Employee State Insurance Corporation (ESIC) - Information for Employees

Information for Employees

a) Medical Benefit

This ECIS Scheme provides comprehensive range of medical/healthcare facilities to an insured individual and his/her dependants including their family members, through a network of ESI Dispensaries & Panel Clinics, ESI Hospitals and Diagnostic Centres. Super-speciality medical facilities are provided to the beneficiaries of this scheme through recognized advanced medical institutions that are empanelled on ECIS list for the purpose on referral basis. The Corporation has set up a Revolving Fund in most of the States across India so as to ensure smooth flow of funds for super-speciality treatments of ESIC beneficiaries.

All insured individuals and their family members are entitled to free and comprehensive medical facilities under this Scheme. The package covers all aspects of healthcare ranging from primary to super-speciality facilities.

b) Identity cards

Temporary identity card (TIC) indicating the Insurance Number and family particulars along with photograph affixed thereon are issued to the employees immediately on submission of declaration form to Branch office to which the employer is attached. This TIC is valid for three months.

After three months, Permanent Identity Card (PIC) is issued to the particular employee. In case, due to any reason, if the PIC is not issued after the period of 3 months, TIC is revalidated for another 3 months by the concerned Branch Manager.This TIC will entitle the insured person and his/her family to avail medical cover for three months or till the extended period.

Advertisement

c) Contribution & Benefit periods

There are two contribution periods of six months duration each in a year, in respect of an insured worker or employee, with corresponding benefit period of six months given below:

Contribution period	Corresponding benefit period
1st April to 30 September	1st January to 30th June of the year following
1st October to 31st March of the year following	1st July to 31st December of the calendar year

In case an individual becomes an employee within the ambit of the ESIC Act for the first time, the first contribution period will commence from the date he/she enters into insurable employment for the first time in the contribution period current on that day and his/her corresponding benefit period will commence on the expiry of nine months from such employment date.

d) Revolving Fund

Revolving Fund is a corpus fund raised for the benefit of insured individuals who undergo speciality / super-speciality treatment by the insured individuals including their family members/dependants under this scheme.

As and when administrative sanctions for reimbursement of medical/healthcare expenses on speciality or super-speciality treatment are accorded in individual cases based on their merits as per the decisions made by the Director of Medical Services up to Rs.75,000/- or the State Government above Rs 75000/- as the case may be, the payment will be made by the Regional Director from the Revolving fund at his/her disposal.

Advertisement

Revolving funds are utilized for making payments in respect of the following claims:

• Pre-authorization or advance given for availing speciality/super-speciality treatments and reimbursement thereof, if the insured person had borne the expenditure incurred on medical expenses from his/her own sources.
• Reimbursement of medical expenses with respect to expensive diagnostic services exceeding Rs 1000/- each.
• Reimbursement of medical expenses case where the patients are admitted in a recognized hospital without any referral from ESI Hospital especially in cases of a medical emergency.