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.
16th June 2011 From India, Pune