I think it will pay by ESI if he qualify below mentioned rule-
I am sending you ESI Benifit type's question & their answer Rule hope it wull help you.
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)
??????? (d)????? Dementia
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;
??????? (b)????? permanent partial i.e. reducing the earning capacity of the insured person generally for every
??????? (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;
??????? (e)????? Certificate 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.[/COLOR][/COLOR]
From India, Delhi
SuraghESIC will pay the compensation and records to submit along accident report are
1. Appointment Letter
2. Attendance details
3. Pay/wages details for the month
4. Temporary ID card ESIC
5. Govt ID Proof
6. Bank details
Same will be verified during survey.
From India, Bengaluru
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