Information - Benefits

Medical Benefits

Insured persons and their dependants are entitled to full medical care from day one of taking up employment in any factory or establishment covered under the ESI Act 1948. The comprehensive package includes primary medical care, specialists and diagnostic services, in-patient care with provision for all super specialist facilities. The scheme provides full range of medical care, namely;

  • Out-Patient services
  • Diagnostic services
  • Specialists services
  • Hospital service through a network of ESI dispensaries,diagnostic centers and ESIC Hospitals.etc

The package covers all aspects of health care from primary to super-specialist facilities as detailed below:-

  • Outpatient treatment
  • Domiciliary treatment
  • Super-specialty treatment
  • Specialist consultation and diagnostic facilities
  • In-Patient treatment
  • Free supply of drugs and dressings
  • X-ray and laboratory investigations
  • Vaccination and preventive inoculations
  • Ante-natal care, confinement and post natal care
  • Ambulance Service or conveyance charges for going to hospitals, diagnostic
    centers, etc. wherever admissible
  • Free diet during admission in hospitals
  • Free supply of artificial limbs, aids and appliances for physical rehabilitation
  • Family welfare services and other national health program services
  • Medical certification
  • Special provisions including super-speciality treatment.

For super-speciality treatment such as

  • Open Heart Surgery, Neuro Surgery, Bone Marrow Transplant, Kidney Transplant or specialized investigations like CAT scan, MRI, Angiography etc.
  • Referral arrangements have been made with the reputed, premier hospitals of the country. The total cost of such treatment, diagnostic facilities or surgical intervention is borne by the ESI Scheme.
  • Though medical care is provided, by and large, to the beneficiaries in modern system of medicine (Allopathic), facilities in indigenous systems such as (i) Ayurveda (ii) Unani (iii) Homoeopathy & Siddha are also being provided to the insured persons, on demand in many areas.

Extension of medical cover to the Retired and Disabled Insured Persons and their spouses (Rule 60 & 61 of ESI Central Rules - 1950).

The scheme also provides for a comprehensive medical cover to the retired and disabled insured persons and their spouses on pre-payment of a nominal contribution of Rs.120/- per annum, per couple, provided that the insured person was in continuous insurable employment for at least 5 years before retirement. The scheme, thus, offers total medical cover to the retired and disabled employees without any upper ceiling on expenditure at a very low premium when compared with medical cover schemes introduced by some other insurance agencies in the business of medical insurance.

Sickness Benefits (Section 49 of the ESI Act)

Sickness Benefit is paid in cash to the insured persons to compensate their loss of wages in the event of sickness certified by an authorized medical officer. It is admissible for 91 days in a year and the cash benefit is equal to 70% of the wages.

Eligibility Conditions for Sickness Benefit & Extended Sickness Benefit

Not less than 78 days contribution in the relevant contribution period for sickness benefit and not less than 156 days contribution in 4 relevant contribution periods and eligibility for sickness benefit at least in one of these contribution periods and two years of service are essential eligibility for conditions Extended Sickness Benefit.

Enhanced-Sickness-Benefits

It is admissible for sterilization operation. Duration is 14 days in case of Tubectomy Operation (extendable by another 7 days on medical advice) and 7 days in case of Vasectomy. Eligibility conditions are same as for sickness benefit mentioned above. The rate approximately equals full wages.

Maternity-Benefits (Section 50 of the ESI Act)

Maternity Benefit is admissible to insured women in the event of confinement or miscarriage etc. for 12 weeks at the rate of 100 percent of the wages.

Eligibility

Maternity Benefit is admissible for :

  • 84 days in case of confinement
  • 42 days in case of Miscarriage

This benefit is also admissible for sickness arising out of pregnancy / miscarriage or confinement for a maximum period of one month, additionally. The rate of this benefit is equal to the wages.Maternity benefit continues to be payable even in the death of an insured woman during her delivery or immediately following the date of her delivery leaving behind a child , for the whole of that period and in case the child also dies, during the said period, until the death of the child.

Contributory-Conditions

An insured woman is eligible for maternity benefit for confinement / miscarriage, if contributions in respect of her have been paid or payable for not less than 70 days in the two immediately preceding consecutive contribution periods with reference to the Benefit Period in which the confinement took place.

Disablement-Benefits (Section 51 of the ESI Act)

Temporary Disablement benefit is paid in cash till the incapacity due to employment injury lasts at the rate of 90% of the wages. In case of permanent physical disablement due to employment injury or occupational disease, disablement benefit is paid for life at a rate proportionate to loss of earning capacity as determined by the medical board.

Temporary Disablement Benefits

TDB is payable to an Employee who suffers employment injury (EI) or Occupational Disease and is certified to be temporarily incapable to work. "Employment Injury" has been defined under Section 2(8) of the Act, as a personal injury to an employee caused by accident or occupational disease arising out of and in the course of his 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 : Contributory-Conditions

Accident Report in form 12, Form 8,9,10, 11 and ESIC Med.13.

