Can ESIC Cover Private Hospital Maternity Costs and Complications? Seeking Advice

Dear All, Lately, I was approached by a woman wanting to receive maternity treatment in a private hospital and claim the incurred expenditure from ESIC. She has been under ESIC coverage since May 2010. Can she receive all the benefits (cash benefit in this case) from ESIC without actually seeking admission to an ESIC hospital? Additionally, in the event of any pregnancy complications, can she claim the incurred costs (which may exceed Rs. 1 lakh) from ESIC?

Thank you.

If the delivery takes place during the benefit period, she can indeed receive super specialty treatment for a maternity case. However, for this to occur, she must be referred to a Specialty Hospital by the Medical Officer of the ESIC. It is not permissible for her to directly seek and undergo specialized private treatment and then claim reimbursement for the expenses. The process involves visiting the local ESI dispensary and obtaining a referral to an approved hospital or even a super specialty hospital.

Regards,
Madhu.T.K

Eligibility for maternity payment under the Industrial Policy (I.P.) requires a minimum of 70 days of previous contributions at the time of delivery confinement. Only then can she avail herself of maternity payment for 84 days at a rate exceeding the standard benefit rate (average salary = daily pay).

In the above case, she can claim maternity payment by submitting a medical certificate as proof for 12 weeks (84 days). Concerning medical expenses, she can claim reimbursement. Please contact your respective dispensary or branch office for more details.

Regards,
Naresh

Reimbursement of Medical Expenses Under the ESI Act

There is a provision for the reimbursement of medical expenses under the ESI Act where an insured person or dependent has availed medical treatment in a private hospital without being referred by an ESI medical officer.

Reimbursement of Expenses Incurred in Respect of Medical Treatment Under Regulation-96 A

Regulation-96 A reads as follows: Claims for reimbursement of expenses incurred in respect of medical treatment of an insured person (IP) and their family may be accepted in circumstances and subject to such conditions as the Corporation may, by general or special order, specify.

The following conditions have been laid down under this Regulation:

- Full authority is vested with the State Government concerned to reimburse expenditure in respect of medical treatment of the IP and their family.
- It may be left to the discretion of the State Government to decide the authority within their machinery who will approve the expenditure in question.
- The time limit for submission of the claims for reimbursement is one year.

The State Government has to keep in view the following points while considering the cases of reimbursement of expenditure on medical care:

- Whether such facilities for which reimbursement is recommended are not available within the State.
- Whether the hospital where the IP was sent or proposed to be sent was/is the nearest hospital having the required facilities/services.

List of Types of Cases for Which Reimbursement is Permitted

1. Reimbursement is permissible in case of failure of the mobile dispensary van due to technical defects or otherwise to adhere to its scheduled timings, or where an IP attached to such a dispensary sustained serious injuries or suffered from serious illness during off-hours of the dispensary.
2. IPs and their family members had to resort to private treatment during the off-hours of the ESI dispensary/Emergency Centre due to unavoidable circumstances.
3. Medicines prescribed by an IMO/Specialist were out of stock in the ESI Dispensary/Approved Chemist, thereby compelling the IPs to make purchases from the market.
4. Medicines prescribed by a Specialist and not provided by the IMO/IMP, where the specialist considered such special medicines absolutely necessary for the treatment of the beneficiaries as no substitute medicine was considered equally efficacious, whether as an outpatient or inpatient.
5. Special appliances prescribed by a Specialist such as spinal supports, cervical collars, walking calipers, and crutches, etc., if considered necessary as part of the treatment.
6. Where an IMO/IMP failed to make a domiciliary visit requested by an IP, thereby compelling the IP to make private arrangements for treatment. Under the panel system, such cost is recoverable from the IMP if recommended after investigation by the Medical Service Committee.
7. Serious cases of accident or illness admitted directly into recognized hospitals where, owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal their identity as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer.
8. Serious cases of accident/illness where a beneficiary was admitted directly at a private hospital or in a non-recognized hospital where admission in a hospital recognized under the scheme would have seriously jeopardized their health, like sudden heart attacks, fracture of the spine, cerebral hemorrhage, etc.
9. Expenditure incurred on investigation for blood transfusion.
10. Mental cases that may have incurred expenditure either as an outpatient on specialized therapy such as ECT, etc.
11. Serious cases of accident and illness admitted to recognized hospitals where all the reserved ESI beds were occupied.

