The Employees’ State Insurance Scheme (ESIS) is a combined measure of Social Insurance placed in the Employees’ State Insurance Act and it is designated to achieve the undertaking of shielding ’employees’ according to the Employees’ State Insurance Act, 1948 against medical incidences of ailments, maternity, impairment, and death owing to employment injury and to deliver medical care to insured employees and their families. The ESIS is applicable to factories and other establishments such as Road Transport, Hotels, Restaurants, Cinemas, Newspaper, Shops, and Educational or Medical Institutions wherein ten or more workers are employed. It must be noted that in certain states the threshold limit for coverage of establishments remains 20. Workforces of the above-mentioned groups of factories and institutions, with a monthly salary of up to Rs.15000 are eligible for social security cover under the ESI Act. There has been an enhancement of ESI Corporation in the wage ceiling for workforce coverage under the ESI Act from Rs.15000 to Rs.21000.
ESI Corporation has also expanded the benefits of the ESI Scheme and has included the workers positioned on the construction sites situated in the implemented regions under ESI Scheme with effect from August 1st, 2015.
The ESI Scheme is funded by aids from employers and workforces. Employers pay the contribution at the rate of 4.75 percent of the employee’s salary. The employee contributes at the rate of 1.75 percent of his or her salary. The government exempts the workers from paying their share of contribution if their daily earning is less than Rs. 137.
BENEFITS
The section 46 of the Act visualizes following six social security benefits:
(a) Medical Benefit: The beneficiary along with his or her family enjoys complete medical care from the first day of insurable employment. This medical benefit is devoid of any upper ceiling on treatment expense of an insured employee or the associated family member. There is also a provision of medical care for the retired individual and the permanently disabled insured individual and his or her spouse on the payment of a token yearly premium of Rs.120.
1. System of Treatment: Usually, under ESIS, there is a provision of allopathic system of medicine. Nevertheless, in specific cases, when there is a huge demand for Indian system of medicine and Homoeopathy (ISM & H) other than Allopathy, and where the State Government has acknowledged the credentials in such system, treatment services could include the ISM & H as well. Generally, the popular ISM &H systems of treatment include Ayurveda, Unani, Siddha, Yoga therapy, and Homeopathy.
The essential certificates for the purpose of Cash Benefits with regards to individuals treated by ISM &H must be granted by IMO /IMP after identifying qualifications in these systems and accordingly employed by the State Government. The issue of certificates under ISM &H is conceivable only where dispensaries in systems other than allopathic medicine are functioning independently with IPs and their family units attached to them and not functioning merely as referral units. In regions where ISM &H units are operating merely as referral centres, certificates would have to be allotted by the Allopathic medical system which is connected with the IP.
2. Scale of Medical Benefit: Under Section 57 of the Act, the scale of the medical benefit will be delivered to the IPs and their family members as prescribed by the State Government in consultation with the Corporation under Section 58 (1 & 3) of Act under State Medical Benefit Rules. The IP or his or her family member is devoid of any medical service entitlement beyond the ones prescribed by the government. The recipients are eligible for equitable medicinal, surgical and obstetric facilities.
To Insured Persons: The insured persons are eligible to obtain treatment in ESI Dispensary/Hospital/Diagnostic Centre and identified institutions such as the ones listed below
- Outpatient therapy.
- Domiciliary treatment through physicians’ home visits.
- Specialists meeting.
- In-patient treatment (Hospitalisation).
- No charges on drugs, dressings, artificial limbs, aids and appliances.
- Imaging and laboratory services.
- Combined family welfare, vaccination and MCH Programme along with any added national health programs.
- Ambulance facility and re-imbursement of transportation expenses for medical check-up visits.
- Medical Certification and Special provisions.
Benefits for Insured Individual’s Household: The family members of a working insured individual enjoy certain government approved health care privileges as mentioned below.
- “COMPLETE” medical care. In other words, the family members of an IP would enjoy all the medical care facilities as given to an IP and this is inclusive of any hospitalisation.
- “EXPANDED” medical care. The family members will be provided all facilities as given to an IP except for hospitalisation. Certain IPs in the states of Bihar and Gujarat fall under this category of health care.
- It is the aim of the Corporation to provide medical care to the family members as per the uniform standards in all implemented regions since the contributory rates paid by both employees and the employers remain equal in all parts of the nation.