Eligibility For TDB :

The benefit is not subject to any contributory conditions. An IP is eligible from the day he joins the insurable employment.

Duration of TDB :

There is no prescribed limit for the duration of TDB. This is payable as long as temporary disablement lasts and significant improvement by treatment is possible. If a Temporary Disablement spell lasts for less than 3 days (excluding day of accident), IP will be paid sickness benefit, if otherwise eligible. A special point for IMOs/IMPs is that some IPs may resist taking a Final Certificate especially before 3 days for fear of loss of TDB.

Dependents-Benefits (Section 52 of the ESI Act)

Dependants benefit is paid as family pension to the dependants of a deceased insured person in the event of death due to employment injury or occupational disease

  • A widow can receive this benefit on a monthly basis for life or till her re-marriage.
  • A son can receive this benefit till twenty five years of age and daughter till her marriage.
  • Other dependants like parents including a widowed mother etc. can also receive this benefit under certain conditions.
  • The first installment is payable within a maximum of three months following the death of an insured person and therefore, on a regular monthly basis.

The dependants benefit is payable to the dependants as per Section 52 of the Act read with provision of 6(A) of Section 2 in cases where an IP dies as result of Employment Injury (EI). The age of dependants, has to be determined either by production of Documentary evidence as specified in Regulation 80(2) or Age certified by Medical Officer In charge of Government Hospital or Dispensary.

Notes:

  • Section 60 of the ESI Act provides that ESI benefits are not assignable or attachable.
  • Section 65 of the ESI Act specifies that where a person is entitled to more than one benefit. He/she shall be entitled to choose which benefit he/she shall receive.
  • Section 71 of the ESI Act states that a benefit is payable up to and including the day of death.

Other-Benefits

  • Funeral Expenses
    Funeral expenses on death of an I.P subject to a maximum of Rs. 10000 payable at the Branch Office
  • Rehabilitation Allowance
    Rehabilitation in case of disabled insured persons under 45 years of age with 40 percent or more disablement.
  • Free Supply
    Free Supply of physical aids and appliances such as crutches, wheelchairs, dentures, spectacles and other such physical aids.
  • Preventive Health care
    Preventive health care services such as immunization, family welfare services, HIV/AIDS detection, treatment etc.
  • Confinement Expenses
    Confinement Allowance @ Rs. 5000/- is paid to an insured woman or in respect of the wife of an insured person in case she does not avail medical facilities of the scheme for child delivery.
  • Rajiv Gandhi Shramik Kalyan Yojana
    Unemployment Allowance named as Rajiv Gandhi Shramik Kalyan Yojana, is payable to those workers facing involuntary unemployment due to closure of factory/establishment; retrenchment or permanent invalidity arising out of non-employment injury. The daily rate of unemployment Allowance is at 50% of the daily wages. This allowance is payable for a maximum period of twelve months either in one spell or in different spells of not less than one month's duration.
  • Old Age Medical Care
    Old age Medical care for self and spouse at a nominal contribution of Rs. 120/- per annum.
  • Incentive to employers in the Private Sector for providing regular employment to the persons with disability:
    • Minimum wage limit for Physically Disabled Persons for availing ESIC Benefits is 25,000/-.
    • Employerss' contribution is paid by the Central Government for 3 years.

Benefits & Contributory Conditions:

An interesting feature of the ESI Scheme is that the contributions are related to the paying capacity as a fixed percentage of the workers’ wages, whereas, they are provided social security benefits according to individual needs without distinction.
Cash Benefits are disbursed by the Corporation through its Branch Offices (BOs) / Pay Offices (POs), subject to certain contributory conditions.

ESI Scheme-a total social security for workmen:
1. Medical Care Primary, Secondary and Tertiary medical care with no cap on individual expenditure.
2. Sickness Benefit 91 days
3. Extended Sickness Benefits 730 days(upto 2 years) for specified 34 diseases.
4. Maternity Benefit 84 days +1 month (due to complications arising out opregnancy, confinement, premature birth of child etc.)
5. Permanent Disablement Benefit/Temporary Disablement Benefit Based on loss of earing capacity/as long as the disability lasts.
6. Dependants Benefit On the death of IP to the wife till she is alive/remarried and to family members as per conditions w.r.t. age/marriage.
7. Rajiv Gandhi Shramik Kalyan Yojna (Unemployment Allowance) 50% of daily average wages upto 12 month unemployment on account of closure of factories, retrenchment or permanent invalidity of not less than 40% arising out of non employment injury.
8. Incentive Scheme to employers for employing persons with disabilities. The employer's share of contribution is paid by government for 3 years for providing employment to persons with disabilities drawing monthly wages upto Rs. 25,000/-.
*9. Medical Care to Retired IPs Medical facility available within ESIC on payment of Rs.120/- per annum.