Reimbursement of conveyance charges incurred by an IP where an ambulance or any other transport under the scheme is not available owing to some reason or the other, and where in the opinion of the IMO/IMP such a patient was non-ambulatory.

In respect of specialized examination, laboratory tests, X-rays, other imaging services, etc., recommended by a specialist, but where the IP either due to the breakdown in the machinery or where the nature of the examination of the laboratory tests was such that it was beyond the scope of the facilities available in the recognized laboratory/hospital.

In addition to the above types of cases, reimbursement may also be allowed in other cases depending upon the merits of each case and the circumstances under which expenditure was incurred.

The above information I got from the official website of ESIC as I am trying for reimbursement of medical expenses incurred by one female employee who got herself admitted to a private hospital without approaching the ESI doctor.

Regards.

Maternity Benefits for Female Employees

The female employee is entitled to maternity benefits for 84 days, which is double the standard benefit rate. Additionally, she can receive 30 days of sickness benefits arising from pregnancy, based on the recommendation of the IMO, at the same rate. Furthermore, she is eligible for medical reimbursement following the procedure, as well as a medical bonus if she delivers in a location where ESI facilities are not available.

Regards,
Sanagapalli

I fully agree with the opinion of Madhu T. K. and would like to add the following:

Procedure to Avail ESIC Benefits

If you want to avail the benefits from ESIC, then you have to follow the procedure of ESIC:

- You have to show ESIC that you were admitted to a private hospital due to an emergency with no time to search for an ESIC hospital.
- Notify ESIC after you have been admitted to the hospital.
- Upon discharge from the hospital, you need to present the admission card along with all the bills incurred until discharge and submit them to ESIC.

By complying with the above procedure, you may be eligible for ESIC benefits.

Thanks & Regards,

Yogesh Kulkarni
Assistant Manager – HR
Krishidhan Seeds Pvt. Ltd.
Contact No.: [Phone Number Removed For Privacy Reasons]
Email ID: [Email Removed For Privacy Reasons]

Eligibility for Maternity Benefit

To be eligible for maternity benefit, the insured woman should have contributed for not less than seventy days in the immediately preceding two consecutive contribution periods prior to the actual or expected date of confinement, as the case may be.

For entitlement to maternity benefit, a confinement should either actually occur or be expected to occur in a benefit period relative to the insured woman.

An insured woman who actually confines (or is expected to confine) on a date before the start of her first benefit period is not entitled to claim maternity benefit, even though part of the period of her maternity leave may fall within her first benefit period.

If the insured woman's date of actual confinement (or expected confinement) falls within her first benefit period, she will be entitled to maternity benefit even if a part of the period of her maternity leave may fall before the start of her first benefit period.

Completing 9 months has nothing to do with ESIC benefits.

Regards, Kamal

Claiming Medical Bills from ESIC

IP's wife delivered in a private hospital. How can we claim medical bills from ESIC? The Medical Officer advised seeking treatment in a government hospital. How should we contribute to ESIC? Please provide advice.

Regards.

Dear all,

I joined a company with a CTC of 150004, but I have now received an increment. So, my CTC will be more than my previous CTC (i.e., 150004). For the last 18 months, ESI was deducted from my salary, and now I am unsure if I can avail of the benefits of ESI at my present CTC or if it is not applicable to me. If it is not applicable to me, what happens to the money deducted from my salary? Is there any way to get it back because I have not used my ESI benefits until now?

Regards,
Sridhar

Hi all,

Is it necessary to claim from ESI hospital to get treatment from there only in a maternity case?

If you are an ESI-covered employee, you should seek treatment at an ESI hospital to avail benefits such as leave. If the facilities at the ESI hospital are inadequate, you may be referred to a private hospital. However, you cannot directly go to a private hospital and claim maternity benefits from ESI.

Madhu.T.K