- Benefits to Retired Insured Persons: The retired insured persons are provided certain medical benefits for their past services to the nation. These facilities are also provided to insured individuals who have suffered permanent disablement. The benefits are as under.
- On a lump sum monthly payment of Rs.10 for an year in advance, the medical benefit could be supplied (under Section 56 of the Act) to:
- An insured individual along with the spouse who leaves insurable service on reaching the age of retirement after being covered for at least a five-year period, till the time for which the contribution is paid.
- An insured individual along with the spouse who stops serving in an insurable job due to a permanent disablement suffered in the course of employment is eligible for medical benefit.
4. Administration of Medical Benefit in a State: The supervision of medical benefit under the ESI Scheme is the constitutional duty of the State Government excluding the case of the Union Territory of Delhi, as the region is under the direct responsibility of ESIC to administer the same with effect from 1.4.1962. The Corporation also has to directly administer the prevailing Occupational Disease Centres at Delhi, Mumbai, Calcutta, Chennai and Nagda along with the Scheme in the industrial pocket of Uttar Pradesh i.e., Noida and Greater Noida.
5. Domiciliary treatment: An insured individual along with the family members if eligible for expense free medical attendance by IMO/IMP at his or her home on rare conditions when the patient is unable to make the necessary journey to the nearest medical centre.
Conveyance Grant for Domiciliary Visit:
* The IMOs are reimbursed for the domiciliary visits. The reimbursement quantum is decided by the State Government in consultation with the Corporation.
* There is no reimbursement for the domiciliary conveyance allowance for the IMPs. This allowance is a part of their capitation fee in a radius of 5 km distance between the IMP’s clinic and the IP’s residence.
* It is mandatory for the IMOs and IMPs to maintain a registered monthly record of domiciliary visits. The columns in this register are provided under the heading “Sickness Absenteeism and Recording”.
6. Specialist consultation: The standard of medical care under the E.S.I.S has a facility for specialist consultation to the insured individual in entire instances and to the respective family members in areas with “Expanded” and “Full” medical care. The specialist consultation could be supplied at Specialist/Diagnostic Centres, E.S.I. Hospitals or other institutes as scheduled by the Specialists or Super Specialists on full-time or part-time basis with an existence of suitable arrangements. These consultations are delivered in the subsequent specialities:- General Medicine, General Surgery, Pulmonary Medicine (Tuberculosis and Chest Diseases), Obstetrics and Gynaecology, Pathology, Paediatrics, Eye, Ear, Nose and Throat Diseases, Skin and STD, Radiology, Orthopaedics Rehabilitation Services (Physiotherapy and Occupational Therapy), Dental, Psychiatry, Critical Care Services, Cardiology, Neurology, Urology and Nephrology, Gastro-entomology, Endocrinology, Oncology, Burns and Plastic Surgery, Cardio Thoracic Surgery, Neurosurgery, Occupational Medicine, Laboratory Services, Blood Transfusion Services, Haematological Services, and Anaesthesiology.
It is not essential to depute specialists in all specialities at entire health-care facilities. Nevertheless, government directs that each diagnostic centre and emergency centre appoints specialists in at least the first thirteen specialities mentioned above. The other specialities should be appointed as per the ailment requirement of a particular region
7. In-Patient treatment: Under the E.S.I.S., insured individuals are eligible for in-patient treatment in all the areas while their family members are eligible for treatment in the areas with “Full” medical care facility.
In-patient treatment is provided at hospitals constructed by E.S.I.C or by reservation of beds in the hospitals owned by the State Government, local Fund Organisation, or private bodies or by developing extensions to such institutes. The E.S.I. Scheme is responsible for making payments for these beds on the basis of occupied bed days. The Corporation has developed a standard plan for creation of diverse sizes of hospitals and their extensions primarily with an objective to attain homogeneity and standardisation in the entire nation.
There have also been certain norms laid down by the Corporation with respect to equipment and staff for hospices of diverse bed strengths.
Drugs and Dressings: All types of drugs and dressings (including vaccines and sera) which might be regarded as essential and in general accordance with the E.S.I.C drug formulary are delivered totally free to the eligible persons. The E.S.I.C Drug Formulary, 1998 has two parts as given below-
Part I: List of medicines for emergency kit for (i) dispensary and (ii) hospital.
