Can We Claim ESIC Reimbursement for Private Hospital Bills Due to Employee's Unawareness?

I have a query regarding ESIC. In my company, one worker took treatment for dengue fever from a private hospital without utilizing ESIC benefits in October due to his ignorance of ESI benefits, even though he is listed in ESIC. His medical expenses exceed his paying capacity.

Now, we want to claim his medical expenses from the ESI department since we have been paying his contributions. Is it possible to claim his expenses from ESIC in this case? If so, what is the complete procedure for this?

Thank you.

Warm Regards,
Deepak Agarwal

Please see the attached format of Medical Reimbursement from ESI for outpatient treatment. Also, please read the article on "Dengue Fever" for simple medical treatments.

Regards,
PBS KUMAR

Seeking ESIC Reimbursement for Employee Injury

We are in the fast food services industry with restaurants located all over India. One of my employees at the Ranchi restaurant was a victim of a robbery while returning home after a night shift, resulting in serious injuries from knife wounds on his head and neck. He is currently hospitalized at Raj Hospital and Research Centre in the ICU due to the severity of his condition.

The company has incurred costs amounting to Rs. 12,000 during his treatment. Following the incident, we submitted an accident report and informed the ESI Branch office, along with sending a letter of intimation to the Administrative Medical Officers at ESIC, Ranchi main office.

However, despite these actions, we have not received any support from ESIC. Can you please guide me on how to seek reimbursement from ESIC? I have the Reimbursement Form from ESI.

Thank you,

Regards,
Sunetra Mukherjee

When sending an ESI-covered employee on official work to out-of-station locations, it is advisable to have the PEHACHAN CARD and carry ESI FORM - 105. This will enable the employee to utilize ESI benefits in case of illness or accidents, etc. A copy of Form - 105 is attached.

Regards,
PBS KUMAR

Subject: Medical Reimbursement Process from ESIC

In reference to your query, please note the following steps to proceed further for Medical Reimbursement from ESIC.

1. Obtain the Discharge Summary or Discharge card from the Private Hospital where the IP received treatment.

2. Collect all bills, including the cost of operation, doctor's charges, anesthetist charges, nursing charges, room service charges, ICU charges, cost of medicines, test examination charges, along with supporting bills from the hospital.

3. Obtain the Emergency Certificate from the treating hospital.

4. Obtain the Essentiality Certificate from the treating hospital.

5. Obtain the No Stock Certificate from ESIC to allow the purchase of treatment materials from outside.

6. Obtain the Eligibility Certificate from ESIC.

7. Provide an Advanced Stamped Receipt for payment.

8. Include Bank Account Details.

9. Submit the required documents as per the checklist issued by ESIC for Reimbursement.

10. Attach a copy of the ESIC Pehchan Card/Permanent ID Card.

11. Provide the Scrutiny Certificate.

12. Ensure all bills are certified by the treating doctor and the Medical Officer of the ESI Hospital where the IP is attached, along with payment proof by the IP.

13. Include a Letter from the IP for the submission of Bills for Medical Reimbursement.

14. Ensure forwarding of a Letter from the Employer by the IP.

15. Provide a Post Card for intimation from ESIC.

Please submit the above documents to the DIMS office for Medical Reimbursement by the IP.

Thank you for your attention to this matter.

Best Regards,

V R RAO PULIPAKA

Yes, this is possible to claim all medical bills from ESIC. Please make sure that you have fulfilled all the formalities, such as:

1. OPD slip from ESIC medical hospital
2. ESIC Card of Employee
3. Reimbursement form duly signed by the medical officer of ESIC with a stamp
4. All the bills must be signed by the healthcare provider who treated the patient.

Regards,
NOBAL KISHOR

Thank you for your suggestions. They will help me a lot. When I visited the ESI dispensary, they said reimbursement is not possible because the IP is not referred by the ESI medical officer from his attached dispensary to the private doctor. Is there any clause like this in bill reimbursements? Should the IP first take a reference from the medical officer?

Thank you.

Warm Regards,

Deepak Agarwal

I cannot exactly quote the clause, but I understand from the ESI officials that prior intimation is required. This is to avoid misuse of super specialty treatment, especially when treatment facilities are available in ESI hospitals. The concept is that if advanced treatment is not available at ESI hospitals, we can seek treatment in private hospitals with their reference. However, this is not strictly required in the case of accidents and critical illnesses.

Regards

Hi, one of our employees working in Bangalore has a mother who resides in Assam state and is covered under the ESI Act. She requires treatment that is outstation. Can you please guide me on the procedure to follow? If there are any specific formats needed, could you kindly send them to me?

