ESI Reimbursement Dilemma: Can We Get Hospital Expenses Back for Non-ESI Treatment?

Hi all, I am working as an HR executive. One of our employees, who is covered under the ESI Scheme, was admitted to a hospital due to typhoid. However, the hospital was not an ESI hospital. Is this person eligible for a refund of the expenses incurred? If yes, what are the procedures to follow?

It is difficult to get any reimbursement at this stage due to the reasons that the treatment has not been obtained from ESIC or an ESIC authorized dispensary/hospital. However, the insured person or his relatives attending to him may contact the authorized ESI dispensary/IMO concerned to which he is attached and discuss with him:
(i) the possibility of reimbursement of past expenses,
(ii) obtaining treatment for the sickness if required, for the next spell of illness if not fully cured.
Regards.

Process for ESI Hospital Admission and Expense Reimbursement

As per the process, the insured person should report to the concerned dispensary or the ESI hospital. Based on the requirements, the RMO will refer the case to any other hospital. In emergencies, the employee can directly get admitted. On the same day, the information should be passed on. Normally, the ESI will issue a credit note to the hospital. However, you can meet the RMO concerned and explain the issue. The bills need to be cleared by the Medical Board; hence, it may be a bit difficult. Instead of wasting more money, let the insured person go and get admitted to the ESI hospital so that the expenditure can be reduced, and they will also get leave.

Procedure for ESI Hospitalization and Reimbursement

The patient should have gone to an ESI hospital only. If one did not go there, one should provide proper justification, such as an emergency and the ESI hospital being unreachable. As soon as the emergency is over and the patient is stable, they should be shifted to the ESI hospital. If not, once the patient is discharged, an application should be made to the Director of the ESI Scheme, attaching all the bills, prescriptions, discharge card, and other documents. Wait for the reply.

Normally, they should pay the expenses for medicines according to their cost structure. If not, approach the ESI Corporation and wait. If you do not receive a satisfactory reply, one can either file a claim before the ESI Court or the Consumer Court. The ESI Corporation has a huge amount of funds available, but since they are not pro-people, they keep accumulating funds collected from workers and employers in the name of workers' welfare but do not use it for workers' welfare.

1. I feel that it is not proper to say that the ESI Corporation has a huge amount of funds available, but since they are not pro-people, they keep accumulating funds collected from workers and employers in the name of workers' welfare without utilizing it for the welfare of workers, as mentioned by one of the participants above.

2. Currently, a major portion of expenses in the ESI Scheme is allocated to "medical benefits."

3. ESI dispensaries, hospitals, or tied-up hospitals are available in every implemented area. If an insured person or their dependent incurs medical expenses at their own discretion, ESIC is not to be held responsible. In my opinion, if medical facilities or expenses are obtained in a hospital or dispensary not recognized by ESIC, there is no basis for filing a case in the EI Court or consumer court.

Thank you.

Of course, the major part of funds collected, being ESIC contributions, goes into the development of infrastructure and administration. However, employees are also required to follow the procedures laid down.

In case someone seeks treatment outside of an ESIC Hospital/Dispensary and directly visits any Government Hospital, they can still receive the due benefits after obtaining approval from the Regional Office, ESIC. Nevertheless, treatment received from a private doctor or hospital is not recognized.

Regards,
P K Sharma

The discussion has been very positive. I just want to add that the reimbursement depends on circumstances. If the insured person (IP) was admitted in an emergency or the ESI medical care arrangements were not available to the IP, he should get the reimbursement as per approved rates. Accordingly, he should make a case and file his claim with the necessary bills in his dispensary/SMC office.

Reimbursement and ESI Procedures

The employee will receive reimbursement for all medicine expenses, covering 100% of the costs. The rent of the room will be at the discretion of the signing authority, who will be the regional director.

The condition is that the employee should have informed the local ESI dispensary about their illness within 48 hours. If not, they can request their company to provide a letter stating their illness and the period of absence. Based on that, the ESI dispensary will forward all expenses to the area ESI inspector's office. However, this process can take a significant amount of time, sometimes up to 12 months.

Please go to the ESIC Dispensary and submit all hospital bills along with the Medical Reimbursement Claim Form. They will proceed as per ESIC rules, and you will benefit from it.

Regards