Can My Colleague's Retired Father Get ESI Coverage for His Heart Surgery?

Respected Seniors, I have a doubt regarding an ESI claim. One of our colleague's fathers has been hospitalized. Doctors told them that a heart operation should be done, and nearly Rs. 3,00,000 in expenses may occur. My colleague is an insured person under ESI, and her father is a retired government servant (pensioner). Now, my question is, can he be treated in an ESI hospital? Or whether the medical expenses can be reimbursed or not?

Some staff in the ESI hospital are saying that medical expenses will be reimbursed, but his pension will be stopped.

Please clear my doubt with your valuable suggestions so I can advise my colleague to take the proper steps.

Thank you.

With reference to the issue raised by you as above, I may request you to kindly go through Section 2(11)(v) of the ESI Act, 1948, which defines "family." Kindly also see Rule 61A of the ESI (Central) Rules, 1950, which lays down as follows:

"61A. Income limit of dependent parents for eligibility for medical benefit - The income of dependent parents for eligibility for medical benefit under sub-clause (v) of clause (11) of Section 2 of the Act from all sources should not exceed five thousand rupees in a month."

To my knowledge, there appears to be no provision for the stoppage of "Pension" except as laid down in the Conduct Rules governing the services or retirement of the dependent parent.

Hope you will refer to the above-quoted provisions of the said Act and rules framed thereunder.

With regards;

I am writing to inform you that your colleague's father cannot receive treatment from the ESI Hospital. This is because, at the time of filling out the declaration form, it was stated that your father's income is not higher than Rs. 5000. Therefore, your father is not eligible to avail of the benefits.

Regards,
V. Subbarao

Please note that the income limit of Rs 5,000/= mentioned earlier in this thread has been increased. It currently stands at Rs 15,000/=. This increase was done via the Ministry of Labour and Employment's Gazette Notification dated 20th April 2010, and the enhanced limit became effective from 1st May 2010. Additionally, there have been some recent press reports in October 2013 that the Ministry intends to raise the income limit further to Rs 25,000/=. I am not aware of any formal notification having been issued in this regard so far.

You could check it out, but in the absence of the most recent enhancement of the limit, the current income limit stands at Rs 15,000/= per month.

While you could re-check if your colleague's father would be eligible under the current income limit for his treatment to be undertaken under the ESI scheme (assuming, of course, that he has been declared as a dependent), you also mention that your colleague's father is a Government Pensioner.

You could check out the eligibility under the CGHS scheme of the Central Government. It should be possible to get the treatment done under this scheme since he would be covered under it. It is likely that there would be some monetary limits for treatment viz., the type of room, etc., but it could be an additional avenue that can be explored by your colleague.

Regards,
Raju Bhatnagar

Dear Mr. Raju Bhatnagar,

The income limit of a dependent parent mentioned by my friend, Harsh Mehtaji, is different from the wage ceiling for coverage of an employee under the ESI, as mentioned by you. The income limit for a dependent parent to receive benefits as part of an ESI-covered employee is still Rs. 5000. This is unrelated to the proposed increase in the wage ceiling for coverage, which is still in the stage of publication of an intention notification. In this particular case, if the pension is greater than Rs. 5000 per month, he will not be eligible for ESI coverage. As you rightly pointed out, he can seek treatment under CGHS.

Thanks & Regards,
S. Sankaralingam
Retd. Sr. Dy. Director, ESIC
Advocate & Labour Law Advisor
Email: [Email Removed For Privacy Reasons]

Dear ssdharwad2005, Please note that the limit mentioned by Shri Sankaralingamji is the correct limit for coverage of dependent parents. The limit of Rs. 15,000 is the wage limit for coverage of employees under ESI. I had erroneously mixed the two.

Regards, Raju Bhatnagar