ESI Medical Benefits

ESI Medical Benefits

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ESI Medical Benefits

Employees’ State Insurance or ESI is a comprehensive social security program for workers in the event of medical contingencies, such as sickness, maternity, death or disablement due to employment injury and occupational disease. The ESI scheme provides access to medical treatment, medical facilities, cash compensation and other support for insured persons. ESI registration and compliance is mandatory in India for businesses and establishments employing 10 or more persons. In this article, we look at the major medical benefits provided under the ESI scheme.

ESI Medical Benefits Eligibility

Some of the main benefits provided under ESI scheme are sickness benefit, disablement benefit, dependants’ benefit, maternity benefit and medical benefit. ESI medical benefit is available to the Insured Person (IP) and immediate family members from the day one enters an insurable employment until the person is in insurable employment . There is no ceiling on expenditure on an individual’s medical care.

The eligibility criteria for ESI is set out in Section 56 (1) of ESI Act, 1948 as under:

“an Insured Person or (where such medical benefit is extended to his family) a member of his family whose condition requires medical treatment and attendance shall be entitled to receive medical benefit”

Availing ESI Medical Care

ESI has the largest medical infrastructure in India for delivering healthcare services through a large network of 150 ESI Hospitals, 1372 ESI Dispensaries, 91 ISM Units, 1380 Panel Clinics and 7340 IMOs. An insured person can walk-in to a ESI hospital or dispensary for medical care and would be provided OPD services, in-patient services, diagnostic facilities, free drugs and dressings etc.

In case of critical patients who cannot be treated at a ESI facility, incidental expenditure on transport, stoppage charges at the centre, traveling expenses for attendants (if required) are also being paid by ESI Corporation. The eligibility for super-specialty treatment is 3 months (with contribution paid for at least 39 days) of insurable employment for insured person (for self) and 6 months (with contribution paid for at least 78 days) of insurable employment by Insured Person for their family members. Super-speciality treatment or critical care is provided through in-house super speciality facilities available in some of ESI Hospitals or ESI-PGIMSRs or through the ESI empanelled medical institutions on referral basis through tie-up arrangements. About 750 private hospitals in all India are now empanelled as tie-up Hospitals for ESIC.

Old Age and Retirement Benefits

The ESI medical benefits have now been extended to insured persons who go out of employment on account of old age or on account of disability due to work related injury. For such persons, medical care is provided free of cost at ESI facilities along with artificial limbs, artificial dentures, spectacles, hearing aids, cardiac pacemaker, walking caliper, surgical boots, spinal support, cerebral collar, intraoccular lens etc., as required.

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