RSS

Employee State Insurance Corporation (ESIC)

13 Dec

Benefits

Under Section 46 of ESIC Act, totally six social security benefits have been conferred on employees working with various organizations across India. These six social security benefits for the welfare of the employees are enlisted as follows:

a) Medical BenefitsUnder the medical benefit, different types have been incorporated for the benefit of factory/establishment employees. The ESIC scheme provides total medical care that comprises of medical attendance by competent physicians and nurses, treatment, drugs and injections, specialist/super-specialist consultation and hospitalization to insured persons including their dependants or members of their families where the facility of benefits has been extended for providing medical coverage to such families.For such families who are eligible for benefits under ESIC Act, these benefits have been categorized into two broad categories as follows:i) Full Medical Care

It comprises of hospitalization facilities incorporating specialist services, drugs/medicines, dressings and diets as required for in-patients admitted in hospitals.

ii) Expanded Medical Care

It comprises of consultations with specialists and supply of special medicines and drugs that may be prescribed with the added advantage of OPD (Out-patient department) care. This also includes facilities for special diagnostic and laboratory tests including X-Ray investigations.

Apart from the curative services provided through service providers such as hospitals, nursing homes and dispensaries, the Corporation provides preventive facilities including family welfare services.

Immunization

The ESIC Corporation has embarked upon a massive programme of immunization of young infants and children of insured persons eligible under this Act. As part of immunization programme, preventive inoculation and vaccines are administered against diseases like diphtheria, pertusis, tetanus, hepatitis B, measles, mumps, polio, rubella, smallpox, tuberculosis etc.

Family Welfare Services

The Corporation has been constantly undertaking measures for implementation of Family Welfare Services with constant upgradation in its services to the beneficiaries eligible under this Scheme. The provisions of ESIC Act has been extended for additional cash incentives to insured persons for propagating and promoting acceptance of sterilization methods by reimbursement of sickness cash benefit that is equivalent to full wage for a period of 7 days for vasectomy procedure (in males) and 14 days for tubectomy procedure (in females). The period for which cash benefit is admissible can be extended beyond the above specified limits subject to any event of complications subsequent to Family Planning procedures.

Supply of Special Aids

Insured persons including their family members and dependants covered under this Act are provided special aids comprising of artificial limbs, hearing aids, artificial appliances like spinal supports, cervical collars, crutches, wheel chairs, walking calipers and cardiac pacemakers which are a part of medical products and services provided under this scheme.

b) Sickness Benefits

Sickness Benefit represents periodical cash payments made to an insured person during the period of illness or sickness certified by a medical practitioner occurring in a benefit period. An insured person requiring medical treatment and attendance with abstention from work on medical grounds are additional features incorporated under Sickness Benefit. Prescribed certificates for Sickness Benefit are: Forms 8, 9, 10, 11 & ESIC-Med.13. Sickness benefit roughly amounts to 50% of the average daily wages that is payable for 91 days during 2 consecutive benefit periods.

Qualifying Conditions

(i) To become eligible for Sickness Benefit, an insured person should have paid contribution for not less than 78 days during the corresponding contribution period.

(ii) An individual who has entered into insurable employment for the first time has a waiting period of nine months (i.e. the individual has to wait for 9 months) before becoming eligible for availing sickness benefit, since his/her corresponding benefit period commences only after this interval (i.e. 9 months) as specified under the provisions of the Act.

(iii) Sickness Benefit is not payable for the first two days of a spell of sickness with the exception in cases such as a spell commencing within 15 days of closure of earlier spell of illness for which sickness benefit was last reimbursed. This period of 2 days is called as “waiting period”. This provision should be clearly understood by medical service providers and medical fraternity as actual experience shows that such of insured persons who want to avail medical leave on flimsy grounds generally come to avail for issuance of First Certificate/First & Final Certificate within 15 days of earlier spell, usually on unpaid holidays and/or on each weekly off etc in order to avoid loss of benefit for 2 days due to fresh waiting period applicable under ESIC Act.

