New to HR: Can ESI Cover Unexpected Surgery Costs After Initial Misdiagnosis?

Respected Seniors, thanks a lot for this forum. As I am very new to the HR field, I have a basic doubt regarding ESI treatment. I request you to kindly clarify.

Injury and Treatment Details

One of our workmen sustained an injury to his left-hand thumb while working. We arranged for first aid at a nearby hospital. They took an x-ray and informed us that there were no issues. The worker then went to another hospital, where they discovered a fracture and performed an operation. Now, the workman states that the treatment charges amount to around Rs. 15,000. He is covered under ESI. Is it possible to receive any assistance from ESI?

Regards

If one doctor is saying that there is no problem, and another is saying that there was a fracture, how should I proceed? I suggest you contact the ESI dispensary, ask them for a report and X-ray. When did this accident happen, and have you informed the ESI hospital? Please check first.

Submitting an Accident Report to ESIC

If the employer has not submitted the accident report to the ESIC Branch Office as well as to the ESI Dispensary concerned, it may be submitted now with an explanation or reasons for such delay.

Post-Accident Procedures

After the accident report is received in the ESI dispensary, the injured insured person may get examined at the ESI dispensary, obtain medical certification, and submit the same to the ESIC Branch Office. However, since the case is delayed, the insured person will have to produce all papers of the operation and treatment received from the private hospital.

Reimbursement and Referral Policies

ESIC has its own system or referral policy, and therefore, it is not certain whether they will reimburse any expenses incurred in private hospitals. The insured person can discuss the issue with the ESI dispensary doctor or in-charge.

Thank you.

Handling ESI Claims for Workplace Injuries

There is always a chance that a second opinion will reveal issues missed in the first medical examination. Therefore, you cannot blame the employee for this. However, you should hold yourselves accountable for not sending the injured worker to an ESI hospital and not submitting the accident report online.

Now, you can submit the accident report online and send the printout to the ESI branch office with an explanation. Since the injury was not initially found to be serious, you only provided first aid. However, when the employee developed pain later, he consulted another hospital where he underwent surgery. The ESIC will reimburse the cost incurred by the insured person, i.e., Rs 15,000, at a later date. He must submit the original bills in support of his claim to the ESI.

There are two alternatives to handle this situation. You can pay the worker now and ask him to reimburse the company once he receives the money from the ESIC. This process will take time. Alternatively, ask him to claim it from ESIC and bear the cost himself for the time being. I recommend at least doing the first option because it concerns a worker whose earnings are very low, possibly less than Rs 15,000, and the accident occurred while on duty.

If you can justify the delay in submitting the accident report, the employee will receive at least his wages (100% of the benefit rate since it is an accident) for the days he may need to be on leave. For an employee like this, losing income for even a single day is significant.

Moral of the Story

Always send an ESI-covered employee to an ESI hospital for treatment. Also, advise employees by putting up a notice that if anyone falls sick, they should never visit any private hospital unless it is an empanelled one. Note that direct admission to an empanelled hospital should not be encouraged because this facility has been withdrawn. To receive better treatment, you must get your case referred from an ESI dispensary or hospital.

Regards,
Madhu.T.K

I thank everyone for your kind consideration and suitable replies. I wish to say a special thanks to T.K. Madhu for his detailed reply. The accident took place on 18th July. We registered the accident report online (ESI portal) on 21st July. After that, we forgot about the matter, which was a major blunder on our part. Now, I realize the importance of follow-up activities. I would like to seek one more clarification from seniors: should the accident report be filed immediately or after two days of the occurrence of the accident?

Once again, I thank everyone.

Regards

1. Sir, in the case of fatal accident cases, the accident report is to be submitted through a special messenger. In serious accident cases that may result in permanent disablement or death, the accident report is required to be submitted immediately. In other types of cases, the accident report is required to be submitted within 48 hours.

2. For more exact details, I hope you will refer to Regulation 68 of ESI (General) Regulations, 1950.

To: Mr. Harsh Kumar Mehta

Sir,

Thank you very much for your valuable guidance. While discussing with peers, one said that it is to be filed immediately, and the other person told me that it can be filed after 2 days. Hence, I raised that question. You clearly clarified that both of my peers' statements are correct, but it depends on the severity of the accident.

Once again, thank you, sir.

I would like to mention that if the injured insured person is declared fit by the ESI dispensary/hospital but feels that there is a permanent disability in the injured hand, please do not forget to have the injured insured person referred to the medical board for an assessment of the loss of earning capacity. If the medical board awards any percentage of loss of earning capacity, the injured person will be entitled to another benefit under the ESI Act, 1948, known as Permanent Disablement Benefit (PDB). Relevant rules and instructions can be found on the ESIC website.

Regards

Dear Seniors,

One of the employees who is under ESI coverage has slipped from the stairs at his home. In this accident, he has been badly injured in his leg and hand, hence he is unable to perform his duties. Please clarify if he is eligible to receive ESI treatment since the accident occurred at his home. Also, provide information on the amount of wages the employee is entitled to receive from the ESI department since he is on leave.

Thank you,
Aman

Sickness Benefits and ESI Coverage

Since this is not an accident occurring during employment, he will not receive a 100% rate as is typically admissible for accident cases. However, if he is within the benefit period (having joined at least 9 months prior), he will be entitled to sickness benefits, which amount to around 90% (ensuring that the recent hike from 70% to 90% has been implemented) of his average wages. For new employees, they will only receive medical benefits and will not be eligible for any cash benefits meant to compensate for lost earnings during ESI leave days.

Regards, Madhu.T.K

Entitlement to ESI Benefits for Non-Employment Related Accidents

1. Since the accident is neither in the course of employment nor out of employment, the insured person will not be entitled to disablement benefits under the ESI Act, 1948, and the rules/regulations framed thereunder.

2. However, the insured person will be entitled to medical treatment/hospital care as admissible under the said Act.

3. Regarding cash benefits, the insured person will be entitled to the payment of ESI leaves, known as "Sickness Benefit," provided that the insured is entitled to the same and has not already exhausted his entitled leaves under the said Act. This is also subject to medical certification from an ESI dispensary/hospital. Sickness Benefit is paid at 70% of the average daily wages calculated as per rules. Further, you can get the required information on benefits under the said Act/rules/regulations from the online link available on the ESIC website. The link to the same is mentioned as follows:

Information - Benefits | Employee's State Insurance Corporation, Ministry of Labour & Employment, Government of India