Road Accident While on Duty: How to Navigate ESI Reimbursement for Hospital Expenses

Hi,
I am working in a textile company as a welfare officer. Recently, a worker in my company had an accident on the road while on duty, and he is covered under ESI. The worker was seriously injured, so he was admitted to a private hospital, incurring expenses of 5 to 6 lakhs. I would like guidance on the reimbursement process. Could you please provide detailed information on the procedure? Thank you.

You need to register an accident report with ESIC in your area. Further, if possible, the injured person has to be brought before a doctor at the ESI Hospital to claim any compensation. Taking treatment in a private hospital is not an offense, but the money spent cannot be claimed from ESIC. The injured person is eligible for medical leave for their absence and any compensation according to their loss of earning capacity.

In most cases, in the absence of prior approval from ESIC, the amount spent in private hospitals is not reimbursed. However, it would be a good idea for you to approach the local ESIC office and explain the matter. They may agree to reimburse part of the expenses.

Further, if this is a motor car accident, he may be eligible for compensation from the insurance company of the consent very good. You should check out how he can get it.

ESIC Referral Policy and Reimbursement Procedure

1. Sir, ESIC has its own referral policy and procedure for reimbursement. As mentioned by seniors and experts in the above remarks, I hope the company/firm concerned official will immediately submit the Accident Report to the appropriate Branch Office of ESIC and the IMO in charge of the ESIC dispensary to which the said employee was attached.

2. The action for reimbursement of expenses incurred, as well as claims for temporary disablement benefit or permanent disablement benefit, if any, in respect of the said employee can be discussed with the above authorities, which are appropriate authorities for such claims.

Emergency Treatment in Private Hospitals

Emergency treatment in a private hospital may be necessary in case of an accident.

Regulation 69: Employer's Responsibilities

Regulation 69 authorizes the employer to arrange for first-aid medical care and transport of accident cases until the injured employee is examined by the IMO/IMP. The employer is entitled to reimbursement of expenses incurred in this regard up to the maximum scale as laid down. However, it is important to note that reimbursement is not permissible if the employer is required to provide such medical aid free of charge under any other enactment, law, or rule.

Reimbursement Process

The cost of providing such emergency treatment would be reimbursed to the employer by the Director/AMO (ESI Scheme) of the respective State. Therefore, all claims duly supported by relevant receipts and vouchers should be submitted to him for verification and necessary payment action.

Additional Regulations

One must also refer to Regulation 96A. With these regulations laying down some sort of arrangement for emergency care, one must visit the local ESIC center and find out the exact procedure and documentation for claiming reimbursement.

Other learned members may comment.

If an insured person meets with an accident, you must fill in the online accident form, whether to stake a claim or not.