1.Applicability of the Act & Scheme

The Act is extended in area-wise to factories using power and employing 10 or more persons and to non-power using manufacturing units and establishments including educational institutions employing 10 or more person.

It has also been extended upon shop, hotels, restaurants, roads motor transport undertakings, etc.

2.Eligibility

Effective 01/01/2017 ,employee receiving wage of Rs.21000/ pm to enroll under ESIC.

However,there is no wage ceiling for coverage of

3.Wage ceiling

Contribution Period

1st April to 30th September, and

1st October to 31st March

Benefit Period

If the person joined insurable employment for the first time, say on 5th January, his first contribution period will be from 5th January to 31st March and his corresponding first benefit will be from 5th October to 31st December i.e after 9 months.

Membership

If an insured person's wages/salary becomes more than 21,000/- per month, even then he/she remains covered till the end of a Contribution Period which is either April to September & October to March.

RATE OF CONTRIBUTION

Employer's Share: 4.75% of wages/salary.

Employee's Share: 1.75% of wages/salary.

5. Wages/Salary

Basic pay

Dearness allowance

House rent allowance

City compensatory allowance

Overtime wages (but not to be taken into account for determining the coverage of an employee)

Payment of weekly off/holiday

Production incentive-if it is paid every month

Bonus other than statutory bonus

Night shift allowance

Heat, Gas & Dust allowance

Payment for unsubstituted holidays

Meal/food allowance

Suspension allowance

Lay off compensation

Children education allowance (not being reimbursement for actual tuition fee)

7.Not As Wages/Salary

Contribution paid by the employer to any pension/provident fund or under ESI Act

Gratuity payable on discharge

Pay in lieu of notice of retrenchment compensation

Benefits paid under the ESI Scheme

Encashment of leave

Payment of Inam which does not form part of the terms of employment

Washing allowance for livery

Conveyance (Actual):
      (1) Amount towards reimbursement for duty related journey.
      (2) Reimbursement of journey on production of ticket.
      (3) Maintenance of vehicle subject to production of record.
      (4) Fixed when paid at an interval exceeding 2 months.

8.Manner And Time Limit for making payment of contribution

The total amount of contribution (employee's share and employer's share) is to be deposited with the authorized bank through a challan in the prescribed form in quadruplicate on or before 15th of month following the calendar month in which the wages fall due.

9.Benefits

ESI Scheme takes care of following needs of the member

Medical sickness, extended sickness for certain diseases, enhanced sickness, dependants maternity, besides funeral expenses, rehabilitation allowance, medical benefit to insured person and his or her spouse.

Direct admission for super specialty benefits

10.SUPER SPECIALITY PROCEDURE

When ESI hospitals are not having the requisite facilities -super specialty treatment

The State Medical Commissioner/Medical Superintendents of ESIC Hospitals/Director, ESI (Medical) Services, have entered into tie-up arrangements with recognized medical institutions to provide cashless treatment to insured persons and their family members for treatment that are not available in ESI/ESIC institutions to ensure that the ESI beneficiaries are provided full medical care. In order to avail treatment in such hospitals, the insured persons are required to obtain eligibility certificate from the concerned Insurance Medical Officer of ESI/ESIC hospital, referring the insured person or his dependents to such hospitals.

The eligibility conditions for super specialty treatment are as follows

An insured person who is eligible for medical treatment is entitled to avail Super Specialty treatment, for self and his/her family.

A newly registered employee is entitled to avail super specialty treatment for self, on completion of three months of service in insurable employment and contribution should have been paid/payable for not less than 39 days during that period.

A newly registered employee‘s dependents are entitled to super specialty treatment on completion of six months of service in insurable employment and contribution should have been paid/payable for not less than 78 days during that period.

The concepts of contribution period and benefit period will not apply while deciding the eligibility of an IP for Super specialty treatment.

The beneficiary can avail the super specialty treatment in a state different from that of the state in which the IP is registered by following the procedure

The referring hospital/dispensary shall send a copy of the reference slip to the SSMC/SMC of the referring and the referred state from where the patient wants to avail, the required super-specialty treatment.

SSMC/SMC of the state from where the patient wants to take treatment, shall intimate the network/tie-up hospital for providing necessary/required treatment. Thereafter, the bill for payment may be sent to the SSMC/SMC of the state from where he was referred on completion of treatment.

