Harsh Kumar Mehta
Consultant In Labour Laws/hr
Bijay_majumdar
Freelancer
Aniket Pathak
Sr. Officer Hr
Srinath Sai Ram
Hr Manager
+2 Others

Thread Started by #VoicetreeHR

Dear Team, As what I know that if someone is covered by ESI then they can go to the private hospitals(covered by ESI) & there are no limitations on the cost of treatment but now I got a doubt when I visited ESI hospital for the treatment of one my friend, then the ESI doctor referred him in private hospital & said the ESI hospital will check his eligibility of amount that how much expenses would be covered by ESI & after going through his ESI account they will tell me his balance for the same.
I just wanted to clarify that is there anything like this that there would be a certain amount of expenses would be covered by ESI or os there any kind of balance based on the ESI deduction i.e if an employees joined the company & from the 2nd month for treatment then what would be his eligibility?
18th December 2017 From India, Jaipur
He will not be eligible for treatment as the case in your last line. also please visit ESIC office as there are clauses as per the period of contribution. Also , person must be eligible for super specialty treatment. you can also refer to the site but, to get a clearer picture visiting local esic office is advisable.
18th December 2017 From India, Pune
Please log in to ESI IP Portal with ESI Insurance Number to know eligibility for various benefits provided therein
18th December 2017 From India, New Delhi
The section 46 of the Act envisages following six social security benefits :-
(a) Medical Benefit : Full medical care is provided to an Insured person and his family members from the day he enters insurable employment. There is no ceiling on expenditure on the treatment of an Insured Person or his family member. Medical care is also provided to retired and permanently disabled insured persons and their spouses on payment of a token annual premium of Rs.120/- .
1. System of Treatment
2. Scale of Medical Benefit
3. Benefits to Retired IPs
4. Administration of Medical Benefit in a State
5. Domiciliary treatment
6. Specialist consultation
7. In-Patient treatment
8. Imaging Services
9. Artificial Limbs & Aids
10. Special Provisions
11. Reimbursement
(b) Sickness Benefit(SB) : Sickness Benefit in the form of cash compensation at the rate of 70 per cent of wages is payable to insured workers during the periods of certified sickness for a maximum of 91 days in a year. In order to qualify for sickness benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months.
1. Extended Sickness Benefit(ESB) : SB extendable upto two years in the case of 34 malignant and long-term diseases at an enhanced rate of 80 per cent of wages.
2. Enhanced Sickness Benefit : Enhanced Sickness Benefit equal to full wage is payable to insured persons undergoing sterilization for 7 days/14 days for male and female workers respectively.
(c) Maternity Benefit (MB) : Maternity Benefit for confinement/pregnancy is payable for Twenty Six (26) weeks, which is extendable by further one month on medical advice at the rate of full wage subject to contribution for 70 days in the preceding Two Contribution Periods.
(d) Disablement Benefit
1. Temporary disablement benefit (TDB) : From day one of entering insurable employment & irrespective of having paid any contribution in case of employment injury. Temporary Disablement Benefit at the rate of 90% of wage is payable so long as disability continues.
2. Permanent disablement benefit (PDB) : The benefit is paid at the rate of 90% of wage in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a Medical Board
(e) Dependants Benefit(DB) : DB paid at the rate of 90% of wage in the form of monthly payment to the dependants of a deceased Insured person in cases where death occurs due to employment injury or occupational hazards.
(f) Other Benefits :
Funeral Expenses : An amount of Rs.10,000/- is payable to the dependents or to the person who performs last rites from day one of entering insurable employment.
Confinement Expenses : An Insured Women or an I.P.in respect of his wife in case confinement occurs at a place where necessary medical facilities under ESI Scheme are not available.
In addition, the scheme also provides some other need based benefits to insured workers.
Vocational Rehabilitation :To permanently disabled Insured Person for undergoing VR Training at VRS.
Physical Rehabilitation : In case of physical disablement due to employment injury.
Old Age Medical Care :For Insured Person retiring on attaining the age of superannuation or under VRS/ERS and person having to leave service due to permanent disability insured person & spouse on payment of Rs. 120/- per annum.
Rajiv Gandhi Shramik Kalyan Yojana : This scheme of Unemployment allowance was introduced w.e.f. 01-04-2005. An Insured Person who become unemployed after being insured three or more years, due to closure of factory/establishment, retrenchment or permanent invalidity are entitled to :-
Unemployment Allowance equal to 50% of wage for a maximum period of upto Two Years.
