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What are the benefits available under ESI Scheme?

Open uri20170510 32134 7ezpi6?1494421819 jaggu asked over 2 years ago

Hi I am preparing for CA exam. Can I know, What are the benefits available under ESI Scheme?

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4 Answers
Avatar 37a3bd7bc7328f0ead2c0f6f635dddf60615e676e6b4ddf964144012e529de45 veeru answered over 2 years ago

Person or his family member. Medical care is also provided to retired and permanently disabled insured persons and their spouses on payment of a token annual premium of Rs.120/- . System of Treatment Scale of Medical Benefit Benefits to Retired IPs Administration of Medical Benefit in a State Domiciliary treatment Specialist consultation In-Patient treatment Imaging Services Artificial Limbs & Aids Special Provisions Reimbursement

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Avatar 37a3bd7bc7328f0ead2c0f6f635dddf60615e676e6b4ddf964144012e529de45 HIMANSHU answered over 2 years ago

(a) Medical Benefit : Full medical care is provided to an Insured person and his family members from the day he enters insurable employment. There is no ceiling on expenditure on the treatment of an Insured Person or his family member. Medical care is also provided to retired and permanently disabled insured persons and their spouses on payment of a token annual premium of Rs.120/- . System of Treatment Scale of Medical Benefit Benefits to Retired IPs Administration of Medical Benefit in a State Domiciliary treatment Specialist consultation In-Patient treatment Imaging Services Artificial Limbs & Aids Special Provisions Reimbursement (b) Sickness Benefit(SB) : Sickness Benefit in the form of cash compensation at the rate of 70 per cent of wages is payable to insured workers during the periods of certified sickness for a maximum of 91 days in a year. In order to qualify for sickness benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months. Extended Sickness Benefit(ESB) : SB extendable upto two years in the case of 34 malignant and long-term diseases at an enhanced rate of 80 per cent of wages. Enhanced Sickness Benefit : Enhanced Sickness Benefit equal to full wage is payable to insured persons undergoing sterilization for 7 days/14 days for male and female workers respectively. (c) Maternity Benefit (MB) : Maternity Benefit for confinement/pregnancy is payable for three months, which is extendable by further one month on medical advice at the rate of full wage subject to contribution for 70 days in the preceding year. (d) Disablement Benefit Temporary disablement benefit (TDB) : From day one of entering insurable employment & irrespective of having paid any contribution in case of employment injury. Temporary Disablement Benefit at the rate of 90% of wage is payable so long as disability continues. Permanent disablement benefit (PDB) : The benefit is paid at the rate of 90% of wage in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a Medical Board (e) Dependants' Benefit(DB) : DB paid at the rate of 90% of wage in the form of monthly payment to the dependants of a deceased Insured person in cases where death occurs due to employment injury or occupational hazards.

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Open uri20170510 32134 1c996lj?1494421732 Anil answered over 2 years ago

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 Benefits Under 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 wages

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Avatar 37a3bd7bc7328f0ead2c0f6f635dddf60615e676e6b4ddf964144012e529de45 jitendra etikala answered over 2 years ago

The section 46 of the Act envisages following six social security benefits :- (a) Medical Benefit : Full medical care is provided to an Insured person and his family members from the day he enters insurable employment. There is no ceiling on expenditure on the treatment of an Insured Person or his family member. Medical care is also provided to retired and permanently disabled insured persons and their spouses on payment of a token annual premium of Rs.120/- . System of Treatment Scale of Medical Benefit Benefits to Retired IPs Administration of Medical Benefit in a State Domiciliary treatment Specialist consultation In-Patient treatment Imaging Services Artificial Limbs & Aids Special Provisions Reimbursement (b) Sickness Benefit(SB) : Sickness Benefit in the form of cash compensation at the rate of 70 per cent of wages is payable to insured workers during the periods of certified sickness for a maximum of 91 days in a year. In order to qualify for sickness benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months. Extended Sickness Benefit(ESB) : SB extendable upto two years in the case of 34 malignant and long-term diseases at an enhanced rate of 80 per cent of wages. Enhanced Sickness Benefit : Enhanced Sickness Benefit equal to full wage is payable to insured persons undergoing sterilization for 7 days/14 days for male and female workers respectively. (c) Maternity Benefit (MB) : Maternity Benefit for confinement/pregnancy is payable for three months, which is extendable by further one month on medical advice at the rate of full wage subject to contribution for 70 days in the preceding year. (d) Disablement Benefit Temporary disablement benefit (TDB) : From day one of entering insurable employment & irrespective of having paid any contribution in case of employment injury. Temporary Disablement Benefit at the rate of 90% of wage is payable so long as disability continues. Permanent disablement benefit (PDB) : The benefit is paid at the rate of 90% of wage in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a Medical Board (e) Dependants' Benefit(DB) : DB paid at the rate of 90% of wage in the form of monthly payment to the dependants of a deceased Insured person in cases where death occurs due to employment injury or occupational hazards. (f) Other Benefits : Funeral Expenses : An amount of Rs.10,000/- is payable to the dependents or to the person who performs last rites from day one of entering insurable employment. Confinement Expenses : An Insured Women or an I.P.in respect of his wife in case confinement occurs at a place where necessary medical facilities under ESI Scheme are not available.

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