Confused About ESI Maternity Benefits? Seeking Clarity on Eligibility and Next Steps

Issue with Maternity Benefit under ESI

I have an issue regarding Maternity Benefit under ESI for one of my employees. Let me explain briefly.

One of my employees was covered under ESI and had been utilizing all ESI benefits for over 3 years. When her salary increased above Rs. 10,000 (the salary limit for ESI at that time), she exited ESI. Later, when the ESI limit was raised to Rs. 15,000, she was reenrolled under ESI in May 2010 as her salary was Rs. 12,000.

Currently, she is on maternity leave starting Dec-10 (12 weeks - 3 months) and had been receiving treatment under ESI until the commencement of her leave. Post-delivery, when she sought reimbursement for maternity expenses from ESI, they declined, stating that nine months must pass for a claim to be made. Given her reinstatement in May-10, she is deemed ineligible for any maternity benefits. Noteworthy is that upon reinstatement, she retained the same ESI card number she had prior to the reinstatement.

Could someone clarify if such a rule exists under the ESI Act? If so, are there alternative ways for her to claim expenses?

This employee has not received any salary since Dec-10 under the assumption that she was still covered by ESI. What steps should be taken now? I am also encountering a similar issue with a male employee whose father was denied treatment for the same reason. He too was reintegrated into ESI following the increase in the ESI limit to Rs. 15,000, as his salary is Rs. 12,000.

Kindly provide guidance.

Regards,
Krishna T B R

Dear Mr. Krishna,

There is some administrative error on the part of ESIC. It is not the mistake of the employer or the employee. She has been in continuous service with you, and it was the ESIC that changed rules every time and subsequently put hardship on the employer and employee.

If a new insurance card number was given to her, then the rule is right. The case is that she already has the number which was in force and then deactivated when the ceiling changed, then activated during reinstating. So, as per the law, ESIC is bound to reimburse the expenses.

I request you to seek legal guidance or approach the Labour Court on the above subject. It is surprising why nobody has given a reply to this tricky query. Justice must be served to this employee.

Regards, Chandru