Sickness benefits are further classified into two broad categories:

i) Extended Sickness Benefit

ii) Enhanced Sickness Benefit

i) Extended Sickness Benefit (ESB)

Earlier insured persons eligible under this scheme suffering from long duration of illnesses were experiencing great hardships on account of expiry of 91 days Sickness Benefit. It was often observed that such individuals that though they were not fit for duty, they were pressed for a Final certificate. Hence, a provision for paying Sickness Benefit for an extended period (Extended Sickness Benefit)of upto 2 years in a ESB period of 3 years was incorporated in the provisions of this Act.

An insured person suffering from certain long term diseases is entitled to avail ESB, only after totally exhausting Sickness Benefit to which he/she may be eligible. A common list of such long-term diseases for which ESB is payable is being constantly reviewed and updated by the Corporation from time to time.

The list was last reviewed in December 1999 and revised provisions of ESB became effective from January 2000. Currently this list includes 34 diseases which are grouped in 11 broad categories as per International Classification of diseases and the names of many existing diseases have been changed as enlisted below:

(I) Infectious Diseases

 Tuberculosis

 Leprosy

 Chronic Empyema

 AIDS

(II) Neoplasm 

 Malignant Diseases

(III) Endocrine, Nutritional and Metabolic Disorders 

 Diabetes Mellitus associated with proliferative retinopathy/diabetic foot/nephropathy

(IV) Disorders of Nervous System 

 Monoplegia

 Hemiplegia

 Paraplegia

 Hemiparesis

 Intracranial Space Occupying Lesion

 Spinal Cord Compression

 Parkinson’s disease

 Myasthenia Gravis/Neuromuscular Dystrophies

(V) Disease of Eye 

 Immature Cataract with vision 6/60 or less

 Detachment of Retina

 Glaucoma

(VI) Diseases of Cardiovascular System 

 Coronary Artery Disease (CAD)

 Unstable Angina

 Myocardial infraction with ejection less than 45%

 Congestive Heart Failure

 Cardiac Valvular Diseases with failure/complications

 Cardiomyopathy

 Heart disease with surgical intervention associated with complications

(VII) Chest Diseases 

 Bronchiectasis

 Interstitial Lung Disease

 Chronic Obstructive Lung Diseases (COPD) with congestive heart failure (Cor pulmonale)

(VIII) Diseases of the Digestive System 

 Cirrhosis of liver with ascities/chronic active hepatitis

(IX) Orthopaedic Diseases 

 Dislocation of vertebra/prolapse of intervertebral disc

 Non-union or delayed union of fracture

 Post Traumatic Surgical amputation of lower extremity

 Compound fracture with chronic osteomyelitis

(X) Psychoses 

 Schizophrenia

 Endogenous depression

 Manic Depressive Psychosis (MDP)

 Dementia

(XI) Others 

 More than 20% burns associated with infection/complications

 Chronic Renal Failure

 Reynaud’s disease/Burger’s disease

In addition to the above list, Director General/Medical Commissioner have the authority to sanction ESB (Extended Sickness Benefit) for a maximum period up to 730 days in cases of rare but treatable diseases or under special circumstances for example adverse reaction to drugs which have not been incorporated in the aforesaid list. Moreover, it depends on the merits of each individual case, on the recommendations of RDMC/AMO or either authorized officers who are in-charge for implementing the medical scheme.

To be entitled to the Extended Sickness Benefit (ESB), an insured person should have been continuously employed for 2 years or more at the commencement of a spell of sickness in which the disease has been diagnosed and should also satisfy other contributory conditions.

ESB (Extended Sickness Benefit) shall be payable for a period of 124 days initially and thereafter may be extended up to 309 days in chronic suitable cases or on basis of merit as decided by Regional Deputy Medical Commissioner/Medical Referee/Administrative Medical Officer/Chief Executive of the E.S.I. Scheme in the State or his authorized nominee on the report of the specialist(s).

ii) Enhanced Sickness Benefit

It was introduced with effect from 1st August, 1976 as an incentive to insured persons for undergoing Vasectomy or Tubectomy operative procedures. Insured persons eligible to ordinary sickness benefit are paid enhanced sickness benefit at double the rate of sickness benefit i.e., about full average daily wage for undergoing sterilization operations for the family welfare and family-planning purposes. Duration of enhanced Sickness Benefits is up to 7 days in the case of Vasectomy and up to 14 days in the case of the Tubectomy from the date of performing operative procedure or from the date of admission in the hospital as the case may be. The period of Enhanced Sickness Benefit can be extended in case of post operative complications.

c) Maternity Benefits (MB)

Maternity Benefit is payable to an insured woman (or pregnant mother) in the following cases subject to contributory conditions:

 Confinement is payable for a period of 12 weeks (84 days) on production of Forms 21 and 23.

