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Employee State Insurance Corporation (ESIC)

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Benefits for Employees

Benefits

Under Section 46 of ESIC Act, totally six social security benefits have been conferred on employees working with various organizations across India. These six social security benefits for the welfare of the employees are enlisted as follows:

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 Benefit

i) 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

Tuberculosis

Leprosy

Chronic Empyema

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

Monoplegia

Hemiplegia

Paraplegia

Hemiparesis

Intracranial Space Occupying Lesion

Spinal Cord Compression

Parkinson’s disease

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)

Unstable Angina

Myocardial infraction with ejection less than 45%

Congestive Heart Failure

Cardiac Valvular Diseases with failure/complications

Cardiomyopathy

Heart disease with surgical intervention associated with complications

(VII) Chest Diseases

Bronchiectasis

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

Schizophrenia

Endogenous depression

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:

Rehabilitation allowance

Vocational Rehabilitation

Unemployment Allowance (Under Rajiv Gandhi Shramik Kalyan Yojana)

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Dear Sir, I joined ESI scheme on 1st Aug'14, I have paid one month contribution only. Now my father needs to undergo eye surgery. Is it possible to have such facility from ESI scheme. Please give me details in this regard.
aprchristumas Thursday, August 14, 2014
Hi, I joined company on 2nd May 2014, Please can you advise when can i and dependent can get full medical treatment or reimbursement from ESIC.
reachankitbansal Tuesday, July 01, 2014
sir i joined a company 3_3-2014`n fill esi form when i got alll the esi facility??????
pankaj1239 Saturday, April 05, 2014
Dear sir Please guide me how to avail the facilty.This is anusuya from bangalore. Thanks and Regards Anusuya ESI Insurance No - 534269872 pls conform me. my esi num its working r not.......regards
anu..



anusuya Tuesday, March 04, 2014
Dear Sir I want to take esi facility but there is no idea of the procedure. Last day I went to renuka orthopaedic hospital in patna, doctor checked and demaded for the fee. But as I know in esi there is nothing to pay from pocket. Please guide me how to avail the facilty Thanks and Regards Manish Kumar ESI Insurance No - 4215223985 Mob- 7781007602
Manish4215223985 Tuesday, January 14, 2014
sir i am naveen kumar ,i go esi hospital for my wife's treatment of eyes, but doctor speak ruffly and said here is no treatment in hospital, we said then reffer any hospital but he said we can not reffer, then i go to another hospital , iwant to treatment another hospital how can i collect my bills to esi
naveensood Friday, November 22, 2013
one of fr she worked with me.nw she relived from our company.her father was in critical stage,whether she can apply for esi with her no.Kindly reply as soon as possible
aparna30 Wednesday, November 13, 2013
Hi, I worked with an organization when I registered for ESIC . Now I moved to another company and its been 2years now. I want to contribute towards my ESIC IP NO. Please let me know how can I initiate contributing towards ESIC with my new company with the changed address. Thanks in Advance, Anil V.
Anee Tuesday, November 12, 2013
I have been working in an organization for the last one year, and astonishingly i found that this company employing around 200 employees is still not registered with ESIC and none of the employees are covered under ESI or even PF. I am wondering as to how a organization can survive like this cheating the employees and minting money like this. Could someone tell me as to how these people can be straightened out using the law.
goodsamaritan Thursday, November 07, 2013
hi my name is raghu my brother worked for 6 years in one organization, 6 months back he resigned due to close of that organization. will he get any benefits of medical and any pay from esi, if so how to get benefits. because he is still searching for job from 6 months. please give some advice
Raghu.M Thursday, November 07, 2013
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