It is a comprehensive Social Security Scheme designed to accomplish the task of socially protecting the 'employees' in the organized sector against the events of sickness, maternity, disablement and death due to employment injury and to provide medical care to the insured employees and their families.
2. How does the scheme help the employees?
The scheme provides full medical care to the employee registered under the scheme during the period of his incapacity for restoration of his health and working capacity. It provides financial assistance to compensate the loss of his/ her wages during the period of his abstention from work due to sickness, maternity and employment injury. The scheme provides medical care to his/her family members also.
3. Who administers the ESI Scheme?
The ESI Scheme is administered by a corporate body called the 'Employees' State Insurance Corporation' (ESIC), which has members representing Employers, Employees, the Central Government, State Government, Medical Profession and the Parliament. The Director General is the Chief Executive Officer of the Corporation and is also an ex-officio member of the Corporation.
4. What are the other bodies of the ESI Corporation?
At the National level, the Standing Committee (a representative body of the Corporation) for administering the affairs of the Corporation, and the Medical Benefit Council, a specialized body that advises the Corporation on administration of Medical Benefit, are functioning.
At the Regional Level, the Regional Boards and Local Committees have been constituted to review the functioning of the scheme and make suggestions for its improvement.
5. How the Scheme is funded?
The ESI scheme is a self-financing scheme. The ESI funds are primarily built out of contribution from employers and employees payable monthly at a fixed percentage of wages paid. The State Governments also contribute1/8th share of the cost of Medical Benefit
6. What are the establishments that attract coverage under ESI?
According to the notification issued by the appropriate Government (Central/State) concerned under Section 1(5) of the Act, the following establishments employing 10 or more persons attracts ESI coverage.
(i) Shops
(ii) Hotels or restaurants not having any manufacturing activity, but only engaged in 'sales'. (iii) Cinemas including preview theatres;
(iv) Road Motor Transport Establishments;
(v) Newspaper establishments (that is not covered as factory under Sec.2(12));
In some states coverage is for 20 or more employees for wages. A few State Governments have not extended scheme to Medical & Educational Institutions.
7. If the wages of an employee exceeds Rs.21,000 in a month ,can he be treated as not covered and deduction of contribution from his wages is stopped?
If the wages of an employee (excluding remuneration for overtime work) exceeds the wage limit prescribed by the Central Government after start of contribution period, he continues to be an employee till the end of that contribution period and hence contribution is to be deducted and paid on the total wages earned by him.
8. What is Registration of an Insured Person?
Registration is the process of obtaining and recording information about the entry of an employee into 'insurable employment', for the purpose of his identification under the Act.
9. Why Registration of an Insured Person is necessary?
Registration of employee is the process of identification to provide the benefits under the Act which are related to the contributions paid by the employer on behalf of each of the insured persons.
10. How are the employees registered under the Scheme?
At the time of joining the insurable employment, an employee is required to provide his and his family details to the employer along with a family photo so that the employer can register the employee online. This exercise of registering an employee has to be a onetime exercise in life time of an employee. The insurance number generated on the first occasion of registration is to be used throughout his life time irrespective of change of employment including change of place.
11. What is an identity card?
On registration under the scheme the employer can take a print out of the temporary identity certificate, affix the photo provided by the employee and authenticate it for use which is valid for a period of 3 months. As soon as possible but not later than a month, the insured person along with his entire family should get themselves enrolled to obtain a “Pehchan Card”. This identity card serves as a means of identification both for availing medical benefit at dispensary/ hospital and availing cash benefits at the ESI branch Office. Any changes in his residence/ dispensary/ employment can be carried out by the employer in the Portal as and when arises.
12. What is Medical Benefit?
Medical benefit means the medical attendance and treatment to the insured persons covered under the Act and their families as and when needed. This is the only benefit provided in kind through the State Governments (except in Delhi), and uniform to all as per their requirement without linking it to their wages and contributions.
Full range of Medical, surgical & obstetric treatment consisting of out-door treatment, in-patient treatment, supply of all drugs and dressings, pathological and radiological investigations, prenatal and post-natal care, super specialty consultation & treatment, ambulance services, provision of artificial appliances etc.