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. Such tertiary care (super-specialty treatment) is provided through in-house super specialty facilities available in some of ESI Hospitals or ESI-PGIMSRs or through large no. of advanced empanelled medical institutions on referral basis through tie-up arrangements. About 750 private hospitals in all over India are now empanelled as tie-up Hospitals for ESIC.

From April 1, the Employees State Insurance Corporation (ESIC) plans to provide super specialty treatment to retired insured persons (IPs), with a ceiling of ₹10 lac a year.

The ESIC said the “option to join shall be one time on retirement (under Rule 61). No enrolment shall be allowed thereafter.” The“ceiling of expenditure on SST/all referrals to tie-up hospitals in a financial year may be restricted to ₹10,00,000.”

Under the norms, only the IP and his/her spouse shall be eligible for treatment; a retired IP who has opted out at any time after retirement shall not be eligible to rejoin on any subsequent date; IPs already retired but not enrolled so far may be given a one time opportunity to join the scheme within three months.

However, they shall be eligible for SST only after six months.

Medical Benefit

For super specialty treatment such as open heart surgery, neuro surgery, bone marrow transplant, kidney transplant or specialized investigations like CAT scan, MRI angiography etc. referral arrangements are available with the reputed hospitals of the country. The total cost of such treatment, diagnostic facilities or surgical intervention is borne by the ESI Scheme.

Family of a deceased insured person, who is not entitled for sickness benefit at the time of death, is not eligible for specialty / super specialty treatment.

Procedure to be followed by the ESI beneficiaries to avail Super specialty medical treatment

The insured person shall approach the ESI Dispensary to which he/she is attached, and the Medical Officer shall issue a referral letter to the IP to approach the concerned empanelled medical institution.

If the IP/beneficiary needs medical attention during the non working hours of the concerned ESI Dispensary, they may directly approach the nearest ESI Hospital for getting referral letter. If there is no ESI Hospital situation nearer to the IP’s place of living, the IP shall approach the nearest Govt. Hospital for getting referral letter.

In the case of an emergency the IP/beneficiary can get Medical attention just by producing his/her ESI identity card at the designated private medical institution, shall produce necessary referral letter and other relevant documents within 48 hours. (If any case referral letter is a must to avail treatment under package deal

The IP/beneficiary shall produce the referral letter along with the ESI Identity Card at the designated private medical institution and avail the treatment without paying any amount from out of his/her pocket. However any facility, other than the items included in the package deal shall be borne by the IP/beneficiary.

While referring the IP/beneficiary to the concerned Empanelled Medical institution, Medical Officer in charge has to verify whether the IP/beneficiary is eligible for treatment.

The IP shall produce all the relevant documents demanded by the designated hospital and extend his/her co-operation to the hospital authorities.

The designated hospital after imparting treatment to the IP/beneficiary shall raise the claim bill directly to the Directorate where it will be settled.

Insured members and his family including children up to age of 25 years will get medical benefits without any ceiling of medical expenses

Medical treatment of insured person and his family members at the ESIC tied up A-1 grade hospitals of Surat such as Mahavir hospital,Apple hospital,Wack heard hospital,Ashutosh hospital will be free of cost for serious sickness.This benefits will be availed at all over India by using ESIC Card

In case of sickness , insured person will get wages from ESIC office and in case of accidental injury , death,insured person will get monthly pension for life time from ESIC

Insured female worker will get expenses of her delivery from ESIC Office and also get her salary for three months.If she develops another sickness during her pregnancy in that case after getting certificate from ESIC , she will get the enhanced amount of benefits

If insured person contributed for 5 years and then retired,he will get ESIC benefits by paying Rs.124 per annum

In case of closure of running establishment, the insured person will get salary up to three years

Factory/establishment is contributing more that the contribution of insured person therefore if any factory is denying the benefits of ESIC, the workers should insist for coverage under the scheme and get the ESIC benefits.

Medical Benefits

ESIC provides reasonable Medical Care for self and family from day one of entering into insurable employment.

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 including Model Hospitals run by ESI Corporation (except in Delhi), and uniformly 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.

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 just covered under the scheme for the first time is eligible for primary and secondary 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 the insured person is in ESI coverage for at least 2 years from the date of Online Registration, contributed for not less than 156 days and IP is eligible for Sickness Benefit in any one of the contribution period and is suffering from any of the 34 specified long term diseases, the medical benefit is admissible till the incapacity lasts or up to 730 days during a period of 3 years for self and family.

Sickness Benefit

ESIC provides 70% of average daily wages in cash during medical leave, up to 91 days in two consecutive benefit periods.

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.

