All policies/supplements are subject to local laws of India.
These policies/supplements are subject to change without prior notification
ESIC Benefits and Claim Procedure
1) Medical Benefits: The Scheme provides full range of medical care to Insured person and family, through a network of ESI Dispensaries & Panel clinics, diagnostic centres and ESI Hospitals etc. Super speciality facilities are provided to the beneficiaries through recognised advanced medical institutions impanelled for the purpose on referral basis. The Corporation has set up a revolving fund in most of the States to ensure smooth flow of funds for super-speciality treatment of ESI beneficiaries.
All Insured Persons and members of their family are entitled to free, full and comprehensive medical care under the Scheme. The package covers all aspects of health care from primary to super speciality facility
Claim Procedure: Every claim for a benefit payable under the Act is to be made in writing to the appropriate Branch Office on Form appropriate for the purpose of the benefit for which the claim is made.
2) Sickness Benefit: Sickness Benefit represents periodical cash payments made to an IP during the period of certified sickness occurring in a benefit period when IP requires medical treatment and attendance with abstention from work on medical grounds.
The maximum duration of Sickness Benefit is 91 days in two consecutive benefit periods. There is a waiting period of 2 days which is waived if the insured person is certified sick within 15 days of the spell for which sickness benefit was last paid. The sickness benefit rate is roughly equivalent to 50% of the average daily wages of the insured person.
Claim Procedure: An insured person intending to claim sickness benefit has to submit a claim for benefit in one of the Forms 12, 13 or 14 appropriate to the circumstances of the case to the concerned branch office. A claim for sickness benefit can be made only on the basis of medical certificates issued by the doctors appointed for this purpose under the Scheme.
However, the Corporation may accept any other evidence of sickness or temporary disablement if in its opinion the circumstances of any particular case so justify.
An insured person may, if he so desires, deposit the certificates in the box, if any, provided for the purpose at the dispensary or at the Branch Office to which he is attached, he may send them by post or may present them in the Local Office in person, or may deliver the same at the Branch Office through his agent or messenger.
3) Maternity Benefit: Maternity benefit consists of periodical cash payments in case of confinement or miscarriage or sickness arising out of pregnancy, confinement, premature birth of child or miscarriage, to an insured woman as certified by a duly appointed medical officer or mid wife.
Claim Procedure:
i. Claim before confinement - An insured woman who is pregnant may submit to her Branch Office a notice of pregnancy (Form 19) together with a certificate of pregnancy (Form 20) issued not earlier than 7 days before the date of notice (Regulation 87).
ii. Claim after miscarriage or confinement - - An insured woman claiming maternity benefit for miscarriage or confinement must submit to her Branch Office a claim for maternity benefit in Form 22 accompanied by a certificate of miscarriage or confinement in Form 23 within 30 days of the date of confinement or miscarriage. However, Regional Directors have been delegated power to relax the time limit of 30 days as provided in Regulation 89 up to a period of six months.
Though there is no time limit in the regulations to obtain a certificate of confinement in cases where maternity benefit is claimed after confinement, it is in the interest of the insured woman to obtain certificate of confinement as early after her confinement as possible because delay in approaching the Insurance Medical Officer may result in disappearance of symptoms of recent child-birth.
iii. Claim after death of insured woman - The person nominated by the deceased insured woman on Form 1 or if there is no such nominee, the legal representative, shall submit a claim for maternity benefit to branch office, in Form 24-A together with a death certificate in Form 24-B .within 30 days of the death of the insured woman during her confinement or thereafter.
iv. Claim for sickness due to pregnancy - Every insured woman claiming maternity benefit in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage, shall submit to her Branch Office a claim for benefit in one of the Forms 12A, 13A, 14A appropriate to the circumstances of the case together with the appropriate medical certificate, in Form 8, 9, 10 or 11 as the case may be.
v. When claim becomes due - A claim for maternity benefit shall of the Act, become due –
a. In case of confinement :
· the date of issue of certificate of expected confinement; or
· a date 6 weeks preceding the date of expected confinement so certified, whichever is later, or
· If no certificate of expected confinement is issued, on the date of confinement.