 Miscarriage or MTP (Medical Termination of Pregnancy) is payable for 6 weeks (42 days) from the date following miscarriage on the basis of Forms 20 and 23.

 Sickness or complications arising out of Pregnancy, Confinement, Premature birth is payable for a period not exceeding more than one month on the basis of Forms 8, 10 and 9.

 In the event of death of an insured woman during confinement leaving behind a child, Maternity Benefit is payable to her nominee on production of Form 24 (B).

 Maternity benefit rate is double the Standard Benefit Rate or is roughly equal to the average daily wage.

d) Disablement Benefits

Disablement Benefits can be categorized into 2 broad groups under ESIC Act as follows:

 Temporary Disablement Benefit (TDB)

 Permanent Disablement Benefit (PDB)

Temporary disablement benefit (TDB)

Benefits

TDB is payable to an employee who suffers injury during the course of working hours of employment which is commonly called as Employment Injury (EI) or Occupational Disease and is certified by the Medical Practitioner to be temporarily incapable to work.

Under Section 2(8) of ESIC Act, “Employment Injury” has been defined as a personal injury to an employee caused by accident or occupational disease arising out of and in the course of his/her 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: 

Accident Report in form 16, Form 8, 9, 10, 11 and ESIC Med.13.

Eligibility for TDB

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

TDB (Temporary Disablement Benefit) Rate is calculated 40% over and above the normal sickness benefit rate. This works out to nearly 85% of the average daily wages.

Duration of TDB 

There is no prescribed limit pertaining to the duration of TDB (Temporary Disablement Benefit). This is payable as long as temporary disablement lasts and significant improvement by treatment is possible. If a Temporary Disablement spell lasts for duration of less than 3 days (excluding day of accident), insured person will be paidsickness benefit, unless if otherwise found eligible for the same. A special point for Medical Officers and Medical Practitioners is that some insured persons may resist taking a Final Certificate especially before 3 days for fear loss of TDB (Temporary Disablement Benefit).

Permanent disablement benefit (PDB) 

PDB is payable to an insured person who suffers permanent residual disablement as a result of EI (Employment Injury) including Occupational Diseases, thereby resulting in loss of earning capacity of that individual. The proper authority designated for assessing actual loss of earning capacity for injuries sustained is the Medical Board. Similarly the proper authority for assessing actual loss on account of Occupational Diseases is Special Medical Board.

The duration of PDB is reimbursed for the period as authorized by Medical Board, if assessment is provisional or for entire life if assessment is final.

PDB Rate

The PDB rate is calculated as percentage of loss of earning capacity based on the assessment made by the Medical Board/MAT/EI Court in relation to TDB (Temporary Disablement Benefit). List of injuries deemed to result in permanent total disablement and percentage loss of earning capacity has been amended in 2nd Schedule to ESIC Act, 1948. Hence, the maximum rate of PDB can be equal to the rate of TDB.

PDB amount is monitored and revised by the ESIC from time to time by taking into consideration the inflation factor prevalent in the Indian market. The latest enhancement is with effect from 1st August, 2002.

Commutation of PDB (Regulation 76-B)

An insured person whose PDB (Permanent Disability Benefit) has been assessed as final and who has been awarded the same at the rate not exceeding Rs.1.50 per day may apply for commutation of periodical payments of PDB into a lump-sum amount. When an application for commutation is made within 6 months from the date of communication of Medical Board decision, periodical payments shall be commuted into a lump sum, provided that the total commuted value does not exceed Rs.10,000/- at the time of commencement of final award. However, there are numerous instances where such an application is made after the expiry of 6 months duration, then LO (Legal Officer)/RO (Regional Officer) will refer the case to appropriate authorities so as to certify whether the concerned insured person has an average expectation of life as applicable for his/her age. Such a certificate is issued by Medical Referee in the relevant place on RO/LO letterhead.

