Navigating ESI Coverage: Can We Pay Salary and Claim Treatment Costs for an Injured Employee?

Hi Friends,

I am working as an HR Executive. One outsourced employee who is working in my organization met with an accident and is receiving treatment from a private hospital, although he is covered by ESI. Since the date of the accident, he has been on leave.

In this case, I would like to know:
1. Can we process his salary even though he has been on leave for more than a month?
2. Can he claim the entire expense of his treatment from ESI? He is regularly visiting an ESI hospital.

I am waiting for some good help from all of you.

Regards,
Vivek

To get sickness registered with the ESI officer, the employee must obtain a sickness certificate and claim for coverage. It is unnecessary to provide double payment by giving the employee salary from both the company and ESI, as this is not permissible. If the salary is provided, the ESI will cancel the claim (as per form 28). It is essential to ensure that the employee does not deceive you.

Amit

Pll

Dear Vivek,

Please let me know, are you submitting his accident form (Form 16) to the ESI Office? It is important. When an employee meets with an accident, you have to submit his Form 16 to the ESI office within 24 hours after the accident. After submitting the form, the ESI officer will come to check the records. Following that, he will file the case with the Regional office, and then the employee will receive the accident benefits. The benefits depend on the type of accident, such as pension, salary, disablement.

As you mentioned that he received treatment from a private hospital, he will not get reimbursed for these expenses from ESI because employees must seek treatment from ESI hospitals, which are free of cost. He can only receive reimbursement if he informs that due to an emergency, he had to seek treatment from a private hospital. However, this process is time-consuming and lengthy.

I believe you now have a clear understanding of this accident.

Thanks,
Amit Pawar

Hi guys,

I would like to inform you that even though the employees are covered under ESI in our company, we are covering all the employees under a Group Personal Accident Policy to claim leave days and 25% of medical expenses. In the case of accidental death, we can claim 60 times the gross salary.

The company will cover all hospital expenses initially and later deduct them from the claim amount. We have also taken out a Group Insurance Policy for any type of death.

We cannot receive satisfactory treatment from ESI, and the compensation for the leave period is very low. However, through insurance, we can receive a better amount. Why can't others follow these systems?

Regards,
Moses Alphonse
moses_alphonse@yahoo.com
09442637009

Dear friend,

Are you submitting the accident report Form 16 at your ESI local office? When did the accident happen? Where did the accident occur - inside the factory premises or outside?

Regards,
MG
9842511533

Dear,

On the occurrence of the accident and compliance under E.S.I.

1. Accident Report Form 16 within 24 hours to E.S.I. Local office.

2. Sickness benefit can only be claimed if treatment in E.S.I. hospital or referred by E.S.I. to another hospital, with treatment lasting a minimum of 3 days.

E.S.I. authority pays the sickness cash benefit only for more than three days of sickness, with a maximum of 91 days in two consecutive benefit periods. Otherwise, the medical referral of E.S.I. suggests a longer period for payment.

3. E.S.I. Local Office seeks abstention verification through Form - 28. This is because the employer should not pay the salary and should mark the employee as on sick leave during the verification period.

4. There is no need to pay salary for the period of sickness, as E.S.I. will pay sickness cash benefits for that period at the Standard Benefit Rate (S.B.R.), which is approximately 50% of the average wages.

5. Do not assign duties to a sick employee.

6. No contribution is payable for the period of sickness if E.S.I. is providing sickness benefits for that period.

7. The Muster Roll and Form - 7 of E.S.I. should indicate that the employee is on sick leave.

I hope this clarifies all doubts on the subject.

For more information, you can write to me at [Login to view].

Mohd. Arif Khan

Hi Friend,

My name is Lakshmanan. I work at HCL Tech in the Corporate HR department. You can claim all the expenses in the ESI procedure because employees who receive their first-month salary should have their ESI (Medical Claim) covered. Therefore, if you make a claim now, the government ESI Department will reimburse you.

If you have any queries, please feel free to call my mobile number at any time. The number is 9941056476.

Regards,
Lakshmanan M

Dear Sir(s),

I understand that ESI is mandatory for employees drawing Rs 10,000 or less. All the employees are regularly taking benefits from mediclaim/group accident schemes. Not a single employee, from the date of ESI coverage, has either gone to an ESI dispensary or taken any ESI benefit. The company is regularly/timely depositing the ESI dues/returns, etc.

1. I want to know whether it is mandatory for an organization to cover ESI if the organization has a suitable and best mediclaim insurance policy/group accident policy (GPA) for its employees.
2. I think we can extend GPA for all employees, including those who are covered by ESI.
3. Is GPA mandatory under any act?
4. Is there any nexus between ESI and GPA?
5. Is it okay if an employee has any of the two coverages, ESI or GPA?

Thanks in anticipation, regards,
Amit

Mohd. Arif Khan's comments are very useful, but Amit's query doesn't get answered in that.