Dear OM
Firstly, the period of minimum of 2 years of service is applicable in normal cases. If the insured person is in ESI coverage for at least 2 years from the date of Online Registration, contributed for not less than 156 days and IP is eligible for Sickness Benefit in any one of the contribution period and is suffering from any of the 34 specified long term diseases, the medical benefit is admissible till the incapacity lasts or up to 730 days during a period of 3 years for self and family.
Further, If the insured person is in ESI coverage for at least 2 years from the date of Online Registration, contributed for not less than 156 days before the date of diagnosis and IP/IW is eligible for Sickness Benefit in at least two contribution period then he along with his family members will be eligible for getting super specialty treatment
In case of an Accident in respect of IP/IW himself or his/her family member this contributory condition shall not be applicable for SST treatment
Secondly, In the event of serious cases of accident or illness the hospital expenses are reimbursable under the following circumstances:
1. Serious cases of accident or illness admitted directly into recognised hospitals where owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal his identity as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer
2. Serious cases of accident/illness where a beneficiaries was admitted directly at a private hospital or in a non-recognised hospital where admission in a hospital recognised under the scheme would have seriously jeopardised his health like sudden heart attacks, fracture of the spine, cerebral haemorrhage, etc.
Regards
P.S.Lakshmanan
S. G. Management Services
(PAN INDIA Consultant – Labour Law Compliance,
PF, ESI, P Tax, Benefit Management &
POSH COMPLIANCE) - KOLKATA