14. How long is Medical benefit available?
The insured person and his family are entitled to the Medical Benefit from the very first day of his/her joining the insurable employment. A person who is covered under the scheme for the first time is eligible for medical care for self and family for three months. If he/she continues in insurable employment for three months or more, the benefit is admissible till the beginning of the corresponding benefit period. If contributions were paid/ payable for not less than 78 days in the said contribution period, medical benefit is admissible till the end of the corresponding benefit period. If the insured person is in ESI coverage for at least 2 years, and contributed for not less than 156 days, and is suffering from any of the 34 specified long term diseases, the medical benefit is admissible till the incapacity lasts or for a period of 3 years for self and family.
15. If the insured person's family is residing in another place in the same State or another State, how the family can avail the medical benefit?
If the family is residing in any other place either in the same State or different State, based on the declaration of the insured person and certified by the employer, the family is provided with a 'family identity card' for receiving medical benefit from ESI Dispensary in the area in which it is residing.
After IT rollout, the 'Family' is also issued a separate by producing Pehchan card, the family can avail the medical benefit from any ESI Dispensary/ Hospital either at their place of residence or in any other part of the country.
16. How to get medical benefit when an insured person is leaving for another station for a temporary period?
Through “Pehchan Card” the employee would get medical benefit across the country in any of the ESIC/ESIS dispensaries subject to entitlement.
17. How long is it paid and at what rate?
The rate of dependants' benefit is 90% of standard benefit rate of the wages of the deceased insured person. It is distributed among the dependants as follows: 1) Widow: Till death or remarriage at 3/5th of the full rate. 2) Widowed mother till death @2/5th of the full rate. 3) Sons @2/5th of the full rate each till he attains the age of twenty –five years. 4) Unmarried daughters @2/5th of the full rate till they get married. 5) If the son or daughter is infirm and wholly dependent on the earnings of the insured person at the time of his death, they continue to receive the benefit even after attaining the age of 25 years/ marriage as the case may be. If the total dependants' benefit for all the dependants worked out as above exceeds at any time, the full rate, the share of each of the dependants shall be proportionately reduced, so that the total amount payable to them does not exceed the amount at full rate.
18. Whether theTDB/PDB/DB is also admissible in the case of a casual or temporary employee if he meets with an employment injury on the very first day or on any day before he completes his first contribution period?
No qualifying conditions or contributory conditions are attached for payment of temporary disablement benefit, permanent disablement benefit or Dependants benefit. Even if he meets with an employment injury on the very first day of his joining the insurable employment, the benefit is admissible.
19. What is the benefit admissible to the family members?
(i) Family members are also entitled to full medical care as and when needed
(ii) The family members are also entitled to artificial limbs, artificial appliances etc. as a part of medical treatment.
(iii) The medical benefit is also admissible to the family during the period the insured person is in receipt of unemployment allowance. In case he dies during the period, his family continues to receive the medical benefit till the end of those twelve months.
(iv) Reimbursement of expenditure incurred on the funeral of the deceased employee.
(v) In case of the death of the insured employee due to employment injury, the widow, widowed mother
and children are entitled to Dependants' benefit.
(vi) Any benefit due to the insured employee at the time of death is paid to the nominee.
20. What is the benefit admissible after retirement of an employee?
An insured person who leaves the insurable employment on attainment of the age of superannuation or retires under a voluntary Retirement Scheme or takes premature retirement, after being an insured person for not less than 5 years, shall be eligible to receive medical benefit for himself and his spouse subject to production of proof thereof, and payment of a nominal contribution of rupees one hundred and twenty for one year. In case the insured person expires, his spouse is entitled to the medical benefit for the remaining period for which the contribution was made, and she can continue to receive the medical benefit on payment of the contribution @ 120/-
p.a. for further period.
This medical benefit is also admissible to an insured person who ceases to be in employment on account of permanent disablement caused due to employment injury for himself and his spouse on payment of similar contribution till the date on which he would have vacated the employment on attaining the age of superannuation, had not sustained such permanent disablement.
21. What are the contribution periods and benefit periods?
The financial year from April to March has been divided in to two six monthly contribution periods
i.e. 1st April to 30th September and 1st October to 31st March of next year. The relevant benefit period corresponding to each contribution period commences three months after the end of that contribution period i.e. Jan to June and July to December (The calendar year from January to December has been divided in to two six monthly benefits periods).