Thank you for your assistance.

In my company, one worker took treatment for multiple sclerosis from a private hospital in February 2016 without referring to ESIC due to his ignorance of ESI benefits, even though he is listed in ESIC. His medical expenses exceed his paying capacity.

Now, we want to claim his medical expenses from the ESI department as we have been paying his contributions. Is it possible to claim his expenses from ESIC in this case? If yes, what is the complete procedure for this?

Thank you.

Warm Regards,
Basavaraju

ESI Reimbursement Procedures

Every employee is eligible for reimbursement through ESI. I will explain the procedures, hoping you will find them helpful.

The insured person must register their ESI card at their ESI branch office. In ESI specialty treatment, ESI has partnered with private hospitals. If the insured person receives treatment at an ESI tie-up hospital, the medical expenses can be reimbursed.

If they have already received treatment at a private hospital, they must submit all medical expenses along with the discharge slip to ESI. After submission to the ESI office, they will examine and inquire about the details from the hospital. Approximately 90% of the bills will be reimbursed. I hope this information will be useful.

Thank you.

Form 7B is available at the employer portal, duly filled by ESIC. After logging in to the portal, the employer has to select "Print TIC/E-Pahchan." At the top of it, there is a link for the "Medical Acceptance Card (7B)" which should be downloaded and used.

Concerns with ESIC in Dehradun

ESIC is very frustrating. I am referring to the case of Dehradun. For whatever illness or complications you go there, the doctor will always give you painkillers or similar medicines, even if you are suffering from cancer. If you are lucky and he refers you to a specialist, there are so many formalities that you will wish you had never come here.

So most of the ESI cardholders never go to the ESI dispensary. For one, if you are working in some far-away places, there is only one or two dispensaries. You will have to take leave from your work, which the employer grudgingly allows. Secondly, there are various formalities to fulfill.

Suggestions for Improvement

Why doesn't the government introduce some bills so that if a person doesn't go to an ESI dispensary, his accumulated money can be returned to him, allowing him to go to a private hospital of his choice? Alternatively, a member could visit a private doctor and produce his bills to claim money since it is his money that he is asking for.

Dear team,

One employee has incurred medical expenses of 5 lakhs for medical or doctor fees. How much percentage of the amount will be reimbursed in this case by ESIC?

Most of the time, when an insured person or employer fails to inform the respective ESI dispensary about the insured person joining a private hospital, the claim will get rejected.

Hi,

Regarding the topic, I have one clarification. One of our employees is also facing the same issues, but the same procedure was followed. Claims bills were rejected because the employee doesn't hold an ICICI bank account.

Please let me know if it is compulsory to issue the reimbursement amount only to an ICICI account.

Regards,
Sheena

Hi everyone,

I have a question regarding maternity benefits for the wife of the insured person (IP).

1) Can she receive treatment in a private hospital?
2) What is the process to claim ESIC benefits after receiving treatment in a private hospital?
3) How much will the company contribute to the total bill payment?

Thank you.

Dear Seniors,

I have a query regarding ESIC medical reimbursement. I have an employee who was covered under ESIC. He admitted his mother to an ESIC tie-up hospital in an emergency situation. He informed the ESI dispensary after 3 days. The ESIC dispensary gave him the referral letter to the tie-up hospital where his mother was admitted. However, the irony was that the tie-up hospital refused to accept the referral letter. He was informed by the hospital authority that they had stopped taking ESIC patients as ESIC is delaying/not paying their payments for months. He had no other choice but to pay the bills himself.

Now, is there any way to claim reimbursement from ESI? If yes, what is the complete procedure to claim it?

Thank you.

Query Regarding ESIC Claim for Medical Expenses

I have a query regarding ESIC. I am a worker who took treatment for my father for psoriasis and MTX toxicity febrile neutropenia from a PGI hospital in Chandigarh in February without referring to ESIC due to my ignorance of ESI benefits. He is listed in ESIC, and his medical expenses exceed his paying capacity.

Now I want to claim his medical expenses from the ESI department as we are paying his contribution. Is it possible to claim his expenses from ESIC in this case? If yes, what is the complete procedure for this?

Thank you.

Warm Regards,
ROHTASH

Hi Friends,

I am working as an HR at an Apparel mall. One of my employees has undergone a minor surgery and wishes to claim the amount under ESIC. What is the process for the same? Which form is to be used for this purpose?

Regards,
Preeti