Age of an insured person needs to be proved to the utmost satisfaction of the Corporation in all such cases. Medical Boards assess the age of insured persons who are unable to produce satisfactory record of age proof and opinion delivered by Medical Board shall be considered as final and binding in this regard.

e) Dependants’ Benefits (DB)

The dependants’ benefit is payable to the dependants of the insured persons under Section 52 of the ESIC Act read along with provision of 6(A) of Section 2 in cases where an insured person dies on account of EI (Employment Injury). The age of dependants, has to be determined either on production of Documentary evidence as specified under Regulation 80(2) or age as certified by Medical Officer who is In-charge of Government Hospital or Government Dispensary.

The minimum rate of DB (Dependants’ Benefits) with effect from 1st January, 1990 is Rs.14/- per day and these rates of the DB are increased with passage of time by taking the inflation factor into consideration . The latest enhancement has been implemented with effect from 1st August, 2002.

f) Funeral Expenses

An interesting aspect of the ESIC Scheme is that the contributions are related to the paying capacity as a fixed percentage of the workers wages and are provided social security benefits according to individual needs without distinction.

Cash Benefits are disbursed by the ESIC Corporation through its Local Offices LOs/ Mini Local Offices (MLOs)/Sub Local Offices SLOs)/pay offices which are subject to certain contributory conditions.

Over and above all, this scheme provides some need based benefits to insured workers as enlisted below:

 Rehabilitation allowance

 Vocational Rehabilitation

 Unemployment Allowance (Under Rajiv Gandhi Shramik Kalyan Yojana)

 

Coverage of ESIC

Originally ESIC Act was only applicable to non-seasonal industries (or factories) utilizing power providing employment to 20 or more individuals. But with the passage of its implementation, the provisions of this Act were modified to extend the coverage to Non-seasonal power using industries (or factories) providing employment to 10 or more individuals along with Non-power using industries (or factories) providing employment to 20 or more individuals.

Under Section 1(5) of the Act, the Scheme has been extended to shops, hotels, restaurants, cinemas including preview theatre, road motor transport undertakings and newspaper establishment employing 20 or more persons.The existing wage-limit for coverage under the Act, is Rs.10,000/- per month (with effect from 1.10.2006).Areas covered under the Act 

The ESIC Scheme is being implemented in various phases area-wise across India. The Scheme has already been implemented in different areas in various States/Union Territories across India except in states like Arunachal Pradesh, Manipur, Mizoram, Nagaland, Tripura and Sikkim.

Coverage of Factories

The Act is applicable to all non-seasonal factories that utilize power providing employment to 10 or more individuals as well as factories not utilizing power employing 20 or more individuals for wages on any day in areas wherein ESIC Act has been implemented. There is an amendment to the Act under Section 1(5) to extend the benefits to other classes of establishment – agricultural, commercial, industrial or otherwise. The provisions of this Act have been extended by majority of the State Governments in India to the following class of establishments such as shops, hotels, restaurants, cinemas road-motor transport agencies, newspaper agencies, workshops, establishments employing 20 or more individuals.

In case, at any stage or in due course of time, if the number of employees  working with an establishment or factory covered under the ambit of this Act falls short of the stipulated number of 10 or 20 employees as specified, ceases to be a beneficiary of ESIC Act without  any aid of power. However, this Act is not applicable to workers engaged in mining operations, railway running sheds and certain seasonal/temporary factories operating for less than 7 months in a calendar year. The employees of establishments or factories run with the aid of Central or State Governments who are in receipt of social security benefits that are substantially similar or superior as compared to those provided under this Act can be exempted from coverage.

Coverage of Employees

The Central Government of India has issued guidelines pertaining to monthly wage limit that has been prescribed for the purpose of coverage of employees/workers of the factories or establishments covered under this Act. Under Section 2(9) of this Act, an employee has been defined as any individual employed for wages in connection with the work related to a factory or establishment which is a beneficiary under ESIC Act. The wage ceiling is revised from time to time. The existing wage ceiling is Rs.15,000/- per month.

Read more: Employee State Insurance Corporation (ESIC) – Coverage – Areas, Organizations and Employees | Medindia http://www.medindia.net/patients/health-regulations/employee-state-insurance-corporation-coverage.htm#ixzz2F1ODd9NY

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Posted by on December 13, 2012 in HRD

 

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