a) Medical Benefits
Under the medical benefit, different types have been incorporated for the benefit of factory/establishment employees. The ESIC scheme provides total medical care that comprises of medical attendance by competent physicians and nurses, treatment, drugs and injections, specialist/super-specialist consultation and hospitalization to insured persons including their dependants or members of their families where the facility of benefits has been extended for providing medical coverage to such families.
For such families who are eligible for benefits under ESIC Act, these benefits have been categorized into two broad categories as follows:i) Full Medical Care
It comprises of hospitalization facilities incorporating specialist services, drugs/medicines, dressings and diets as required for in-patients admitted in hospitals.ii) Expanded Medical Care
It comprises of consultations with specialists and supply of special medicines and drugs that may be prescribed with the added advantage of OPD (Out-patient department) care. This also includes facilities for special diagnostic and laboratory tests including X-Ray investigations.
Apart from the curative services provided through service providers such as hospitals, nursing homes and dispensaries, the Corporation provides preventive facilities including family welfare services.Immunization
The ESIC Corporation has embarked upon a massive programme of immunization of young infants and children of insured persons eligible under this Act. As part of immunization programme, preventive inoculation and vaccines are administered against diseases like diphtheria, pertusis, tetanus, hepatitis B, measles, mumps, polio, rubella, smallpox, tuberculosis etc.Family Welfare Services
The Corporation has been constantly undertaking measures for implementation of Family Welfare Services with constant upgradation in its services to the beneficiaries eligible under this Scheme. The provisions of ESIC Act has been extended for additional cash incentives to insured persons for propagating and promoting acceptance of sterilization methods by reimbursement of sickness cash benefit that is equivalent to full wage for a period of 7 days for vasectomy procedure (in males) and 14 days for tubectomy procedure (in females). The period for which cash benefit is admissible can be extended beyond the above specified limits subject to any event of complications subsequent to Family Planning procedures.Supply of Special Aids
Insured persons including their family members and dependants covered under this Act are provided special aids comprising of artificial limbs, hearing aids, artificial appliances like spinal supports, cervical collars, crutches, wheel chairs, walking calipers and cardiac pacemakers which are a part of medical products and services provided under this scheme.b) Sickness Benefits
Sickness Benefit represents periodical cash payments made to an insured person during the period of illness or sickness certified by a medical practitioner occurring in a benefit period. An insured person requiring medical treatment and attendance with abstention from work on medical grounds are additional features incorporated under Sickness Benefit. Prescribed certificates for Sickness Benefit are: Forms 8, 9, 10, 11 & ESIC-Med.13. Sickness benefit roughly amounts to 50% of the average daily wages that is payable for 91 days during 2 consecutive benefit periods.Qualifying Conditions
(i) To become eligible for Sickness Benefit, an insured person should have paid contribution for not less than 78 days during the corresponding contribution period.
(ii) An individual who has entered into insurable employment for the first time has a waiting period of nine months (i.e. the individual has to wait for 9 months) before becoming eligible for availing sickness benefit, since his/her corresponding benefit period commences only after this interval (i.e. 9 months) as specified under the provisions of the Act.
(iii) Sickness Benefit is not payable for the first two days of a spell of sickness with the exception in cases such as a spell commencing within 15 days of closure of earlier spell of illness for which sickness benefit was last reimbursed. This period of 2 days is called as "waiting period". This provision should be clearly understood by medical service providers and medical fraternity as actual experience shows that such of insured persons who want to avail medical leave on flimsy grounds generally come to avail for issuance of First Certificate/First & Final Certificate within 15 days of earlier spell, usually on unpaid holidays and/or on each weekly off etc in order to avoid loss of benefit for 2 days due to fresh waiting period applicable under ESIC Act.
Sickness benefits are further classified into two broad categories:
i) Extended Sickness Benefit
ii) Enhanced Sickness Benefiti) Extended Sickness Benefit (ESB)
Earlier insured persons eligible under this scheme suffering from long duration of illnesses were experiencing great hardships on account of expiry of 91 days Sickness Benefit. It was often observed that such individuals that though they were not fit for duty, they were pressed for a Final certificate. Hence, a provision for paying Sickness Benefit for an extended period (Extended Sickness Benefit)of upto 2 years in a ESB period of 3 years was incorporated in the provisions of this Act.
An insured person suffering from certain long term diseases is entitled to avail ESB, only after totally exhausting Sickness Benefit to which he/she may be eligible. A common list of such long-term diseases for which ESB is payable is being constantly reviewed and updated by the Corporation from time to time.
