Navigating ESIC Coverage Issues: How to Handle Employee Medical Treatment Challenges?

Hi Seniors, I came across a problem that one of our employees has been injured inside the organization. In this accident, his right foot has been badly injured on the lower side. He is covered under the ESIC Act, and the ESIC dispensary has already certified him for treatment in a tied-up hospital. We admitted him to the emergency ward and completed all document formalities. However, after seven days, they discharged the patient and halted the treatment, stating that our agreement with ESIC is valid for only 7 days for surgery. We resubmitted all the documents, and after another seven days, they discharged the patient again. His surgery was performed during this period, but one operation remains, which is scheduled for 26.07.2011. Now, the hospital says that they cannot accommodate the patient for just dressing and medication, so currently, the patient is receiving treatment in the same hospital, and the company is covering the expenses.

Course of Action Needed

What should I do in this matter? Management is questioning why we contribute around 150,000/- to ESIC. They have advised us to go to the dispensary and inform them in writing that we cannot provide treatment in such cases.

Please suggest a course of action.

Regards,

Hi Anuj, your employee is covered under ESIC. He is referred to the panel hospital of the ESIC by ESIC itself.

The contract between ESIC and the hospital is not valid as of today, which is not a mistake on your part. As an employer, you have deducted and contributed towards the ESIC and submitted the return on time.

Just report this matter to your ESIC local office with a copy to ESIC HQ and the Director of Medical Services. Continue taking the treatment in the same hospital, pay from your pocket, collect all the documents, and claim the money from the ESIC.

ESIC must pay the money since we have contributed.

Dear Anuj,

As Dhillon has rightly suggested, you can claim reimbursements for expenses made by you as long as you avail treatment at the hospital referred to by ESIC. The approach of ESIC officials is changing from inspection to social security, and you can rest assured that ESIC will reimburse the amount incurred by your organization upon the production of the bills. In the meantime, you can meet the officials at the local ESI office and appraise them of the situation in writing.

M.V. Kannan

Dear Anuj,

While continuing treatment and keeping documents, immediately call your Jurisdictional ESI Medical Director. Normally, they will be in the region; explain the situation followed by a written complaint. Use the ESI site to submit this inquiry. If possible, arrange a meeting with the medical director. Don't limit yourself to the local office.

Success will be yours, and you will find relief, while management appreciates your efforts.

Best wishes,

Ram K Navaratna
Chief Executive
HR Resonance
[Phone Number Removed For Privacy Reasons]
Visit: hrresonance.googlepages.com

Please make sure the patient is admitted to the ESI Hospital only. Reimbursement from ESI is quite "tiresome" as, in most cases, they don't pay the actual cost incurred by the patient or employer. Please meet the local ESI office and appraise them of the situation.

Note: At the earliest, ensure the patient is admitted to the ESI Hospital only.

As a regular practice, the patient will be discharged as per the doctor's advice. For dressing and tablets, he may visit the dispensary. As informed by you, for another surgery, he has to visit the dispensary again and take a referral letter to the hospital (approved by ESI).

Hospitals will not keep any patient for dressing and tablets. The hospital has to give a valid reason for keeping the patient with them, as they will be questioned by the ESI authorities.

Regards,
Raja Narra