If an insured person who has completed two years of insurable employment and contributed for not less than 156 days during this period is entitled to extended sickness benefit for a period of 309 days for the 34 specified long term diseases. This period can be extended up to 730 days or till the insured person attains the age of 60 years whichever is earlier. The insured person and his family are also entitled to Medical Benefit during this extended period. The daily rate of extended sickness benefit shall be equal to eighty percent of the standard benefit rate.

Maternity Benefit

ESIC provides 100% of average daily wages in cash up to 26 weeks in confinement and 6 week in case of miscarriage, during maternity leave and 12 weeks for commissioning mother and adopting mother.

Maternity benefit is periodical payment(s) to an insured woman for specified period of abstention from work, due to confinement, miscarriage or sickness arising 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. W.e.f.20.1.2017

Confinement Expenses is lump sum payment made to an insured woman or an insured person in respect of his wife if the confinement occurs at a place where necessary facilities under the ESI Scheme are not available. At present the confinement expenses paid is Rs. 5000/- w.e.f. 1.10.2013 per confinement. It is admissible for two confinements only.

Dependants' Benefit

ESIC provides monthly payment apportioned among dependants in case of death due to employment injury.

Dependants' Benefit is a monthly pension payable to the eligible dependants of an insured person who dies as a result of an employment injury or occupational disease. The first benefit payment is made from the Branch Office. Subsequent periodical payments are made through direct bank transfer (DBT) to the beneficiaries.

The rate of dependants' benefit is 90% of standard benefit rate of the wages of the deceased insured person. It is apportioned 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) To each child @ 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 dependents worked out as above exceeds at any time, the full rate, the share of         each of the dependents shall be proportionately reduced, so that the total amount payable to them does not exceed the amount at full rate. In case deceased Insured person    does not leave behind any of the dependents referred above, then his parents will get 3/10 share or if no parent is alive then alive his paternal grant parent will get 3/10 share     of Full rate of dependent benefit.

Disablement Benefit

ESIC provides continuous monthly payment till injury lasts for temporary disablement and for whole life for permanent disablement.

Disablement is a condition resulting from employment injury, which may render the insured person temporarily incapable of doing his work and necessitating medical treatment (temporary disablement). It may reduce his earning capacity (permanent partial disability) or it may totally deprive the insured person from the capacity of doing any work (permanent total disability).

Disablement Benefit

ESIC provides continuous monthly payment till injury lasts for temporary disablement and for whole life for permanent disablement.

Employment Injury

It is a personal injury to an employee caused by an accident or occupational disease arising out of and in the course of his insurable employment within or outside territorial limits of India.

Temporary Disablement Benefit

It is a periodical payment to an insured person suffering from Disablement as a result of 'Employment injury' for the period of abstention from work duly certified by an Authorized Medical Officer. This is paid @ 90% of standard benefit rate till the temporary disability lasts and the employee is able to resume his normal duties.

Permanent Disablement Benefit

If there is any residual disability of permanent nature due to employment injury, the insured person is examined by a Medical Board to assess the loss of his earning capacity, if any, and its percentage. The insured person is paid monthly periodical payments of permanent disablement for life from the date following the date of termination of temporary disablement at that percentage out of full daily rate of disablement benefit. Periodical increase in the benefit is also granted due to erosion in the cost of living. The benefit can be paid through ECS in the bank Account of IP or by Money Order at the cost of the Corporation. The insured person can also opt for the payment in lump sum if his daily rate of PDB does not exceed rupees ten or even if it exceeds ten per day, and the commuted value does not exceed Rupees 60000.

BENEFITS AFTER RETIREMENT

An Insured person who superannuates 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 shall continue to receive medical benefit under Rule 61 on payment of contribution as mentioned above.

Funeral Expenses

On production of a death certificate by the eldest surviving member/ dependents/any person who actually incurs the expenditure on funeral One time payment defraying expenses on funeral of an Insured person.Maximum Rs.10,000/-only.

If the Insured Person did not have family or was not residing with his family at the time of death, funeral expenses are paid to the person who actually performs the funeral.

Penal Provision

Different punishments have been prescribed for different types of offences in terms of

Section 85 (i) Six months imprisonment and fine Rs. 5,000, and(ii) One year imprisonment and fine,

Section 85-A :(five years imprisonment and not less to 2 years)

Besides these provisions, action also can be taken under section 406 of the IPC in cases where an employer deducts contributions from the wages of his employees but does not pay the same to the corporation which amounts to criminal breach of trust.