Seeking Guidance on Claiming ESI Reimbursement for My Late Father's Medical Bills

Dear Sir/Madam,

My father passed away on 5th November 2014 due to liver and heart problems. At that time, I admitted my father to SUM Hospital in Odisha, which is an ESI tie-up medical facility. My father was also under the ESI Scheme. I have medical bills and all necessary documents. Can anyone help me with how to claim reimbursement for these expenses? Is there a possibility of receiving assistance from ESI?

Please assist me, as I am currently facing significant financial challenges. Your prompt response and support would be greatly appreciated.

Thank you.

Mr. Goutham, you have all medical bills and all documents. You are eligible for medical reimbursement. First, you have to approach your dispensary; they will provide all the information on how to apply for medical reimbursement.

You cannot get reimbursement for medical expenses incurred for your father unless he was referred to a private hospital by the ESI Medical Officer.

Madhu.T.K

1. Sir, I fully agree with the views expressed by Sh. Madhu T.K. above. But I feel that a period of about 4 months has elapsed, and you should have promptly contacted the concerned authorities.

2. I suggest visiting the appropriate ESI dispensary and discussing the issue with them.

ESIC Dispensaries and Referral Policies

Sir, ESIC has its own dispensaries and hospitals. Therefore, in my opinion, they will not favor referring each and every patient to other private hospitals where they have tie-up arrangements. However, ESIC has its own policies, including a referral policy for medical facilities. Accordingly, in my earlier comments, I suggested contacting the appropriate ESIC Dispensary to which you are attached.

Circulars on ESIC Medical Benefits

I am attaching herewith a few circulars indicating the policies of ESIC in medical benefits, including its policies relating to referring patients to tie-up hospitals. I hope the same may be helpful to you or other readers of this site. These instructions/circulars are available on the website of ESIC and can be downloaded by any person interested in the matter.

Reimbursement Procedures

From these circulars, I think you can find and ascertain the procedure regarding reimbursement, if allowed, in the matter you wanted to know in this thread.

Even for private hospitals that are tied up with ESIC, there are certain referral procedures. Other learned members have advised you correctly, and Mr. Harish Kumar Mehta has attached some circulars that are useful. Read the circulars to get some information about the whole process.

However, you need to visit the ESIC office and discuss the whole matter. Further delay in meeting the officials on the ground who will handle your case of reimbursement is the most important step.

People can advise you and guide you in this learned forum, but you, as the claimant, will have to do the legwork of meeting, discussing, and finding out ways and means to get the reimbursement.

Don't be confused about this. Just contact your ESI branch manager. They will help you clearly with what you need to do.

Dear Gautam, with all your medical bills and the circumstances that led you to approach a private dispensary, as well as the conditions of your patient, please make an application and approach the Directorate of Medical-ESIC in your region to submit it. Every month, ESIC will hold a meeting to review such applications, and the committee will examine them and take necessary actions. Please ensure to ascertain the venue, time, etc., from the medical directorate and be present on the day with a copy of your application and all related documents. If possible, the patient should also accompany you. Obtain a recommendation letter from your concerned employer and, if possible, from the dispensary as well.

ESIC is a generous organization and is very accommodating in considering genuine cases and providing help. I am confident that you will succeed in this endeavor. Please act without delay. All the best.

Regards,
Ram K. Navaratna
HR Resonance
Bangalore
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