Part II: A medications’ list supplied by dispensaries in Service Regions or by authorized chemists or depots on medical prescriptions in panel regions.
8. Imaging Services: Imaging and investigations that include CT Scan, MRI, Echocardiography and laboratory facilities are given without any cost to insured individuals and their families members at any state level speciality hospital or other medical facility with a connection with E.S.I. Scheme.
9. Artificial Limbs & Aids: Insured individuals and their family members are supplied many times of artificial limbs, aids and appliances as a directive under the E.S.I. Scheme.
* Artificial Dentures, teeth (Only to insured individuals)
* Artificial Eye (Only to insured individual)
* Artificial limbs
* Cardiac pacemaker
* Cervical collars
* Crutches
* Hearing Aids
* Hip prosthesis, total hip
* Intra ocular lens (IOL)
* Spectacles (An insured individual can order a frame up to Rs. 100 and is eligible for the replacement of frame in 5 years duration)
* Spinal supports (such as jackets and braces)
* Walking callipers, surgical boots etc.
* Wheel Chair/tricycle
* Wigs (Provided only to female beneficiary with a replacement date of 5 years)
Any other support or applications as per the specialist’ prescription for an effective treatment.
The total expense on artificial limbs, aids and appliances would be covered from the shareable pool of medical care expenses.
10. Special Provisions:
| Aids provided to Insured Individual- Not allocated or attachable | Sec 60 |
| Bar on aids under other enactments | Sec 61 |
| No decrease of salaries during illness | Sec 72 |
| No termination/Sacking/Expulsion/ Reduction during illness | Sec 73 |
| Medical Board- Medical appeal tribunal workers’ Insurance Court | Sec 54-A |
Appeal could be lodged within three months with a provision to period extension
Members of medical appeal tribunal
- Judicial member
- Doctor of applicable speciality
- Workforce Leader
- Medical Board- Medical appeal tribunal employees’ Insurance Court
Other Provisions of ESI Act
| Punishment for deceitful statement by Insured Individual | Sec 84 |
| Founding of E.I. Court | Sec 74 |
| Submission of Return of Contribution | Sec 44 |
| Facility for Action for Non-submission | Sec 85 |
| RETURN OF CONTRIBUTION IS ESSENTIAL TO BE SUBMITTED BY THE EMPLOYER ON A SIX-MONTHLY BASIS | |
| FOR HALF YEAR ENDING 31ST MARCH | 12 MAY |
| FOR HALF YEAR ENDING 30TH SEPTEMBER | 11 NOV |
| Accountability of Transferee – Joint & Severally | Sec 93-A |
| Limited to the value of Assets | |
| Reimbursement of Aids wrongly obtained | Sec 70 |
| Recovery of Worker’s part of contribution through salary reduction and no other means- Shall associate with the duration or part of the duration with regards to which contribution is payable – AND would not exceed the amount demonstrating the Workers’ Contribution for the duration | Sec 40 |
| Power of Central Government to deliver directives | Sec 92 |
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Provision for Prosecution For non or delayed payment of contribution, there will be non-submission of returns and records | Sec 85, 85-A & 86 |
11. Reimbursement: Under Regulation 69, every employer has to provide for First-aid Medical care and transportation of accidental instances till the injured insured individual is checked by the IMO/IMP and such employer is eligible for recompense of expenditures suffered in this respect up to the maximum of scale recommended from time to time. Nevertheless, compensation is not permitted, if the employer is needed to supply such medical facility devoid of any charges under any other enactments.
The expense of delivery of such emergency handling would be repaid to the employer by the Director or AMO under ESI Scheme of the concerned State and, hence, entire prerogatives duly maintained by pertinent receipts and vouchers would be addressed to him for authentication and imbursement.
Repayment of expenditures suffered with regards to medical treatment under regulation-96 A.
Regulation-96 A reads as follows: Statements for refund of expenditures suffered with regards to medical treatment of insured individual and his family might be acknowledged in conditions and subject to such circumstances as the Corporation might by general or exceptional order postulate.
The following circumstances have been laid down under this Regulation:
Total power is conferred with the State Government concerned to compensate expenses with regards to medical treatment of insured person and the family.
The State Governments are discredited to select the authority inside their systems to sanction the particular expenses; and
Time constraint for submission of the claims for repayment is one year.
The State Government must follow certain paradigms while looking into the cases of repayment of spending on medical care:
- Whether the State has such facilities for the recommended reimbursement.
