Clarification In ESI Treatment- REG - CiteHR
Madhu.T.K
Industrial Relations And Labour Laws
Harsh Kumar Mehta
Consultant In Labour Laws/hr
KIRTI28.AUTI
Hr -executive
+2 Others

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Respected Seniors, Thanks a lot for this forum. As i am very new to HR field, i have a basic doubt in ESI treatment. I request you to kindly clarify. One of our workman got injury in left hand thumb while working. We arrange for first aid at near by hospital. They took x-ray and told no issues. Then the worker went to another hospital, there they told that there was a fracture and done operation. Now the workman requests the traeatment charges costs around Rs.15,000.He is covered under ESI. Is it possible to get any help from ESI?
If one doctor is saying that no problem and another saying that there was a fracture? How , i suggest you can contact esi dispensary, ask them report plus x ray , when this accident happen , have you informed to esi hospital? Please check first
1. Sir, if the employer has not submitted the accident report to ESIC Branch Office as well as to ESI Dispensary concerned, it may be submitted now with explanation or reasons of such delay.
2. After Accident Report is received in the ESI dispensary, the Injured Insured Person may get himself examined in ESI dispensary, obtain medical certification and submit the same to ESIC Branch Office. However, since the case is delayed, the insured person will have to produce all papers of his operation and treatment he got from private hospital.
3. ESIC has its own system or referral policy and therefore, it is not sure whether they will reimburse any expenses incurred in private hospitals. Insured Person can discuss the issue with the ESI dispensary doctor/Incharge.

There is always a chance that when a second opinion is taken only we will come to know about something wrong in the first medical examination. Therefore, you cannot blame the employee for this. But you should blame yourselves for not sending the injured to ESI hospital and not submitting the accident report online. Now you can submit the accident report online and send the printout to the ESI branch office with an explanation that since the injury was not found fatal you gave only first aid but when he developed pain subsequently, he consulted another hospital where he was operated. The ESIC will reimburse the cost incurred by the insured person, ie, Rs 15000, on a later date. He has to submit the bills in support of his claim in original to the ESI.

There are two alternatives to handle this situation. You can pay it to the worker now and ask him to pay it back to the company when he gets the money from the ESIC. This will take time. Otherwise, ask him to claim it from ESIC and bear the cost by himself for the time being. I would recommend that you should at least do the first thing because it is a matter of a worker whose earning is very less, say less than Rs 15000 and the accident had happened while on duty.

If you can convince the delay in submitting the accident report, the employee will get at least wages (100% of benefit rate since it is an accident) for the days he may have to be on leave. Again for an employee like this a loss of income for a single day is a huge loss.

Moral of the story: Always send an ESI covered employee to ESI hospital only for treatment and also advise the employees putting a notice that if any one falls sick never visit any private hospital unless it is an empanelled one. Also note that even direct admission to empanelled hospital should not be encouraged because this facility has been withdrawn and in order to get better treatment you have to get your case referred from ESi dispensary or hospital.

Madhu.T.K

Respected Seniors, I thank everyone for your kind consideration and suitable reply. I wish to say special thanks to T.K. Madhu for his detailed reply. The accident takes place on 18th july . We registered the Accident report through online (ESI portal) on 21st july. After that we forgot the matter. It is a major blunder done by our side. Now I realised the importance of follow-up activity. I expect one more clarification from seniors that whether the accident report to be filed immediately or after two days of the occurance of the accident? Once again i thank everyone and all.
1. Sir, in case of fatal accident cases, the accident report is to be submitted through special messenger. In serious accident cases which may result into permanent disablement or death accident report is required to be submitted immediately. In other type of cases, the accident report is required to be submitted within 48 hours.
2. For more and exact details, hope you will go through Regulation 68 of ESI (General) Regulations, 1950.

To : Mr. Harsh kumar Mehta. Sir, Thank you very much for your valuable guidance. While discussing with peers, one said that it is to be filed immediately and other person told that it can be filed after 2 days. Hence, i raised that question. But you clearly clarified that both of my peers statement is correct but it depends on the severity of the accident. Once again thank you sir.
1. Sir, thanks for appreciation.
2. I will like to mention here that if after the injured insured person is declared fit by ESI dispensary/hospital, but if he will feel that there is permanent disability to him in the injured hand, then please donot forget to get the said injured insured persons referred to medical board for assessment of loss of earning capacity. If medical board awards any %age loss of earning capacity, then the said injured person will be entitled for another benefit under ESI Act, 1948, which is called Permanent Disablement Benefit (PDB). You can get relevant rules/instructions on the website of ESIC.

Dear Seniors,
one of employee who is under ESI coverage has been sliped from stair at his home in this accident he has been badly injured in his Leg, Hand, hence he is unable to perform his duty also. pls clarify since this accident has taken place at his home is he eligible to get ESI treatment also clarify for how much wages the employee is emtitled to get from ESI deptt. since he is on leave,
Thanks,
Aman

Since this is not an accident while and during the course of employment, he will not get 100% rate as is admissible for accident cases. At the same time, if he is in the benefit period (joined at least 9 months before)he will get sickness benefit which is around 90% (make sure the hike proposed from 70% to 90 % a few months back has been implemented) of the average wages. In case of new employee, he will get only medical benefits and will not be eligible for any cash benefits which is paid to compensate the loss of earnings during ESI leave days.
Madhu.T.K


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