b. In case of miscarriage: In case of miscarriage and in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage, on date of issue of the medical certificate of such miscarriage or sickness, as the case may be.
vi. When claim becomes payable - The first payment of maternity benefit will be made not later than 14 days after the claim together with the relevant medical or other certificates and any other documentary' evidence which may be called for, has been furnished complete in all particulars, to the Branch Office. Second and subsequent payments of maternity benefit shall be made along with the first payment or within the calendar month following the month to the whole or part of which they relate, whichever is later.
4) Disablement Benefit: Disablement benefit is admissible for disablement caused by employment Occupational Diseases injury/OD. At the first instance, temporary disablement benefit is payable as long as the temporary disability lasts. If the employment injury results in partial or total/permanent disability, permanent disablement benefit is payable till the death of the insured person.
No contributory conditions are prescribed for this benefit. While the rate of temporary disablement benefit is 70% or a little more of the wages and that of permanent disablement benefit is proportionate to the loss of earning capacity caused by the injury.
Claim Procedure:
i) Temporary disablement Benefit (TDB) :
1. Notice of the injury should be given either orally or in writing personally or through an agent, to the employer/foreman/duty supervisor or particulars of the injury should be entered in the Accident Book kept in the factory, personally or through an agent.
2. A medical certificate of incapacity should be obtained from the Insurance Medical Officer/Insurance Medical Practitioner.
3. The claim Form printed on the back of the medical certificate should be filled in and submitted promptly to Branch Office along with the medical certificate.
4. A final certificate should be obtained from the Insurance medical Officer/Insurance medical Practitioner and submitted to the Local Office before resumption of duty.
ii) Permanent Disablement Benefit (PDB) :
1. If suffering from permanent effects of employment injury, the insured person should make an application to the Regional Office of the Corporation for reference of his case to the Medical Board (reference to the Medical Board is made otherwise also by the Regional Office).
2. Where loss of earning capacity has been assessed and communicated to the insured person, he should submit a claim in the appropriate Form to the Branch Office.
3. After the claim has been admitted, the beneficiary should submit at six-monthly intervals (with the claim for June and December every year) a life certificate in appropriate Form duly attested by the prescribed authority.
5) Dependant Benefit: Dependants' benefit consists of periodical payments to dependants of an insured person who dies as a result of an employment injury sustained as an employee under the ESI Act. There are no contributory conditions for qualifying to this benefit. Thus, if a person dies of employment injury even on the first day of his employment, his dependants are entitled to the benefit.
Claim Procedure: A claim for dependants’ benefit may be submitted to the concerned Branch Office by each dependant or jointly by all or by some of the dependants in Form18. Also the claim may be made by the legal representative of a beneficiary or in case of a minor, by his guardian. It must be attested by any of the competent authorities mentioned on the Form and be supported by documents for evidence.
List of documents to be enclosed as evidence for claiming dependants’ benefit:
· Evidence that death of the insured person has occurred due to an employment injury in shape of a death certificate issued by an Insurance Medical Officer/Insurance Medical Practitioner on Form 17 or ESIC-Med-12, or a certificate of death issued by a hospital or dispensary doctor, or any other medical practitioner who may have been on the spot at the time of death or visited the deceased after death. Municipal death certificate supported by evidence that the insured person died due to employment injury will also be sufficient for the purpose. If the original death certificate is required by the dependants for any legitimate purpose, it may be returned on written request after retaining a copy thereof duly attested by the Manager. This may be done only after the claim has been decided.
· Evidence that the claimant/claimants is/are dependant(s). This evidence may be in the Form of a declaration by the claimant, supported by counter-signatures of a Magistrate, a Workmen's Compensation Commissioner or Sarpanch of gram panchayat, or a Municipal Commissioner (Form 18).