- Whether the hospital where the insured person was treated or proposed to be treated was the nearest medical institute having the essential facilities or services.
A List of Types of cases for which repayment is acceptable is given below:-
- Repayment is accepted in the instance of failure of the mobile dispensary van owing to technical deficiencies or otherwise to abide by its schedule visits, or where insured individual connected to such a medical facility sustains severe wounds or suffers from severe ailments during the time when the medical clinic is shut down.
- Insured persons and their family members were forced to take up private treatment in the course of an emergency and during the time when the ESI dispensary/Emergency Centre was off-hours.
- Medications suggested by IMO/Specialist were not available in the ESI Dispensary/Approved Chemist thus forcing the insured persons to purchase the same from the marketplace.
- Medications suggested by Specialist but not delivered by the IMO/IMP and where specialist regards such special medications as essential for the healing of the beneficiaries, since there exist no good substitute for such medications for beneficiary both as an out-patient or an in-patient.
- Special appliances suggested by Specialist like Spinal supports, Cervical Collars, Walking Callipers, and Crutches if considered an essential part of the treatment.
- Where an IMO/IMP were unable to undertake domiciliary appointment requested by an insured person thereby forcing him or her to go for private treatment. The panel system states that IMP is responsible to pay for such expense if it is commended by the Medical Service Committee after an investigation.
- Severe instances of accident or ailments admitted directly into a reputed hospital, and due to the patient’s condition (unconscious or otherwise), unable to reveal his identity as an ESI member, therefore the hospital authorities charged the employer or the patient for the hospital expenses.
- Severe instances of accident or ailments where an insured individual or the family member was admitted directly at a non-ESIS recognized hospital because the ESIS recommended hospital would have been incapable to assist in serious health conditions such as sudden heart attacks, fracture of the spine, or cerebral haemorrhage.
- Expenses faced on examination for blood transfusion.
- Mental cases that could have brought in unwanted expenses in the form of out-patient on specialised therapy like ECT.
- Severe instances of accident and ailments admitted to a recognised hospital in the case when all the allotted ESI beds were occupied.
- Repayment of transportation expenses suffered by insured individual in an area devoid of any ambulance service under the scheme due to certain reason and where the IMO or IMP sanctioned the patient’s condition as non-ambulatory.
- With regards to specialised examination, laboratory test, X-ray, and other imaging services, as suggested by the specialist, but not availed by the insured person owing to machine break down or any other cause like the nature of the examination of the Laboratory tests being beyond the scope of the available services in the recognised laboratory or hospital.
- Additionally, repayment would also be granted in certain other instances depending on the qualities of each case and the situations that called for such expenses.
Reimbursement of Transportation Expense: During an emergency, if an ambulance is not available due to any reason, then any quick alternative type of conveyance could be utilized and this expense would be reimbursed to the insured individual to the maximum degree as recommended by the Government or Transport authority (both ways).
To save any form of difficulty to the insured person and his family who need to visit any hospital or medical institution for admission, specialist consultation, or investigation, but whose condition do not require an ambulance, facility has been granted for the compensation of transportation expenses, if the referred hospital or medical institute lies in a different village or town or if the medical institute is more than 8 km away from the insured person’s home. The expense is limited to actual IInd class railway ticket cost or the cost of a single seat in any both way public conveyances whichever is feasible.
If the beneficiary is unfit to travel alone, then on the certification of an IMO or IMP, the escort also receives equal transportation expense.
The IMO and IMP must maintain an independent record of such payments in a prescribed register and send an updated quarterly statement of these disbursements to the Director or AMO by the 15th of the month following the quarter ending in March, June, September, and December. The returns received from different areas in the State may be consolidated area-wise by the Director and AMO must consolidate area-wise the various statements received from different regions of State and sent quarterly statements to the Corporation.
The transportation expenses form a part of the medical care under the E.S.I.S. and therefore shared by both Corporation and the State Government in the general ratio inside the prescribed ceiling.
(b) Sickness Benefit (SB): An insured worker is eligible for sickness benefit in the shape of cash payment at the rate of 70 percent of the existing salary during the duration of certified sickness. The maximum sickness duration is 91 days in a year. The insured worker can avail the sickness benefit by contributing for 78 days in six-month duration.
