Clarification About Esi - CiteHR
Madhu.T.K
Industrial Relations And Labour Laws
Harsh Kumar Mehta
Consultant In Labour Laws/hr
Loginmiraclelogistics
Asso.prof.(commerce & Management) Pg
+5 Others

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Dear team,
I am working in a private company as as hr executive. I need clarification about esi benefits. One of our company employee has taken treatment for major operation in a private hospital. The employee is covered under esi. Is possible to claim the amount in esi.
regards
B.K

posible. Ask him to contect ESIC administrativeoffice to clam the benefits.
Dear Member,,,
Yes he can claim the amount in ESI,
But he has to get the certificate/ Letter from near by ESI hospital saying that, we are lacking facility for that major operation and he is eligible for benefits, otherwise it will be difficult.... .
Just check the details in below url
esic.nic.in#8206;
Thanks

Before getting admitted in the private hospital for treatment he should have obtained the aforesaid certificate from the ESI Medical Officer. If so, he would have got it cashless from the said private hospital. If he has directly went to private hospital, in normal case, he will get the money back only as reimbursement which may take years to come.
I would say it is due to the negligence of HR that the employee had to take treatment from private hospital directly without first consulting the ESI Medical Officer and then getting referred to that private hospital.
Madhu.T.K

Sir,

The Insured Persons covered under ESI Act and Rules/Regulations framed thereunder are entitled for benefits (as their legal right) as laid down under said Act provided the procedure laid down under said scheme of Act/rules/regulations is complied with. Your company employee may have his insurance number and identity card and on that basis, he could have contacted authorised ESI Dispensary/IMO concerned and could have obtained the treatment as per procedure laid down. In case the required medical facilities were not available in ESI institutions of the area, the concerned IMO could have referred the patient to the authorised Super Speciality Hospital, where such tie-up arrangements are made.

Now, when the formalities have not been complied with, I am doubtful if any benefit can be claimed at this stage. However, the concerned employee can approach the authorised ESI dispensary of his area with all documents.

In case your employee contacts the ESI Dispensary/IMO, even at this stage, then for future he can avail medical facilities as well as Cash Benefit, if otherwise eligible.

With regards;

Harsh Kumar Mehta

Respected Sir
Gdevng Sir
With out knowing anything How can we blame the HR personnel.
Most of Employees are not willing for ESI treatment.
In some Emergency cases due to lack of time other than approaching private Hospital we have any other option.
In emergency cases also ESI is following Rules and Regulations.
Saturday, Sunday, Public Holidays, Festivals and after 6 :00 PM whom to we contact sir for ESI benefits
for all this how can we blame HR and how he is responsible for all this.
Sorry Sir
With Regards
Swetha

Of course you are raising practical difficulties. But ESI go by the rule book. I afraid now it is possible to arrange back dated documents from ESI by some method. Nothing wrong in trying to overcome the problems. But it is for sure ESI has every right to deny the claim which treatment is not referred by them to a private hospital especially not recognised by ESI as a referral case facility with prior approved hospitals. Whom shall you blame then ?
Hi,
ESI Hospitals functions 24x7 days. For any emergency or treatment, first should go to ESI Hospital and all formalities commence thereafter. In peculiar circumstances, doctors refer the IP to super-specialty hospital even AIIMS where treatment is given at the earliest and priority is given to the IP. Only IP No. is required and rest data is available on their website. I have gone through such circumstances. Later claim/reimbursement is difficult because case is not referred by their doctor/medical board. If private treatment is emergent, then find the ESI approved private hospitals who handle the matter.
Thanks
V K Gupta

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