Understanding ESIC Benefits: When and Where Can Employees Access Hospital Care?

Hello,

I have a few questions regarding ESIC benefits. Please check and help me with your valuable answers.

1. When will employees and their dependents be eligible to receive hospital treatment after registration?
2. Do employees have to visit the nearest ESIC hospital for treatment, or can they go to any ESIC hospitals?
3. Can an employee directly visit an ESIC hospital without being referred by any panel doctors?

Looking forward to your valuable feedback.

Thanks,
Sandip Kumar Ghosh
Accounts Administrator

1. The ESIC-covered employee is entitled to ESIC benefits from the very beginning in case of an accident.

2. After three months, the employee may avail family benefits. He/she can visit an ESIC hospital and, if necessary facilities are not available there, may be referred to other hospitals.

3. Yes.

Eligibility for Medical Benefits under the ESI Act

As soon as a person becomes an "employee" within the meaning of the ESI Act, 1948, and obtains a TIC or Identity Card from the appropriate ESIC office, they and their family members become entitled to medical treatment (referred to as Medical Benefit) from the ESIS dispensary or Panel Doctor they are attached to. The employee or their family members must first report to the ESIS dispensary or an ESIC Panel Doctor, as only these institutions or Panel Doctors can recommend the case to an ESIC Hospital or any authorized private hospital.

If the employee directly goes to an authorized private hospital, the treatment will not be free, and it may be difficult to obtain reimbursement from ESIC in the end. The ESI Hospital will not accommodate the employee (except in emergency cases) without a referral slip from the concerned ESIS Dispensary or Panel Doctor.

Referral Policy for Medical Treatment

ESIC has formulated and enforced its referral policy for medical treatment in such cases from private authorized hospitals or ESI Hospitals. Every insured person or covered employee should comply with the instructions before seeking treatment from higher hospitals. Copies of such referral policy instructions were uploaded by me in some other threads earlier. If needed, you can confirm the position from the ESIC Branch Office, as well as from the ESIS dispensary or Panel Doctor you are attached to for such benefits.

Regards

Dear Sandip,

Please find the attached document for detailed benefits and eligibility criteria for ESI.

Thanks,
Murali
9440706968

Dear Harsh Kumar Mehta,

Our employee's right hand has been fractured during working hours. Hence, he is unable to perform his duty.

Please clarify how to get him admitted to ESI Hospital and the required forms and procedures to be followed for the same. Also, clarify that since he is unable to perform his duty, how much cash benefit he will get from ESI and for how long. However, his gross salary is 12700 PM.

Please guide, it's urgent.

Thanks,
Amit

ESIC Benefits and Accident Reporting

Dear Amit ji, thank you for contacting me through citeHR. I would like to emphasize that if you are an employer, HR personnel, or a relevant individual in your establishment or factory, please ensure initially that the employee who experienced an accident possesses all necessary documents, such as their ESIC Identity Card. Additionally, confirm that your organization has submitted an Accident Report to the appropriate Branch Office of ESIC and the concerned ESIC dispensary.

It is crucial to verify that your establishment has made timely contributions and that the employee is eligible for the benefits. The Incharge of the concerned ESI dispensary (Dr.) is the authorized person who can recommend an employee for treatment at an ESIC or other approved hospital. The ESIC Branch Office plays a vital role as it disburses Benefits (excluding medical treatment) to the insured individual based on essential documents, including the accident report, contribution data received from the employer, and medical certificates from the relevant ESIS dispensary/hospital.

You may consider generating the Accident Report online and submitting it to the appropriate offices as mentioned earlier, if deemed suitable at this point.

The critical issue is not the injured employee's ability to perform duties but whether they have obtained medical certification from the appropriate ESIS dispensary. If the employee has undergone a medical examination or treatment at the said dispensary, it can be presumed that the doctor has issued the necessary medical certificates. Only with such medical documentation from the ESI dispensary or a referred hospital can the employee claim benefits such as Temporary Disablement Benefit (TDB) or Permanent Disablement Benefit (PDB) if certified by an ESIC Medical Board.

The current rate of TDB, as indicated above, amounts to 90% of the average daily wages of the employee, calculated in accordance with the ESI (General) Regulations or Central Rules, 1950. I trust that your establishment and the employee can contact the designated offices mentioned above if any ESI Act, 1948 benefits are required.

Best wishes.

ESIC Benefits Query

My query is related to ESIC benefits: One of the employees has contributed to ESIC for more than 20 years. For the last two years, he was above the ESIC contribution salary limit (earning more than 15K). Now, he is under the ESIC contribution limit again, as his salary is less than 21K (as of 01/01/2017). He is suffering from a heart problem, and the doctor has advised him to undergo surgery.

Please clarify, will he receive ESIC benefits?

Highly thankful for your valuable advice.

Regards

ESIC Coverage and Benefits

1. Since the employee has re-entered ESIC coverage as of 01/01/2017, he is currently entitled to medical benefits only. This includes medical treatment from ESIS hospitals and dispensaries. In my opinion, this will also cover reimbursement of expenses incurred in ESI-authorized hospitals if referred by ESIC as per their referral policy.

2. However, the insured person/employee will not be entitled to cash benefits, known as Sickness Benefits, because his benefit period has not yet started. Due to his illness, his contributing days may be fewer.

3. I suggest asking the concerned employee to first obtain a Permanent Identity Card (if not already obtained) from the respective ESIC Branch Office. Additionally, discuss his entitlement to medical treatment from ESIC institutions, including treatment in ESIC-sponsored hospitals if required.

4. The respective ESIC Branch Office and the ESIS dispensary are the appropriate authorities to certify and provide local guidance regarding the employee's eligibility for benefits and medical treatment under the Act. Therefore, it is in the interest of the concerned employee to stay in touch with these offices.

Regards,
[Username]

Dear Mehta sir,

Please enlighten me on the difference between sick benefit and medical benefit.

Regards,
Amit

Understanding ESIC Benefits

Sickness Benefit is a cash benefit paid from the ESIC Branch Office. As you know, Medical Benefit provides medical treatment and facilities, and is therefore provided in kind. There are eligibility conditions for various cash benefits under the ESI Act, 1948, and the rules and regulations framed thereunder.

For further details, I hope you will download the necessary information from the website of ESIC for guidance on the subject, if required. The online link is also mentioned below:

http://esic.nic.in/page.php?pid=NzU=