1. Extended Sickness Benefit (ESB): The sickness benefit could be extended up to a two-year period in the instance of thirty four malignant and long-term ailments at a heightened rate of 80 percent of existing salary.
2. Enhanced Sickness Benefit: Enhanced sickness benefit equivalent to total existing salary is reimbursed to the insured employee who undergoes sterilization for 7 days (male) or 14 days (female).
(c) Maternity Benefit (MB): Maternity benefit during the time of pregnancy is provided for twenty-six week duration. This benefit could be extended for another month on medical advice at the rate of total existing salary. This benefit is subject to contribution for 70 days in the preceding two contributory durations.
(d) Disablement Benefit
1. Temporary disablement benefit (TDB): If an employee suffers from temporary disablement in the course of the service, then he or she is eligible for temporary disablement benefit. This benefit is applicable from the first day of entering insurable employment and is free of any constraint of having paid an earlier contribution. The disabled employee would be paid this benefit at the rate of 90 percent of the existing salary for the total period of proclaimed disability.
2. Permanent disablement benefit (PDB): If the insured employee suffers a permanent disability then he or she is compensated in the form of monthly payments of 90 percent of the existing salary. The duration of this benefit would depend on the degree of loss of earning capability as certified by a medical board.
(e) Dependants Benefit (DB): In the instance of a death of an insured employee in the period of his or her service and occurring due to occupational hazard or employment injury, the dependent would be compensated in the form of monthly payments. These payments would be paid at the rate of 90 percent of the last approved salary of the deceased.
(f) Other Benefits:
Funeral Expenses: In the instance of an untimely death of the insured employee, the dependent is provided with an amount of Rs.15,000 to overcome the expenses related to funeral rites. This facility is provided to all the employees from the first day of entering into insurable service.
Confinement Expenses: A relevant confinement expense is given to an insured woman or an I.P. in the capacity of his wife in the instance of a confinement at a place devoid of any essential medical facility under the ESI Scheme.
Additionally, there is also a provision under the scheme for certain other requirement based benefits to insured workers.
Vocational Rehabilitation: This facility is given to permanently disable insured individual to undergo VR Training at VRS.
Physical Rehabilitation: This facility is provided in the instance of physical impairment owing to employment injury.
Old Age Medical Care: The ESIS scheme also takes care of its aged employees. An insured employee continues to enjoy the benefits of ESIS even after retirement either by attaining the specific age of retirement or via schemes like VRS and ERS, or termination of service owing to permanent disability on an annual payment of Rs. 120.
Rajiv Gandhi Shramik Kalyan Yojana: This scheme of unemployment allowance was introduced on April 1st, 2005. If an insured individual with three or more years of insured service becomes unemployed owing to factory closure, retrenchment, permanent invalidity, or any other cause if eligible for below mentioned facilities.
- Unemployment allowance equivalent to 50 percent of the last salary for a maximum of two years duration.
- Medical care for both insured individual and the family members from ESI Hospitals/Dispensaries during the time when the insured individual is compensated with unemployment allowance.
- Vocational training provided for upgrading skills: All the expenditure involving the fee and travelling allowance would be taken care by the ESIC.
Atal Beemit Vyakti Kalyan Yojana: This scheme is a welfare measure for workers protected under Section 2(9) of ESI Act, 1948. Here the workers receive a cash compensation up to 90 days, only once in a lifetime. This claim could be collected after three months either in one or more spells for being rendered unemployed on the condition that the employee has completed two years of insurable service and has contributed for a minimum of seventy eight days in each of the four succeeding contribution durations instantaneously preceding to the claim of the fund. The payment would not surpass twenty five percent of the daily average earning.
This scheme was introduced on July 1st, 2018 and implemented on pilot basis for an initial duration of two years.
Incentive to employers in the Private Sector for providing regular employment to the persons with disability:
- Minimum salary limit for Physically Disabled Persons for receiving ESIC Benefits is Rs. 25,000.
- The Central Government pays for the part of employers’ contribution for three-year duration.
Benefits & Contributory Conditions:
ESIS has an interesting feature wherein the contributions are associated with the paying capacity as a fixed percentage of the workers’ earnings, while they are supplied social security assistances as per their individualistic requirements and with an absence of any distinction.
Cash benefits are expended by the Corporation via its Branch Offices (BOs) and Pay Offices (POs). These benefits are subject to specific contributory circumstances.
