ravikanth.msv Started The Discussion:
Lately i was approached by a women wanting to take treatment(maternity) in a private hospital and claim the same incurred expenditure from ESIC, shez been in ESIC since May-2010. Can she get all the benefits(cash benefit in this case) from ESIC without actually approaching/admitting in ESIC hopsital?
And in case of any complication in pregnancy,can she claim the incurred costs(which may be more than Rs.1 Lakh) from ESIC?
If the delivery takes place in the benefit period, naturally she can get super specialty treatment for maternity case also. But for that she should be referred to Specialty Hospital by the Medical Officer of the ESIC. It is not like that she can directly go and take specialised private treatment and then claim for the sum incurred. Go to local ESI dispensary and get the case referred to approved hospital or even super specialty hospital.
Elegibility for maternity payment I.P Should have minimum 70 days of previous contribution at the time of delivery confinment.
then only she can avail maternit payment for 84 days more than standard benefit rate(average salary=daily pay).
in the above case she can claim maternity payment submitting proof of medical certificate for 12 weeks(84 days)
coming to the medical expences she can claim for the reimbursment,contact your concern dispensary or branch office more details.
There is a provision of re-imbursement of medical expenses under ESI Act where an insured person or dependent availed medical treatment in private hospital without being referred by ESI medical officer.
Reimbursement of expenses incurred in respect of medical treatment under regulation-96 A.
Regulation-96 A reads as follows:- Claims for reimbursement of expenses incurred in respect of medical treatment of IP and his family may be accepted in circumstances and subject to such conditions as the Corporation may by general or special order specify.
The following conditions have been laid down under this Regulation :-
a.Full authority is vested with the State Government concerned to reimburse expenditure in respect of medical treatment of IP and his family.
b.It may be left to the discretion of the State Government to decide the Authority within their machinery who will approve the expenditure in question; and
c.Time limit for submission of the claims for reimbursement is one year.
The State Government has to keep in view the following points while considering the cases of reimbursement of expenditure on Medical Care:
i.Whether such facilities for which reimbursement is recommended are not available with the State;
ii.Whether the hospital where the IP was sent or proposed to be sent was/is the nearest hospital having required facilities/services.
List of Types of cases for which reimbursement is permitted is given below:-
1.Reimbursement is permissible in case of failure of the mobile dispensary van due to technical defects or otherwise to adhere to its schedule timings or where IP attached to such a dispensary sustained serious injuries or suffered from serious illness during off hours of the dispensary.
2.IPs and their family members had to resort to private treatment during the off hours of ESI dispensary/Emergency Centre due to unavoidable circumstances.
3.Medicines prescribed by IMO/Specialist were out of stock in the ESI Dispensary/Approved Chemist thereby compelling the IPs to make purchases from the market.
4.Medicines prescribed by Specialist and not provided by the IMO/IMP and where specialist considered such special Medicines absolutely necessary for the treatment of the beneficiaries as no substitute medicine was considered equally efficacious whether as an out patient or in patient.
5.Special appliances prescribed by Specialist such as Spinal supports, Cervical Collars, Walking Callipers, and Crutches, etc. if considered necessary as part of the treatment.
6.Where an IMO/IMP failed to make domiciliary visit requested by an IP thereby compelling the IP to make private arrangement for treatment. Under the panel system such cost is recoverable from the IMP if recommended after investigation by the Medical Service Committee.
7.Serious cases of accident or illness admitted directly into recognised hospitals where owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal his identity as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer.
8.Serious cases of accident/illness where a beneficiaries was admitted directly at a private hospital or in a non-recognised hospital where admission in a hospital recognised under the scheme would have seriously jeopardised his health like sudden heart attacks, fracture of the spine, cerebral haemorrhage, etc.
9.Expenditure incurred on investigation for blood transfusion.
10.Mental cases that may have incurred expenditure either as an out patient on specialised Therapy such as ECT etc.
11.Serious cases of accident and illness admitted to recognised hospitals where all the reserved ESI beds were occupied.
1.Reimbursement of conveyance charges incurred by IP where ambulance or any other transport under the scheme is not available owing to some reason or the other and where in the opinion of the IMO/IMP such a patient was non-ambulatory.
2.In respect of Specialised examination, laboratory test, X-ray, other imaging services etc., recommended by specialist, but where the IP either due to the break down in the machinery or where the nature of the examination of the Laboratory Tests was such that it was beyond the scope of the facilities available in the recognised laboratory/hospital.
3.In addition to above types of cases, reimbursement may also be allowed in other cases depending upon the merits of each case and the circumstances under which expenditure was incurred.
The above information I got from the official website of ESIC as I am trying for reimbursement of medical expenses incurred by one female employee where she got herself admitted in a private hospital without approaching the ESI doctor.
The women employee is entitled for the Maternity benefit for 84 days which is double the standard benefit rate, further 30 days sickness arising out of pregnancy on the recommendation of the IMO at the same rate. Further also she is entitled to medical reimbursement of expenditure as per the proceedure besides medical bonus if she delivered in a place where esi facility is not there.
I am fully agree with opinion of Madhu T. K. & wanting add the following
If you want to take the benefits from ESIC then you have to follow the procedure of ESIC
- You have to show to ESIC that you have admitted in private hospital as it was emergency with no time to search the ESIC hospital.
- Intimation to ESIC after you get admitted in the hospital
- After discharge from the hospital, you have to give admission card alonwith with all the bills till discharge from the hospital and submit to ESIC.
If you comply with above procedure you may get the ESIC benefits.
Thanks & Regards,
Assistant Manager – HR
Krishidhan Seeds Pvt. Ltd.
Contact No. : + 91 98908 45553
Email ID :
For entitlement to maternity benefit, the insured woman should have contributed for not less than seventy days in the immediately preceding two consecutive contribution periods prior to actual or expected date of confinement as the case may be.
To be eligible to maternity benefit, a confinement should either actually occur or should be expected to occur in a benefit period relative to the insured woman.
An insured woman who actually confines (or is expected to confine) on a date before the start of her first benefit period, is not entitled to claim maternity benefit even though part of the period of her maternity leave may fall within her first benefit period.
If the insured woman's date of actual confinement (or expected confinement) falls within her first benefit period, she will be entitled to maternity benefit even if a part of the period of her maternity leave may fall before the start of her first benefit period.
Completing 9 months has nothing to do with ESIC benefits
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