling on the expenditure incurred in the treatment of the insured person or his/her dependent. The Act also provides medical care to retired and permanently disabled insured person and their spouse on payment of a token annual premium of ₹ 120. The following are the provisions and benefits.

  1. System of Medicine
  2. Entitlement
  3. Benefits to retired persons
  4. Domiciliary Hospitalization
  5. Consultation with Specialists
  6. Investigation and Imaging Services
  7. In-patient treatment
  8. Artificial Limbs and Aids
1. System of Medicine

The Allopathic system of Medicine is the normal system of treatment. However, considering the request of a substantial number of workers to provide treatment in the Indian System of Medicine and Homoeopathy (ISM & H), treatment is now been provided through Ayurveda, Unani, Siddha, and Homoeopathy, and also through Yoga therapy.

The required certificates for availing of the benefits have to be issued by the concerned Insurance Medical Officer (IMO) or Insurance Medical Practitioner (IMP) appointed by the State government. This facility is available in 95 selected ESI Hospitals/Dispensaries throughout the country.

2. Entitlement

The State Government in consultation with the Corporation prescribes the level of entitlement benefits that members or their family members are entitled to. An IP or a family member can only avail of the medical benefits prescribed. All beneficiaries are entitled to reasonable medical, surgical, and obstetric treatment.

Entitlement of IPs

ESI Hospital / Dispensary / Diagnostic Centre and other recognized institutions offer the following treatment to all IPs.

– Outpatient Treatment

– Domiciliary Treatment

– Hospitalization as In-patient

– Full supply of Drugs, dressings, aids, appliances, and artificial limbs.

– Laboratory and Imaging services.

– Entitled to receive benefits under the Integrated family welfare scheme, MCH, and other national health programs.

– Ambulance service or reimbursement of conveyance charges for visiting hospitals or diagnostic centres.

– Medical Certification

– Other special provisions.

Entitlement of Family Members

Family members of an IP are entitled to one or other medical benefit:

– Full Medical Care which means all facilities entitled to IPs including hospitalization

– Extended Medical Care which includes all facilities provided to IPs but without hospitalization.

However, plans are afoot to provide uniform Medicare Care to family members in all implemented areas as the rates of contribution paid by the employee and employer are uniform across the country.

2.  Benefits to Retired IPs and Disabled Persons

Under Section 56 of the Act, a member on payment of a lump sum ₹ 120 for one year in advance, (₹ 10 per month) can avail of the following benefits:

– This benefit is available till the period for which the Insured person contributes. The insurance should not be for less than five years and the IP should have left insurable employment on attaining the age of superannuation or taken VRS or retired prematurely. The spouse is also entitled to this benefit.

– An insured person or his/her spouse who ceases to be in insurable employment on account of permanent disablement due to injury suffered during employment shall be entitled to receive medical benefits.

3.  Domiciliary Treatment

The IPs and his/her family members are entitled to free medical treatment at their residence when the patient’s condition is such that he/she cannot undertake travel to attend the clinic/dispensary. The concerned IMO/IMP is required to attend to the person at his/her residence. The IMO/IMP is required to maintain a proper record of the domiciliary visits in a register month-wise.

4.  Consultation with Specialists

As per the Act, Specialist consultation to IPs and members of their family is to be provided in areas with “Expanded” and “Full” Medical care. Specialist consultation may be provided at Specialist/Diagnostic Center’s, ESI Hospitals, and at such other institutions where Specialists/Super Specialists have been appointed on a full-time/part-time basis.

Such Specialist Consultations are available in specialties like General medicine, Surgery, Pulmonary Medicine, Obstetrics and Gynaecology, Paediatrics, Ophthalmology, ENT, Orthopaedics, Cardiology, Neurology, Urology & Nephrology, Gastroenterology, Endocrinology, Oncology, and many other specialties.

5. In-Patient Treatment

In areas with “FULL” Medical Care facilities, the family members are entitled to hospitalization. IPs are eligible for hospitalization in all areas. All ESI Hospitals provide in-patient treatment. This facility is also available by reservation of beds in hospitals owned by the State government, or in Private institutions, or by constructing annexes to such institutions.

6.  Investigation and Imaging Services

The IPs and family members are entitled to free Laboratory Investigation and Imaging Services. The Imaging facilities include CT Scans, MRI & Echo-Cardiograph. These services can be availed from state-level specialty hospitals or other institutions that have tie-up with ESIC.

7. Artificial Limbs and Aids

IPs and their family member are provided the following Artificial Limbs and aids as part of the medical care under the ESI scheme.

Artificial Limbs, Hearing Aids, Wigs (for women beneficiaries only), Cardiac Pacemaker, Wheelchair/Tricycle, Spinal support, Cervical Collar, Crutches, Surgical Boots, Hip Prosthesis, intra-Ocular Lens, and any other aids or appliances prescribed by the Specialist. Apart from this, Spectacles, Artificial Dentures, and Artificial Eyes are available to the IPs only. The expenses incurred for purchasing artificial limbs and aids are met from the shareable pool of expenditure on medical care.

II.  Sickness Benefits

Sickness Benefit is a benefit in the form of cash compensation payable to the IPs during periods of certified sickness. 70% of average daily wages are payable to the IP up to a maximum of 91 days in a year on condition that the insured person has contributed for 78 days in a contributory period of 6 months.

