Is My Employer Responsible for My ESIC Claim Rejection Due to Missing Documents?

My insurance claim was rejected because I was admitted to a private hospital. However, the same medical services were available in government hospitals and ESIC-registered hospitals. So, I'm wondering if this is a legally valid reason for rejecting my medical claim.

Lack of ESIC Documentation

Before my hospitalization, my employer did not provide me with any ESIC documents, such as an E-Pehchaan Card, Form 37, or Med 7 A. Only after two months of my recovery from illness did I receive these documents. Nevertheless, my employer was deducting my ESIC premium from my salary every month, which means my ESIC policy was active. But due to the unavailability of the necessary documents, I was unable to access medical services from ESIC-empanelled or government hospitals.

Liability for Insurance Claim Payment

In such a scenario, I would like to know who is liable for the payment of my insurance claim? And how will this process take place?

The Employee's State Insurance Corporation (ESIC) in India provides medical and cash benefits to employees covered under the ESI Act, 1948. In your case, where your insurance claim was rejected due to receiving treatment at a private hospital instead of an ESIC-registered or government hospital, it is essential to understand the responsibilities of the employer in such situations.

Responsibility for Payment of Insurance Claim:
1. The ESIC premium being deducted from your salary indicates that your ESIC policy was active, even though the necessary documents were provided to you after your recovery.
2. As per the ESI Act, it is the employer's responsibility to ensure that employees are provided with ESIC documents and access to ESIC empanelled medical facilities.
3. Since your employer deducted the premium but failed to provide you with the required documents timely, they bear responsibility for the situation.

Steps for Payment of Insurance Claim:
1. Contact your employer: Inform your employer about the rejection of your claim and the reasons behind it.
2. Seek assistance: Request your employer to assist you in rectifying the situation by liaising with the ESIC authorities.
3. Submit necessary documents: Provide all relevant documents, including proof of premium deduction and hospital bills, to support your claim.
4. Follow up: Stay in communication with your employer and the ESIC office to ensure the claim process moves forward smoothly.

Resolution of the Issue:
1. Your employer should take necessary steps to rectify the situation and ensure your claim is processed.
2. If required, escalate the matter to the ESIC authorities or seek guidance from a legal advisor specializing in labor laws to protect your rights as an employee.

In conclusion, while the delay in providing ESIC documents was an oversight on the part of your employer, they hold the responsibility for ensuring your access to ESIC benefits. By engaging with your employer and the relevant authorities, you can work towards resolving the issue and receiving the insurance claim rightfully owed to you.