Understanding ESI Coverage: Are There Limits on Treatment Costs and Eligibility?

Dear Team, As far as I know, if someone is covered by ESI, they can go to private hospitals covered by ESI, and there are no limitations on the cost of treatment. However, I recently encountered a situation when I visited an ESI hospital for the treatment of a friend. The ESI doctor referred him to a private hospital and mentioned that the ESI hospital would check his eligibility for coverage of expenses. After reviewing his ESI account, they would inform me of the balance for the same.

Clarification on ESI Coverage

I would like to clarify if there are specific expenses covered by ESI or if there is a balance based on ESI deductions. For instance, if an employee joins the company and requires treatment from the second month onwards, what would be their eligibility?

Thank you.

He will not be eligible for treatment as indicated in your last line. Also, please visit the ESIC office as there are clauses based on the period of contribution. Additionally, the person must be eligible for super specialty treatment. You can also refer to the site but to get a clearer picture, visiting the local ESIC office is advisable.

Please log in to the ESI IP Portal with your ESI Insurance Number to determine your eligibility for the various benefits provided there.

Thank you.

Section 46 of the Act: Social Security Benefits

Section 46 of the Act envisions the following six social security benefits:

(a) Medical Benefit: Full medical care is provided to an insured person and their family members from the day they enter insurable employment. There is no ceiling on expenditure for the treatment of an insured person or their family member. Medical care is also provided to retired and permanently disabled insured persons and their spouses on payment of a token annual premium of Rs.120/-. The benefits include:

- System of Treatment
- Scale of Medical Benefit
- Benefits to Retired IPs
- Administration of Medical Benefit in a State
- Domiciliary treatment
- Specialist consultation
- In-Patient treatment
- Imaging Services
- Artificial Limbs & Aids
- Special Provisions
- Reimbursement

(b) Sickness Benefit (SB): Sickness Benefit in the form of cash compensation at the rate of 70% of wages is payable to insured workers during periods of certified sickness for a maximum of 91 days in a year. To qualify for sickness benefit, the insured worker must contribute for 78 days in a contribution period of 6 months. Additional benefits include:

- Extended Sickness Benefit (ESB): Extendable up to two years for certain diseases at an enhanced rate.
- Enhanced Sickness Benefit: Payable to insured persons undergoing sterilization.

(c) Maternity Benefit (MB): Maternity Benefit for confinement/pregnancy is payable for twenty-six (26) weeks, extendable by one month on medical advice.

(d) Disablement Benefit includes:

- Temporary disablement benefit (TDB)
- Permanent disablement benefit (PDB)

(e) Dependants Benefit (DB): Paid to the dependants of a deceased insured person.

(f) Other Benefits include Funeral Expenses, Confinement Expenses, Vocational Rehabilitation, Physical Rehabilitation, Old Age Medical Care, and Rajiv Gandhi Shramik Kalyan Yojana.

The scheme also provides need-based benefits to insured workers, including vocational training and incentives for employers in the private sector.

An interesting feature of the ESI Scheme is that contributions are related to the paying capacity as a fixed percentage of the workers' wages, while social security benefits are provided according to individual needs without distinction. Cash benefits are disbursed by the Corporation through its Branch Offices (BOs) / Pay Offices (POs), subject to certain contributory conditions.

How long is Medical benefit available?

The insured person and their family are entitled to the Medical Benefit from the very first day of their joining the insurable employment. A person who is covered under the scheme for the first time is eligible for medical care for themselves and their family for three months. If they continue in insurable employment for three months or more, the benefit is admissible until the beginning of the corresponding benefit period. If contributions were paid/payable for not less than 78 days in the said contribution period, medical benefit is admissible until the end of the corresponding benefit period. If the insured person is in ESI coverage for at least 2 years, and contributed for not less than 156 days, and is suffering from any of the 34 specified long-term diseases, the medical benefit is admissible until the incapacity lasts or for a period of 3 years for themselves and their family.

Conditions for Super Specialty Treatments under ESIC

Sir, ESIC has framed certain conditions regarding super specialty treatments and long-term serious diseases. If an insured person is sick but does not meet the conditions for such super specialty treatment, ESIC refuses to provide any such treatment. Even for ordinary diseases or operations for which patients are referred to any private hospital by ESIC, there are ceilings on the amounts fixed for such treatments with private hospitals at the time of entering into contracts with referral hospitals.

Discussing Treatment Options with ESI Hospital

It would be better if the attendants or family members of the sick insured person discuss the issue in detail with the concerned doctor of the ESI Hospital or ESIS dispensary to which the insured person is attached.

Levels of Treatment Under the ESI Scheme

Dear friend, first try to know the various levels of treatments one can get under the ESI Scheme:

01. Primary level treatment: It can be given at IMP or Dispensaries, where an IP along with his family members can get treatment including medicines from day one of his entry into insurable employment.

02. Secondary level treatment: It can be given at ESI State Hospitals, where an IP along with his family members can get treatment including medicines from day one of his entry into insurable employment. The difference between primary and secondary levels is that in secondary level hospitals, you can find good specialties supported with diagnostic/lab services like ECG, X-ray, scanning, blood tests, etc.

Any Insured Person along with his dependent family members can get treatment at these two levels. Now, the issue arises for super specialty (i.e., the facilities generally not available at ESI State Hospitals, viz., Neurology, Nephrology, Cardiology, etc.) which needs a referral to private tie-up hospitals by the ESI State-run hospitals.

Eligibility for Super Specialty Treatment

In earlier days, the Super Specialty treatment eligibility conditions were so liberal that for an individual Insured Person, if he worked for 3 months, he would be entitled to be referred to SST. In the case of family members, that Insured Person should work for 6 months. However, for the last one and a half years, this rule was changed. Now, the condition to get SUPER SPECIALTY TREATMENT is that one should COMPLETE 2 YEARS OF INSURABLE EMPLOYMENT, and the cost ceiling will be 10 lakhs per individual. This means an IP or his family members can be eligible to get treatment of SST for Rs. 10 lakh per person per year.

I hope I have cleared all your doubts, friends, and wish you all the best.