Eligibility Of Medical Claim Policy To Dependents Of Employees Whom Employers Are Registered Under Shop And Commercial Establishment Act

Respected Senior,
Your expert comments are requested on below concern
My office mate me with an medical treatment of his wife in previous month which was costed more then fifty thousand. After the treatment he has raise the claim for medical treatment amount. But HR replied him that as per medical claim policy adopted by the company, the medical claim for your dependent can not be processed because as per the policy only the medical claim can be processed for employee treatment not for its dependent. (The firm is registered under the provisions of Shops and Commercial establishment Act and the work place of the company (site) is (Village) is not listed in the villages list notified by ESIC.
Please make clarity with your expert advice on above requested matter

Normally, Shops and Estt Acts do not apply to villages if not specially notified. Reimbursement of medical expenses under medi-claim insurance policies would be only as per the coverage offered by the Insurer. If dependents are not covered under the policy, no reimbursement can be claimed.

Dear,

Mediclaim policy may be of different types . It may cover employee only or may cover dependents also.

Rightly said by Umakant Sir that the benefit would be as per policy you opted and I believe your employer opted for coverage of employees only. To cover dependents also employer would have to pay more premium.

But on the same day of accident you could have at least informed the nearest ESI dispensary about the accidents and got some hospitals recommended by them in your area as no ESI hospitals were there or you could have asked your employer to inform ESI dispensary.

Remember 6.5% of your gross goes to ESIC so that you could get the benefit. On meeting accidents everybody should visit nearest ESI dispensary to inform them and to get the treatment. In case the ESI dispensary or ESI authorised hospitals fails to cure permanently, they may refer your case to the other hospitals and in that case they reimburse the expenses at the maximum extent as per ESI act.

In your case also, as no ESIC hospitals were there, showing the urgency/criticality of the accidents to the ESI dispensary personnel, you could have got outside hospitals recommend by them in your place and could have raised bill for reimbursement.