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Medical Benefit

Disclaimer: This document is intended solely for educational purposes. The content herein is subject to change based on evolving finance trends and any relevant rulings by the Government of India. Readers are advised to consult with qualified professionals for specific guidance related to their individual circumstances.

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.

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.

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

'Pehchan card'. By producing this 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.

Through “Pehchan Card” the employee would get medical benefit across the country in any of the ESIC/ESIS dispensaries subject to entitlement.

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 amountat full rate.

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.


Benefit to Family

  1. Family members are also entitled to full medical care as and when needed
  2. The family members are also entitled to artificial limbs, artificial appliances etc. as a part of medical treatment.
  3. 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.
  4. Reimbursement of expenditure incurred on the funeral of the deceased employee.
  5. In case of the death of the insured employee due to employment injury, the widow, widowed mother and children are entitled to Dependants' benefit.
  6. Any benefit due to the insured employee at the time of death is paid to the nominee.


Benefit after Retirement to the IPs/WIDOW, etc.

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.

Further, this medical benefit is also available to widows of insured persons who are in receipt of dependant benefit on payment of contribution as prescribed under rule 60 However, the medical benefit extended under this rule does not include super specialty treatment (SST).

In the event of closure of factory/establishment or non-employment injury related unemployment, the insured Person would be entitled to un-employment allowance subject to three years of insurable employment. The un-employment allowance is payable for twelve months in life time.

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