Maternity Benefit Payment and Reimbursement
Sir, I may submit that, regarding the payment of cash benefits, namely Maternity Benefit (MB), for the entitled period of such leaves, ESIC generally allows the payment of such cash benefits (MB) as an ALTERNATIVE EVIDENCE (AE) case. This depends on the facts of each case and the entitlement of the insured woman during the relevant benefit period. These powers, as far as I know, are vested with the Manager/Branch Officer and the concerned senior officer at the Divisional/Regional Office of ESIC. Therefore, even if delivery takes place in a private hospital, the period of maternity leave is generally sanctioned as an alternative case and paid, subject to confirmation by the employer regarding absence from work for the period of such claims. In my opinion, the insured woman/claimant can contact the concerned office as mentioned above along with the original certification of delivery, birth of child/fitness certificate, etc., issued by such a private hospital. If medical leave is still continuing, she can visit her ESIS dispensary and get the relevant certificate if allowed by the Doctor In charge.
Reimbursement of Medical Expenses
However, regarding the reimbursement of medical expenses incurred in a private hospital, such expenses, if the referral policy is not followed, are not reimbursed. However, there is a provision for reimbursement of Rs. 5000/- in confinement cases incurred at places where there are no ESIS facilities (viz. non-implemented areas) (please see Rule 56-A of ESI (Central) Rules, 1950).
Regards