The list was last reviewed in December 1999 and revised provisions of ESB became effective from January 2000. Currently this list includes 34 diseases which are grouped in 11 broad categories as per International Classification of diseases and the names of many existing diseases have been changed as enlisted below:(I) Infectious Diseases
AIDS (II) Neoplasm
Malignant Diseases (III) Endocrine, Nutritional and Metabolic Disorders
Diabetes Mellitus associated with proliferative retinopathy/diabetic foot/nephropathy(IV) Disorders of Nervous System
Intracranial Space Occupying Lesion
Spinal Cord Compression
Myasthenia Gravis/Neuromuscular Dystrophies (V) Disease of Eye
Immature Cataract with vision 6/60 or less
Detachment of Retina
Glaucoma (VI) Diseases of Cardiovascular System
Coronary Artery Disease (CAD)
Myocardial infraction with ejection less than 45%
Congestive Heart Failure
Cardiac Valvular Diseases with failure/complications
Heart disease with surgical intervention associated with complications (VII) Chest Diseases
Interstitial Lung Disease
Chronic Obstructive Lung Diseases (COPD) with congestive heart failure (Cor pulmonale) (VIII) Diseases of the Digestive System
Cirrhosis of liver with ascities/chronic active hepatitis (IX) Orthopaedic Diseases
Dislocation of vertebra/prolapse of intervertebral disc
Non-union or delayed union of fracture
Post Traumatic Surgical amputation of lower extremity
Compound fracture with chronic osteomyelitis (X) Psychoses
Manic Depressive Psychosis (MDP)
Dementia (XI) Others
More than 20% burns associated with infection/complications
Chronic Renal Failure
Reynaud’s disease/Burger’s disease
In addition to the above list, Director General/Medical Commissioner have the authority to sanction ESB (Extended Sickness Benefit) for a maximum period up to 730 days in cases of rare but treatable diseases or under special circumstances for example adverse reaction to drugs which have not been incorporated in the aforesaid list. Moreover, it depends on the merits of each individual case, on the recommendations of RDMC/AMO or either authorized officers who are in-charge for implementing the medical scheme.
To be entitled to the Extended Sickness Benefit (ESB), an insured person should have been continuously employed for 2 years or more at the commencement of a spell of sickness in which the disease has been diagnosed and should also satisfy other contributory conditions.
ESB (Extended Sickness Benefit) shall be payable for a period of 124 days initially and thereafter may be extended up to 309 days in chronic suitable cases or on basis of merit as decided by Regional Deputy Medical Commissioner/Medical Referee/Administrative Medical Officer/Chief Executive of the E.S.I. Scheme in the State or his authorized nominee on the report of the specialist(s). ii) Enhanced Sickness Benefit
It was introduced with effect from 1st
August, 1976 as an incentive to insured persons for undergoing Vasectomy or Tubectomy operative procedures. Insured persons eligible to ordinary sickness benefit are paid enhanced sickness benefit at double the rate of sickness benefit i.e., about full average daily wage for undergoing sterilization operations for the family welfare and family-planning purposes. Duration of enhanced Sickness Benefits is up to 7 days in the case of Vasectomy and up to 14 days in the case of the Tubectomy from the date of performing operative procedure or from the date of admission in the hospital as the case may be. The period of Enhanced Sickness Benefit can be extended in case of post operative complications.c) Maternity Benefits (MB)
Maternity Benefit is payable to an insured woman (or pregnant mother) in the following cases subject to contributory conditions:
Confinement is payable for a period of 12 weeks (84 days) on production of Forms 21 and 23.
Miscarriage or MTP (Medical Termination of Pregnancy) is payable for 6 weeks (42 days) from the date following miscarriage on the basis of Forms 20 and 23.
Sickness or complications arising out of Pregnancy, Confinement, Premature birth is payable for a period not exceeding more than one month on the basis of Forms 8, 10 and 9.
In the event of death of an insured woman during confinement leaving behind a child, Maternity Benefit is payable to her nominee on production of Form 24 (B).
Maternity benefit rate is double the Standard Benefit Rate or is roughly equal to the average daily wage.d) Disablement Benefits
Disablement Benefits can be categorized into 2 broad groups under ESIC Act as follows:
Temporary Disablement Benefit (TDB)
Permanent Disablement Benefit (PDB)Temporary disablement benefit (TDB)Benefits
TDB is payable to an employee who suffers injury during the course of working hours of employment which is commonly called as Employment Injury (EI) or Occupational Disease and is certified by the Medical Practitioner to be temporarily incapable to work.
