ESI Benefits Confusion: Can Our Employee Claim Surgery Costs Through ESI?

I am working in a private company as an HR executive. I need clarification about ESI benefits. One of our company employees has undergone a major operation in a private hospital. The employee is covered under ESI. Is it possible to claim the amount through ESI?

Regards,
B.K

Possible Solution for ESI Benefits Claim

Yes, it is possible. Ask him to contact the ESIC administrative office to claim the benefits.

Yes, he can claim the amount in ESI. However, he has to obtain a certificate/letter from a nearby ESI hospital stating that we are lacking the facility for that major operation, and he is eligible for benefits. Otherwise, it will be difficult.

Just check the details at the following URL: http://esic.nic.in.

Thanks

ESI Benefits and Reimbursement Process

Before getting admitted to the private hospital for treatment, he should have obtained the aforesaid certificate from the ESI Medical Officer. If so, he would have received it cashless from the said private hospital. If he had directly gone to the private hospital, in normal circumstances, he would get the money back only as reimbursement, which may take years to process.

I would say it is due to the negligence of HR that the employee had to seek treatment from a private hospital without first consulting the ESI Medical Officer and then getting referred to that specific private hospital.

Regards,
Madhu.T.K

Understanding ESI Benefits and Procedures

The insured persons covered under the ESI Act and the rules/regulations framed thereunder are entitled to benefits (as their legal right) as laid down under the said Act, provided the procedures laid down under the scheme of the Act/rules/regulations are complied with. Your company employee may have his insurance number and identity card, and based on that, he could have contacted the authorized ESI Dispensary/IMO concerned and obtained treatment as per the laid-down procedure. If the required medical facilities were not available in ESI institutions in the area, the concerned IMO could have referred the patient to the authorized Super Specialty Hospital, where such tie-up arrangements are made.

Now, when the formalities have not been complied with, I am doubtful if any benefits can be claimed at this stage. However, the concerned employee can approach the authorized ESI dispensary of his area with all documents.

If your employee contacts the ESI Dispensary/IMO, even at this stage, then for the future, he can avail medical facilities as well as Cash Benefit if otherwise eligible.

Regards,
Harsh Kumar Mehta

Without knowing anything, how can we blame the HR personnel? Most employees are not willing to opt for ESI treatment. In some emergency cases, due to a lack of time, other than approaching a private hospital, do we have any other option? Even in emergency cases, ESI adheres to rules and regulations. On Saturdays, Sundays, public holidays, festivals, and after 6:00 PM, whom do we contact for ESI benefits? How can we blame HR for all of this and hold them responsible?

Regards,
Swetha

Understanding ESI Benefits and Challenges

Of course, you are raising practical difficulties. However, ESI operates based on the rule book. I am afraid it is not currently possible to arrange backdated documents from ESI through any method. There is nothing wrong with attempting to overcome these problems. However, it is certain that ESI has the right to deny a claim for treatment that was not referred by them to a private hospital, especially if the facility is not recognized by ESI as a referral case facility with prior approved hospitals. Whom should you blame then?

Regards,
Swetha

ESI Hospital Procedures and Reimbursement Challenges

ESI Hospitals function 24/7. For any emergency or treatment, one should first go to an ESI Hospital, and all formalities commence thereafter. In peculiar circumstances, doctors may refer the Inpatient (IP) to a super-specialty hospital, even AIIMS, where treatment is provided at the earliest, with priority given to the IP. Only the IP number is required, and the rest of the data is available on their website. I have experienced such circumstances. However, later claiming reimbursement can be challenging if the case is not referred by their doctor or medical board. In cases where private treatment is emergent, one should locate ESI-approved private hospitals capable of handling the matter.

Thanks,
V K Gupta