Harsh Kumar Mehta
Consultant In Labour Laws/hr
Apex Management
Labour Laws Consultants
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Asso.prof.(commerce & Management) Pg
PTRC
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Hai All,
I am working as an HR executive. One of our employee, who is covered under ESI Scheme get admitted in hospital, due to typhoid. And the hospital was not an ESI hospital. Is this person eligible for the refund of the expenses? Is yes, what are the procedures to follow?
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Sir,
1. It is difficult to get any reimbursement at this stage on account of the reasons that the treatment has not been obtained from ESIC or ESIC authorised dispensary/hospital.
2. However, the insured person or his relatives attending to him may contact the authorised ESI dispensary/IMO concerned to which he is attached and discuss with him (i) possibility of reimbursement of past expenses (ii) obtaining treatment for the sickness, if required, for next spell of illness if not fully cured.
As per the process the Insured Person should report to the concerned dispensary or the ESI hospital and basing on the requirements the RMO will refer the case to any other hospital and in emergencies also the employee can directly get admitted by on the same day the information should be passed on. Normally the ESI will issue a credit note to the hospital, however you can meet the RMO concerned and explain the issue.
The bills need to be cleared by the Medical board hence it may be bit difficult. Instead of wasting some more money let the IP go and get admitted in the ESI hospital so that the expenditure can be reduced and he will also get leave.
The patient should have gone to ESI hospital only.If one did not go there one should give proper justification like emergency and ESI hospital was unreachable etc. AS soon as emergency is over and patient is stable one should be shifted to ESI hospital. If not, once patient h=is discharged, one should make application addressed to Director ESI Scheme and attach all the Bills, prescription, discharge card and other docs. Wait for the reply.
Normally they should pay the expenses for medicines according tho their cost structure.
If not, approach ESI Corporation and wait.
If you do not get satisfactory reply, one can either file claim before ESI Court or Consumer Court. ESI Corporation has huge amount of funds available but since they are not pro-people, they keep on accumulating funds collected from workers and employers in the name of workers welfare but do not use it for worker's welfare.
Sir(s),
1.I feel that it is not proper to say that "ESI Corporation has huge amount of funds available but since they are not pro-people, they keep on accumulating funds collected from workers and employers in the name of workers welfare but do not use it for worker's welfare" as mentioned by one of participant above.
2. At present major part of expenses in ESI Scheme is incurred on "medical benefit".
3.ESI dispensaries or hospital or tie-up hospitals are available in every implemented area. If any insured person or his dependant obtains medical expenses at his own discretion or will, ESIC is not to be blamed. If medical facilities or expenses are incurred in such hospital or dispensary which are not recognised by ESIC, there is no question, in my opinion, of filing any case in EI Court or consumer court.
Dear Mehta ji,
Of course the major part of funds so collected being ESIC contributions go into the developments of infrastructure and administration part but the employees are also required to follow the procedure laid down.
In case if some one took treatment other then ESIC Hospital / Dispensary and goes directly to any Government Hospitals even then he can get the due benefits after taking approval from Regional Office, ESIC but treatment taken from private doctor or hospital is not recognized.
P K Sharma
The discussion has been very positive.
I just want to add that the Reimbursement depends on circumstances. If IP was admitted in Emergency or the ESI medical care arrangements were not available to the IP he should get the Reimbursement as per approved rates. Accordingly he should make a case and file his claim with necessary bills in his Dispensary/SMC office.
The employee will get the reimbursement of all medicine 100% of expenses and of rent of room will be on the discretion of signing authority that will be regional director..
Conditions is that he should have intimated about his illness to the local esi dispensary in 48 hrs if not then he can ask his company to provide him a letter stating his illness and the period for which he was absent. on behalf of that esi dispensary will forward all his expenses to the area esi inspector office. But this process take a lot of time many time 12 months also.
Dear friends,
ESI has been created for a noble cause of serving the employees in various establishments. Unfortunately the purpose has not fully served. I'm sorry to say this, but I have seen instances in ESIC, like any other Indian authorities, corrupt systems, misuse of power, wasting of nation's wealth & infrastructure omnipresent here as well. People in cases like this by bribing get their bills passed for reimbursement, get their leave approved/reimbursed. I'm not declaring everybody like this nor encourage Praisen to adopt such methods, but such things do happen in the system.
Dear Sir
Please go to ESIC Dispensary submit all hospital bills along with Medical reimbursement claim form, they will proceed as per Esic Rules
you will get benefited
S.I.Hiremath
9448397220
Executive HR
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