Can I Claim ESIC Reimbursement for My Knee Treatment at a Private Hospital?

Hi,

Please help me. I met with an accident and suffered a knee fracture. I received treatment for my knee from a private hospital last week without referring to ESIC. Is it possible to claim my expenses from ESIC in this case? If yes, what is the complete procedure for this? Please let me know what to do. Please help me.

Thanks,
MUZAMMIL HASSAN

You will have to go to your ESIC clinic and submit all medical case papers. Urgent or emergency treatment was necessary due to off hours of ESIC clinic. You can try to convince ESIC authorities. Read Regulation 69 and 96A of ESIC, which deals with accident cases, etc.

Dear,

Nowadays, cashless card facility has made it easy. ESIC hospitals refer patients to private hospitals only when they are unable to provide complete treatment. In this case, they also reimburse the expenses up to the maximum extent. Hence, one needs to visit an ESI hospital first.

In your case, you may try to convince the ESI personnel by showing the last-minute urgency of your case for hospitalization and that there were no ESIC hospitals nearby, etc., if it is true.

Dear Muzamil, ESI is for employees' welfare. You should have intimated your ESI dispensary immediately through your relatives or your employer. An accident case can be treated as an emergency, and you have not intimated them.

Collect all your medical case history, expense bills, and a letter from the hospital where you were treated, mentioning that your case was an emergency or accident case. Ask your employer to provide a covering letter to ESIC stating that you faced an accident and were unable to intimate in time/delayed intimation and may be allowed for medical expense reimbursement.

Then deposit it in the ESI dispensary, and they will forward it to their ESI hospital. There, you need to convince the medical officer/authorized person. Once they are convinced, they will forward it to the regional office, and your bills will be reimbursed. It will take around one month's time.

Hope you will avail the monetary benefit.

Regards,