Under Section 2(8) of ESIC Act, "Employment Injury" has been defined as a personal injury to an employee caused by accident or occupational disease arising out of and in the course of his/her employment, being in insurable employment, whether the accident occurs or the occupational disease is contracted within or outside the territorial limits of India. Certificates Required for TDB:
Accident Report in form 16, Form 8, 9, 10, 11 and ESIC Med.13.Eligibility for TDB
The benefit is not subject to any contributory conditions. An insured person is eligible from the day he joins the insurable employment.
TDB (Temporary Disablement Benefit) Rate is calculated 40% over and above the normal sickness benefit rate. This works out to nearly 85% of the average daily wages.Duration of TDB
There is no prescribed limit pertaining to the duration of TDB (Temporary Disablement Benefit). This is payable as long as temporary disablement lasts and significant improvement by treatment is possible. If a Temporary Disablement spell lasts for duration of less than 3 days (excluding day of accident), insured person will be paid sickness benefit
, unless if otherwise found eligible for the same. A special point for Medical Officers and Medical Practitioners is that some insured persons may resist taking a Final Certificate especially before 3 days for fear loss of TDB (Temporary Disablement Benefit).Permanent disablement benefit (PDB)
PDB is payable to an insured person who suffers permanent residual disablement as a result of EI (Employment Injury) including Occupational Diseases, thereby resulting in loss of earning capacity of that individual. The proper authority designated for assessing actual loss of earning capacity for injuries sustained is the Medical Board. Similarly the proper authority for assessing actual loss on account of Occupational Diseases is Special Medical Board.
The duration of PDB is reimbursed for the period as authorized by Medical Board, if assessment is provisional or for entire life if assessment is final.PDB Rate
The PDB rate is calculated as percentage of loss of earning capacity based on the assessment made by the Medical Board/MAT/EI Court in relation to TDB (Temporary Disablement Benefit). List of injuries deemed to result in permanent total disablement and percentage loss of earning capacity has been amended in 2nd
Schedule to ESIC Act, 1948. Hence, the maximum rate of PDB can be equal to the rate of TDB.
PDB amount is monitored and revised by the ESIC from time to time by taking into consideration the inflation factor prevalent in the Indian market. The latest enhancement is with effect from 1st
August, 2002.Commutation of PDB (Regulation 76-B)
An insured person whose PDB (Permanent Disability Benefit) has been assessed as final and who has been awarded the same at the rate not exceeding Rs.1.50 per day may apply for commutation of periodical payments of PDB into a lump-sum amount. When an application for commutation is made within 6 months from the date of communication of Medical Board decision, periodical payments shall be commuted into a lump sum, provided that the total commuted value does not exceed Rs.10,000/- at the time of commencement of final award. However, there are numerous instances where such an application is made after the expiry of 6 months duration, then LO (Legal Officer)/RO (Regional Officer) will refer the case to appropriate authorities so as to certify whether the concerned insured person has an average expectation of life as applicable for his/her age. Such a certificate is issued by Medical Referee in the relevant place on RO/LO letterhead.
Age of an insured person needs to be proved to the utmost satisfaction of the Corporation in all such cases. Medical Boards assess the age of insured persons who are unable to produce satisfactory record of age proof and opinion delivered by Medical Board shall be considered as final and binding in this regard.e) Dependants’ Benefits (DB)
The dependants’ benefit is payable to the dependants of the insured persons under Section 52 of the ESIC Act read along with provision of 6(A) of Section 2 in cases where an insured person dies on account of EI (Employment Injury). The age of dependants, has to be determined either on production of Documentary evidence as specified under Regulation 80(2) or age as certified by Medical Officer who is In-charge of Government Hospital or Government Dispensary.
The minimum rate of DB (Dependants’ Benefits) with effect from 1st
January, 1990 is Rs.14/- per day and these rates of the DB are increased with passage of time by taking the inflation factor into consideration . The latest enhancement has been implemented with effect from 1st
August, 2002.f) Funeral Expenses
An interesting aspect of the ESIC Scheme is that the contributions are related to the paying capacity as a fixed percentage of the workers wages and are provided social security benefits according to individual needs without distinction.
Cash Benefits are disbursed by the ESIC Corporation through its Local Offices LOs/ Mini Local Offices (MLOs)/Sub Local Offices SLOs)/pay offices which are subject to certain contributory conditions.
Over and above all, this scheme provides some need based benefits to insured workers as enlisted below:
Unemployment Allowance (Under Rajiv Gandhi Shramik Kalyan Yojana)