1. Extended Sickness Benefit

Continuous insurable employment for two years with 156 days contribution in four consecutive periods is required to avail of this benefit if suffering from 34 specified long-term diseases.

The benefit is available for 309 days which may be extended up to two years on medical advice up to 60 years of age and can be availed during a period of three years. Rate: 80% of the average daily wages.

2. Enhanced Sickness Benefit

Payment of contribution for 78 days in the corresponding contribution period of six months

This benefit is payable to IPs undergoing sterilization for family planning. Full wages are paid for 7 days for Vasectomy and 14 days for Tubectomy, and are extendable on medical advice. The rate of payment is 100% of the daily average wages.

III.  Maternity Benefit

Payment of contribution of 70 days in two preceding contribution periods (one year).

Benefit: Up to 26 weeks in case of normal delivery and up to 6 weeks in case of miscarriage, that is extendable by 4 weeks on medical advice. For insured women with two or more surviving children Maternity Benefit will be for 12 weeks. Rate: 100% of the average daily wages.

IV. Disablement Benefit

1. Temporary Disablement Benefit

From day one of entering insurable employment irrespective of  having paid any contribution and payable for employment injury cases only.

Benefit: As long as temporary disablement lasts.  Rate: 90% of the average daily wages.

2.  Occupational Diseases

The Occupational Diseases is defined in the third schedule of ESI Act, 1948 and as confirmed by the Special Medical Board are treated as Employment injury.

Benefit: As long as temporary disablement lasts.  Rate: 90% of the average daily wages.

3.  Permanent Disability Benefit

Same as in the case of temporary disablement but after Medical Board decision.

Benefit:  For whole life.  Rate: 90% of the average daily wages if permanent disability is total.  In case of partial disablement proportionate to the loss of earning capacity.

V.  Dependent Benefit

If the IP is deceased and the cause of death is due to employment injury or occupational hazard, then the benefit is paid to the dependents of the deceased IP.

To the widow for life or until her re-marriage. To children till the age of 25 years. To dependent parents for life.

Rate: 90% of the average daily wages shareable in fixed proportion.

VI. Other Benefits

1. Funeral Expenses

From day one of entering insurable employment and if eligible for any benefit as an insured person. Rate:  Actual expenses subject to a maximum of ₹ 15,000 (w.e.f. 01-03-2019).

2. Confinement Expenses

Confinement expense is paid to a woman IP or an IP in respect of his wife in case the confinement occurs in a place where necessary medical facilities under the ESI scheme are not available.

Benefits: Up to two confinements only.  Rate: ₹ 5,000 per case.

In addition to the above, Vocational Rehabilitation benefit is provided to permanently disabled IPs for undergoing Vocational Rehabilitation training at the VT Centres. IPs are also eligible to receive Physical Rehabilitation benefits in case of physical disablement due to employment injury.

3. Unemployment Allowance

The IP also benefits from 2 schemes introduced by the Government:

1. Rajiv Gandhi Shramik Kalyan Yojana

This scheme was launched on 01-09-2005. In case of involuntary loss of employment due to closure of the establishment, retrenchment of due to permanent disablement due to non-employment injury and the contribution in respect of him have been paid/payable in for a maximum of 2 years prior to the loss of employment.

Benefit:  maximum twenty four months during the lifetime.  Rate:  50% of the average daily wages for first 12 months and thereafter 25% of average daily wages up to 24 months.

2. Atal Beemit Vyakti Kalyan Yojana

The ESI Corporation has introduced the Atal Beemit Vyakti Kalyan Yojana (ABVKY) with effect from 01-07-2018 as a welfare measure for employees who have been rendered unemployed.

Benefit:  Subject to the eligibility conditions, in the form of cash compensation up to 25% of the average daily wages up to 90 days, once in a lifetime, to be claimed after 3 months from unemployment in one or more spells.

4. Vocational Training

Vocational Training is provided in case of physical disablement due to employment injury.

Benefits: As long as vocational training lasts.  Rate:  Actual fee charged or ₹ 123 a day or whichever is higher.

5. Physical Training

Physical Training is provided in case of physical disablement due to employment injury.

Benefits: As long as a person is admitted in an artificial limb Centre. Rate:  100% of the average daily wages.

6. Skill Upgradation Training

Skill Upgradation Training is provided in case of physical disablement due to employment injury.

Benefits: For a short duration maximum up to 12 months.

7. Quota for MBBS/BDS Admission

The children of Insured Person/Insured Woman who satisfy the eligibility conditions as per the guidelines issued by ESIC Headquarters from time to tome published in the website www.esic.nic.in will be eligible for admission under IP quota in Medical Institutions.

Benefits:  MBBS/BDS seats are reserved for wards (children) of IP in ESIC Medical/Dental Colleges. The candidate should attend the NEET Examination and should find a place in the rank list.

Conclusion

The benefits provided to employees through the ESI scheme have enabled employees to withstand the financial pressures due to medical emergencies and injuries caused in the course of employment. Both the IPs and their family members have benefitted greatly from these schemes and they stand testimony to the various welfare measures introduced for the welfare of employees.

GetifyHR, one of the premier outsourcers of Payroll Processing and HR Management has been assisting clients across the country in all aspects of payroll processing and statutory compliance issues. We have been able to also assist employees to receive all their benefits so that they could tide over very serious crises in their life by way of hospitalization due to medical emergencies and injuries suffered during employment. This has enabled management to enjoy a greater rapport with the employees and has helped to promote positive growth.

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