How Should Employers Handle ESIC Claims for Private Hospital Treatments?

In my company, one worker took treatment for multiple sclerosis from a private hospital in August 2017 without referring to ESIC due to his ignorance towards ESI benefits. He is listed in ESIC. Now, how should the employer write a request letter to ESIC?

In my company, one worker took treatment for multiple sclerosis from a private hospital in August 2017 without referring to ESIC due to his ignorance towards ESI benefits. He is listed in ESIC and now needs to write a request letter to ESIC by the employer for late submission.

Please let me know if you need further assistance with the letter.

Role of Employer in ESIC Cases

The employer has no direct role in such cases; the employee must visit the AMO of their regional ESIC zone to explain the circumstances under which they received treatment without informing ESIC. The AMO will provide a proforma to be submitted along with a few forms that need to be signed by the hospitals and doctors where the treatment was availed. After this, the employee can submit the bills for processing. It is uncertain whether the expenses will be admissible, as ESIC rules require notification within 72 hours of such incidents.

Guidance for HR and Employee

It is important to note that this post assumes the perspective of an employer representative. If an employee does not attend work for more than three days, it is assumed that the employer is aware of the employee's medical status. HR should advise the employee or their family members to contact the ESIC dispensary with the necessary details. From there, they will be referred to any nominated private clinic or nursing home at zero cost. This process is crucial, and any negligence by HR in not following these steps could be evident.

As per the query posted above, it appears that hospitalization, treatment, and even being absent from work were not known to the employer. However, the employee is required to submit an ESIC medical leave certificate if the leave extends beyond 3 days. Moreover, the employer cannot re-employ the person without a fitness certificate from the designated ESIC panel doctor or RMO ESIC, as the establishment is covered under the ESIC act.

So, how can the employer assist the employee in such a situation?

Hi,

As per the ESIC Act, an employee has to utilize medical benefits solely from ESIC dispensaries or hospitals. In cases of emergencies, if it is proven, or in situations where ESIC facilities are not available in a specific region, employees may seek medication or treatment from private hospitals with prior approval from ESIC. In the event of an emergency or accident, employees can receive benefits from the nearest private hospital and subsequently claim reimbursement from ESIC, subject to ESIC approval.

Dear sir,

My name is Manish. My wife's delivery is emergency, so we are going to a private hospital without an ESI referral. How can we claim the bill?