Seeking Clarity on ESI Benefits: Age Limits, Coverage, and Hospitalization Queries

Dear HR Seniors,

Please solve my few doubts:

Q. 1: Maximum Age Limit for Dependents to Avail ESI Benefit

What is the maximum age limit for dependents to avail ESI benefit?

Q. 2: Standard Rate under the ESIC Act

What is the standard rate under the ESIC Act?

Q. 3: Provision for Using Non-ESI Hospitals

What is the provision to avail the facility of hospitals other than ESI hospitals?

Q. 4: Diseases Covered under ESI and Entitlement

What kinds of diseases are covered under ESI, and who is entitled?

Q. 5: Recovery of Hospitalization Expenses

How can expenses incurred for hospitalization bills be recovered?

Q. 6: Provision to Change a Dispensary

What is the provision to change a dispensary?

Regards

No Age Limit for Insured Employees and Dependents

There is no age limit for insured employees or their dependents. This scheme is unique as it does not consider the age or pre-existing conditions of the beneficiaries. No conditions are attached to diseases; thus, all diseases are treated, including existing ones when you join ESI. Additionally, if an employee is undergoing treatment for a specific disease and loses ESI coverage, they will continue to receive medical benefits until the treatment is no longer needed for that disease.

Standard Rates for Employees

Standard rates apply to employees, not dependents. These rates are the wages paid during sick leave and vary case by case. For on-duty accidents, full salary is provided, while for other cases, it may be 70% or other percentages.

Referral to Other Hospitals

If required treatment is unavailable at the ESI hospital, the ESI will refer the patient to other hospitals, potentially including super-specialty hospitals.

Free Treatment and Reimbursement

At ESI-affiliated hospitals, treatment is free. If treatment is sought at other hospitals, the incurred costs will be reimbursed by the ESIC at a later date.

Changing the Dispensary

To change the dispensary, request HR to make the change online.

Regards,
Madhu.T.K

Questions on ESIC Benefits

Q. 7: How many family members are covered for ESIC benefits?

Q. 8: Are parents of employees covered for ESIC benefits? What are the conditions?

Q. 9: What are the provisions for medical facilities in higher facilitated hospitals?

Q. 10: What benefits are given to dependents in the case of the death of an employee? To whom, for how many dependents, what percentage of benefits, and up to which age?

Q. 11: Are dependents entitled to funeral expenses in the case of the death of an employee other than on the job/work?

Q. 12: Does the company grant leave salary if an employee is hospitalized? If not, for how many days does ESIC provide salary for leave? What is the rate?

Q. 13: What is rehabilitation allowance?

Regards

Please find below the required details for your reference.

Question 1: Maximum Age Limit for Dependents to Avail ESI Benefit

According to the act: Family means all or any of the following relatives of an insured person, namely:

- A spouse;
- A minor legitimate or adopted child dependent upon the insured person;
- A child who is wholly dependent on the earnings of the insured person and who is:
- Receiving education, till he or she attains the age of twenty-one years,
- An unmarried daughter;
- A child who is infirm by reason of any physical or mental abnormality or injury and is wholly dependent on the earnings of the insured person, so long as the infirmity continues;
- Dependent parents, whose income from all sources does not exceed such income as may be prescribed by the Central Government;
- In case the insured person is unmarried and his or her parents are not alive, a minor brother or sister wholly dependent upon the earnings of the insured person.

Question 2: Standard Rate under ESIC Act

The ceiling is a maximum of Rs. 15,000. Average daily wages are:

- Below Rs. 28: Rs. 14 or full average daily wage, whichever is less
- Rs. 28 and above but below Rs. 32: Rs. 16
- Rs. 32 and above but below Rs. 36: Rs. 18
- Rs. 36 and above but below Rs. 40: Rs. 20
- Rs. 40 and above but below Rs. 48: Rs. 24
- Rs. 48 and above but below Rs. 56: Rs. 28
- Rs. 56 and above but below Rs. 60: Rs. 30
- Rs. 60 and above but below Rs. 64: Rs. 32
- Rs. 64 and above but below Rs. 72: Rs. 36
- Rs. 72 and above but below Rs. 76: Rs. 38
- Rs. 76 and above but below Rs. 80: Rs. 40
- Rs. 80 and above but below Rs. 88: Rs. 44
- Rs. 88 and above but below Rs. 96: Rs. 48
- Rs. 96 and above but below Rs. 106: Rs. 53
- Rs. 106 and above but below Rs. 116: Rs. 58
- Rs. 116 and above but below Rs. 126: Rs. 63
- Rs. 126 and above but below Rs. 136: Rs. 68
- Rs. 136 and above but below Rs. 146: Rs. 73
- Rs. 146 and above but below Rs. 156: Rs. 78
- Rs. 156 and above but below Rs. 166: Rs. 83
- Rs. 166 and above but below Rs. 176: Rs. 88
- Rs. 176 and above but below Rs. 186: Rs. 93
- Rs. 186 and above but below Rs. 196: Rs. 98
- Rs. 196 and above but below Rs. 206: Rs. 103
- Rs. 206 and above but below Rs. 216: Rs. 108
- Rs. 216 and above but below Rs. 226: Rs. 113
- Rs. 226 and above but below Rs. 236: Rs. 118
- Rs. 236 and above but below Rs. 250: Rs. 125
- Rs. 250 and above but below Rs. 260: Rs. 130
- Rs. 260 and above but below Rs. 270: Rs. 135
- Rs. 270 and above but below Rs. 280: Rs. 140
- Rs. 280 and above but below Rs. 290: Rs. 145
- Rs. 290 and above but below Rs. 300: Rs. 150
- Rs. 300 and above but below Rs. 310: Rs. 155
- Rs. 310 and above but below Rs. 320: Rs. 160
- Rs. 320 and above but below Rs. 330: Rs. 165
- Rs. 330 and above but below Rs. 340: Rs. 170
- Rs. 340 and above but below Rs. 350: Rs. 175
- Rs. 350 and above but below Rs. 360: Rs. 180
- Rs. 360 and above but below Rs. 370: Rs. 185
- Rs. 370 and above but below Rs. 380: Rs. 190
- Rs. 380 and above: Rs. 195

Question 3: Provision to Avail Facility of Hospitals Other Than ESI Hospitals

Procedure to be followed by the ESI beneficiaries to avail of super specialty medical treatment:

- The insured person shall approach the ESI Dispensary to which he/she is attached, and the Medical Officer shall issue a referral letter to the IP to approach the concerned empanelled medical institution.
- If the IP/beneficiary needs medical attention during the non-working hours of the concerned ESI Dispensary, they may directly approach the nearest ESI Hospital for getting a referral letter. If there is no ESI Hospital situated nearer to the IP's place of living, the IP shall approach the nearest Govt. Hospital for getting a referral letter.
- In the case of an emergency, the IP/beneficiary can get medical attention just by producing his/her ESI identity card at the designated private medical institution and shall produce the necessary referral letter and other relevant documents within 48 hours. (In any case, a referral letter is a must to avail treatment under a package deal.)
- The IP/beneficiary shall produce the referral letter along with the ESI Identity Card at the designated private medical institution and avail of the treatment without paying any amount from out of his/her pocket. However, any facility, other than the items included in the package deal, shall be borne by the IP/beneficiary.
- While referring the IP/beneficiary to the concerned empanelled medical institution, the Medical Officer in charge has to verify whether the IP/beneficiary is eligible for treatment.
- The IP shall produce all the relevant documents demanded by the designated hospital and extend his/her cooperation to the hospital authorities.
- The designated hospital, after imparting treatment to the IP/beneficiary, shall raise the claim bill directly to the Directorate where it will be settled.

Question 4: Diseases Covered Under ESI & Who Are Entitled

The enactment of the Employees' State Insurance Act, 1948 in Indian Parliament envisaged the requirement for a comprehensive, integrated, and need-based social insurance scheme that would go a long way in providing protection in the interest of workers. This ESIC would be beneficial in ever-pervading risks lurking in each and every corner of human lives, especially in contingencies comprising sickness, temporary or permanent physical disablement, maternity, death due to employment injury, thereby resulting in loss of wages or earning capacity. This Act facilitates medical care to all employees (workers) including their immediate family dependents, devoid of any discrimination or prejudice which is reasonably satisfactory in nature.

Question 5: How to Recover Expenses Incurred for Hospitalization Bills

You have to submit the actual bills to the local dispensary, and the same will be forwarded to the regional office, which will be directed to the directorate for scrutiny, and the reimbursement will be done. It's a lengthier process.

Question 6: Provision to Change Dispensary

It can be done online itself.

Regards

Update on Standard Benefit Rate Under ESI Act

I believe the Standard Benefit Rate (Table), which has been mentioned by one of the members in the above remarks, has been changed or deleted effective from 01/07/2011 by omitting Rule 54 of ESI (Central) Rules, 1950. The rates of benefits under the ESI Act/rules/regulations, which are paid in cash, have now been modified effective from 01/07/2011.

Regards

No Age Limit for Spouse and Parents

There is no age limit for spouses and parents. The limit applies only to children.

Regards,
Varghese Mathew
HR/Labor Law Adviser
Trivandrum
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