Medical care for self and family from ESI Hospitals/Dispensaries during the period IP receives unemployment allowance.
Vocational Training provided for upgrading skills - Expenditure on fee/travelling allowance borne by ESIC.
Incentive to employers in the Private Sector for providing regular employment to the persons with disability :
Minimum wage limit for Physically Disabled Persons for availing ESIC Benefits is 25,000/-.
Employerss' contribution is paid by the Central Government for 3 years.
Benefits & Contributory Conditions :
An interesting feature of the ESI Scheme is that the contributions are related to the paying capacity as a fixed percentage of the workers wages, whereas, they are provided social security benefits according to individual needs without distinction.
Cash Benefits are disbursed by the Corporation through its Branch Offices (BOs) / Pay Offices (POs), subject to certain contributory conditions.
19th December 2017 From India, Vadodara
33.How long is Medical benefit available? Esic Benefits
The insured person and his family are entitled to the Medical Benefit from the very first day
of his/her joining the insurable employment. A person who is covered under the scheme
for the first time is eligible for medical care for self and family for three months. If he/she
continues in insurable employment for three months or more, the benefit is admissible till
the beginning of the corresponding benefit period. If contributions were paid/ payable for
not less than 78 days in the said contribution period, medical benefit is admissible till the
end of the corresponding benefit period. If the insured person is in ESI coverage for at
least 2 years, and contributed for not less than 156 days, and is suffering from any of the
34 specified long term diseases, the medical benefit is admissible till the incapacity lasts or
for a period of 3 years for self and family.
19th December 2017 From India, Vadodara
1. Sir, ESIC has framed / laid down some conditions in respect of super specialty treatments / long term serious diseases. If an insured person who is sick, but do not fulfill conditions for such super specialty treatment, then in such cases ESIC refuses to provide any such treatment. Even in respect of ordinary diseases / operations for which patients are referred to any private hospital by ESIC there are ceilings of amounts which are fixed for such treatments with such private hospitals at the time of entering into such contracts of referral hospitals.
2. It will be more better if the attendants or family members of the sick insured person may discuss the issue in detail with concerned doctor of ESI Hospital or ESIS dispensary to which the said insured person is attached.
21st December 2017 From India, Noida
Dear friend first try to the know various levels of treatments one can get under ESI Scheme:
01. Primary level treatment: Its can be given at IMP or Dispensaries, where an IP along with his family members can get treatment including medicines from day one of his entry in to insurable employment;
02. Secondary level treatment: Its can be given at ESI State Hospitals, where an IP along with his family members can get treatment including medicines from day one of his entry into insurable employment;
The difference between primary and secondary level is .... In secondary level hospitals, you can find a good specialities supported with diagnostic/lab services like ecg, x ray, scanning, blood tests etc.,
Any Insured Person along with his dependant family members can get the treatment at these two levels, now the issue comes for super speciality (i.e, the facilities generally not available at ESI State Hospitals, viz., Neuro, Nephrology, Cardiology etc.,) which needs refereal to private tie up hospitals by the ESI State run hospitals.
In earlier days the Super Speciality treatment eligibility conditions are so liberal that for an individual Insured Person if he works for 3 months he will be entitled to refer to SST & in case of family members that Insured Person should work for 6 months..... But for last one and half year this rule was changed and now the condition to get SUPER SPECIALITY TREATMENT one should COMPLETE 2 YEARS OF INSURABLE EMPLOYEMENT and the cost ceiling will be 10 laksh per individual, that means an IP or his family members can eligible to get treat of SST for Rs. 10 lakh per each person per year.
Hope i cleared all your doubts friends and all the best....
22nd December 2017 From India, Hyderabad
Now the SST condition has changed to 6 months for IP and 1 year for IPs family with some terms and conditions...
14th December 2018 From India, Hyderabad
Reply (Add What You Know) Start New Discussion

Cite.Co - is a repository of information created by your industry peers and experienced seniors. Register Here and help by adding your inputs to this topic/query page.
Prime Sponsor: TALENTEDGE - Certification Courses for career growth from top institutes like IIM / XLRI direct to device (online digital learning)





About Us Advertise Contact Us
Privacy Policy Disclaimer Terms Of Service



All rights reserved @ 2017 Cite.Co™