· Evidence of the age of claimant. Proof of the age may be given by means of any of the following documents which should normally be insisted upon:
Certified extract from an official record of births showing the date and place of birth and father's name.
Original horoscope prepared soon after birth
Certified extract from baptismal register.
Certified extract from school records showing the date of birth and father's name.
Each dependant whose claim for DB is admitted may submit subsequent claims for each Calendar month in Form 18-A. Every half year while claiming the benefit for the month of June and December, a declaration in Form 27 duly attested by the competent authority is to be submitted
6) Funeral Expenses: Funeral expenses are in the nature of a lump sum payment. The amount has been enhanced up to Rs. 10,000/- w.e.f. 1-04-2011 from earlier Rs 5000 /-. The payment is made at branch office to defray the expenditure on the funeral of deceased insured person. The amount is paid either to the eldest surviving member of the family or, in his absence, to the person who actually incurs the expenditure on the funeral.
Claim Procedure: Regulation 95-E requires the claim for funeral expenses to be submitted by the claimant entitled to receive the same under the Act, to the appropriate Branch Office by post or otherwise in Form 25-A renumbered as Form 22 w.e.f. 1.1.05 ,supported by documents proving the death of the insured person and, in addition –
a. that the person claiming the funeral expenses is the eldest surviving member of the family of deceased insured person and incurred the expenditure necessary for the funeral of the deceased, or
b. in case the claimant is other than the eldest surviving member of the family –
(i) that the deceased insured person did not have a family or that he was not living with his family at the time of his death, and
(ii) that the claimant actually incurred the expenses claimed on the funeral of the insured person
Provided that where the appropriate office is satisfied about the bona fides of the applicant or about the truth of the facts relating to any of the matters mentioned above, one or more of the documents may be dispensed with.
For the purpose of items (a) and (b), a declaration of the claimant duly
Countersigned by any of the under-mentioned authorities is considered to be sufficient proof and may be accepted: -
(I) An officer of the revenue, judicial or magisterial department of the government;
(II) A Municipal Commissioner.
(III) A Workmen’s Compensation Commissioner.
(IV) The head of gram panchayat under the official seal of the panchayat or MLA/MP.
(V) Gazetted Officer of Central /State Govt.
(VI) A Member of the Local Committee /Regional Board.
(VII) Any other authority considered as appropriate by BM concerned.
Any other evidence or declaration acceptable to the appropriate office in the circumstances of a particular case can also be accepted as proof for purpose of clauses (a) and (b).
7) Old age–disabled Medicare: The Medical Benefit has further been extended to the insured persons who go out of employment on account of attaining the age of superannuation (Old Age) or on account of permanent disability (arising out of employment injury). The Medical care is provided in ESI institutions only, to such insured persons and their spouse on payment of a lump sum amount for one year at the rate of 10/- per month.
8) Rehabilitation:
. A. Vocational Rehabilitation allowance: This Scheme has been designed to provide financial assistance to the insured persons who are referred to vocational rehabilitation Centre for training. The vocational rehabilitation scheme framed under the provisions of section 19 of the ESI Act, 1948 has been made applicable for the present to those insured persons in whose case loss of earning capacity resulting from an employment injury has been assessed as not less than 40% as per percentages given in Schedule II to the Act for scheduled as well as non-scheduled injuries resulting from an employment injury i.e. accident arising out of and during the course of employment or from an occupational disease as defined in ESI Act.
Eligibility: Only those insured person who satisfy following conditions are entitled to avail benefits of the vocational rehabilitation scheme:
i) whose permanent loss of earning capacity has been determined as 40% or more
ii) who is in receipt of permanent disablement benefit under the ESI Act, 1948
iii) who is not in any gainful employment, and
iv) who is not more than 45 years of age on the date of his application
. B. Physical Rehabilitation allowance: Disabled insured persons who remain admitted in an artificial limb Centre for fixation or repair or replacement of the artificial limb are entitled to rehabilitation allowance for each day on which they remain admitted at Artificial limb Centre at double the standard sickness benefit rate. This is not subject to any contributory condition