22. What is the Present Rate of Contribution?
Employee’s contribution: 0.75 % of the monthly gross salary & Employer’s contribution: 3.25 % of the monthly gross salary.
23. What is‘SicknessBenefit'?
If an insured person requires medical treatment and attendance and needs abstention from work on medical grounds, Sickness benefit is paid for the period of abstention duly certified by the Authorized Medical Officer, for a period not exceeding 91 days in two consecutive benefit periods (say one year) @ 70% of standard benefit rate, subject to payment of contribution for not less than 78 days in the corresponding contribution periods.
24. What is maternity benefit?
Maternity benefit is periodical payments to an insured woman for specified period of abstention from work, due to confinement, miscarriage or sickness out of pregnancy, pre-mature birth of child or miscarriage or confinement. The rate of maternity benefit shall be equal to the standard benefit rate.
25. What is 'miscarriage' and how long is the benefit admissible?
'Miscarriage' means the expulsion of the contents of a pregnant uterus at any time prior to or during the 26th week of pregnancy, but does not include a miscarriage, the cause of which is punishable under the Indian penal code. Maternity benefit is payable for miscarriage for a period of 6 weeks (42 days) from the date following the date of miscarriage subject to fulfilment of the contributory condition prescribed.
26. What is sick nessarising out of pregnancy etc? How long the Maternity benefit is admissible for it?
If the insured woman needs medical treatment and attendance and abstention from work due to sickness arising out of pregnancy, miscarriage, premature child birth or confinement, duly certified by an authorized Medical Officer, Maternity Benefit at is payable for a period one month.
27. What are funeral expenses? Who is to be paid?
A lump sum payment not exceeding Rs.15,000/- towards expenditure on the funeral of a deceased insured person, is paid either to the eldest surviving member of the family or if he has no family or not residing with his family at the time of death, to the person who actually performs the funeral of the deceased insured person.
28. How to claim ESIC Funeral Expenses?
- Family members are also entitled to full medical care as and when needed
- The family members are also entitled to artificial limbs, artificial appliances etc. as a part of medical treatment.
- The medical benefit is also admissible to the family during the period the insured person is in receipt of unemployment allowance. In case he dies during the period, his family continues to receive the medical benefit till the end of those twelve months.
- Reimbursement of expenditure incurred on the funeral of the deceased employee.
- In case of the death of the insured employee due to employment injury, the widow,widowed mother and children are entitled to Dependants' benefit.
- Any benefit due to the insured employee at the time of death is paid to the nominee.
29. How to claim ESIC Death claim?
(i) Family members are also entitled to full medical care as and when needed
(ii) The family members are also entitled to artificial limbs, artificial appliances etc. as a part of medical treatment.
(iii) The medical benefit is also admissible to the family during the period the insured person is in receipt of unemployment allowance. In case he dies during the period, his family continues to receive the medical benefit till the end of those twelve months.
(iv) Reimbursement of expenditure incurred on the funeral of the deceased employee.(v) In case of the death of the insured employee due to employment injury, the widow, widowed mother
and children are entitled to Dependants' benefit.
(vi) Any benefit due to the insured employee at the time of death is paid to the nominee.
| To claim ESIC funeral expenditures, the deceased member's relatives must submit ESIC funeral expenses claim form 22 along with the deceased member's ESIC Pehchan card to an ESIC branch office within 6 months of the conclusion of the final ceremonies. There are a slew of other benefits that ESIC provides to its members. |
| Form 22: https://drive.google.com/file/d/1vr7BGa-rATkYwQmMDL0VJBlNj7I6YsPt/view?usp=drive_link |
| Form 15 or pension claim form Form 95-D for funeral expenses Accident report Witness report Attendance report of deceased employee and witness employees Hospital bill if any Post mortem report Marriage certificate of widow |
Please fill the details in the below link for the TIC Card Format Updation
https://docs.google.com/spreadsheets/d/12wvYImK0AskJ9a2NXMcfhiHd_p_PLc- n/edit?usp=drive_link&ouid=108530123908396351983&rtpof=true&sd=true
31. Where can I get the Form12?
Please find the Form 12 accident report through the below link:
https://docs.google.com/spreadsheets/d/1gdZpS6BbqYVMBRWbJspiq10RDRZssw6y/edit?usp=drive_link&oui d=108530123908396351983&rtpof=true&sd=true
32. What are the Cash & Medical benefits?
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