BENEFITS @

ESIC

….. By Sathyanarayana Manikara ,M.B.A ,M.A(Econ.)LL.M

Joint Director (Training)Zonal Training Institute, South Zone

Bangalore.

INTRODUCTIONEmployees’ State Insurance Scheme of India, is

an integrated social security scheme tailored to provide protection to workers in the organized sector and their dependants in contingencies, such as sickness, maternity or death and disablement due to an employment injury or occupational disease. Towards this objective3 the scheme of health insurance provides full medical facilities to insured persons and their dependants, as well as, cash benefits to compensate for any loss of wages or earning capacity in times of physical distress.

CONTRIBUTIONThe ESI Scheme is mainly financed by contributions raised from employees covered under the Scheme and their employers, as a fixed percentage of wages. As of now, the rates of contribution are:-(i) Employees’ Contribution: 1.75% of wages(ii) Employer’s Contribution : 4.75% of wages.

• Employees’ earning upto Rs. 70/- a day as wages are exempted from payment of their part of contribution.

• The State Govts. Bear one-eighth share of expenditure on Medical Benefit within the per capita ceiling of Rs. 1200/- per annum and any additional expenditure beyond the ceiling.

WAGE CEILINGEmployees of covered units and establishments drawing wages upto Rs. 15000/- per month come under the purview of the ESI Act, 1948 for multi-dimensional social security benefits.

APPLICABILITY OF THE ESI ACTThe ESI Act applies to any premises / precincts,

where 10 or more persons are employed.The “appropriate Government” State or Central

is empowered to extend the provisions of the ESI Act to various classes of establishments, industrial, commercial, agricultural or otherwise in nature. Under these enabling provisions, most of the State Governments have extended the ESI Act to certain specific classes of establishments, such as Medical and Educational Institutes, Shops, Hotels, Restaurants, Cinemas, preview theatres, motor transport undertakings, newspaper and advertising establishments etc., employing 10 or more persons.

SO MUCH TO GAIN FOR SO LESS PREMIUM

MEDICAL BENEFITCASH BENEFIT

(SICKNESS AND DISABLEMENT)

DEPENDANT BENEFIT

MATERNITY BENEFIT

4.75% EMPLOYERS CONTRIBUTION

UNEMPLOYMENT ALLOWANCE

VOCATIONAL REHABILATION

FUNERAL EXPENSESOLD AGE HEALTH

CARE.

1.75%EMPLOYEES CONTRIBUTION

CASH BENEFIT(1) SICKNESS BENEFIT normal extended enhanced

(2) DISABLEMENT BENEFIT (employment injury)……temporary & permanent

SICKNESS BENEFIT

Contributory condition

DURATION RATE

Payment for78 days in relevant contribution period

91 days in any two consecutive period

About 60% of wages

EXTENDED SICKNESS BENEFITfor 34 specified long term diseasesContributory period

Duration Rate

Continuous employment for a period of two years and contribution for 156 days in four consecutive contribution period

two years 75% of the wages

ENHANCED SICKNESS BENEFITFor undergoing sterilization operation for family planning

Contributory period

Duration Rate

Payment for at least 78 days in the relevant contribution period

7 days for vasectomy and14 days for tubectomy ; extendable in case of POC

Full wages

DISABLEMENT BENEFIT(employment injury or occupational diseases)

BENEFIT Contributor-y condition

Duration Rate

TDB (incapacity should be > 3 days Exc DOI

He should be employed at the date of injury, no relation to contribution.

Till the incapacity lasts

75% of the wages

PDB (partial or total)

same For life Determine by the medical board, depends upon loss of earning capacity. Commutation of PDB is not > Rs 30,000

DEPENDANTS BENEFITContributorycondition

Duration Rate

Deceased should be employee on the date of fatal accident.

1.To widow/s for life or until remarriage(3/5 DBR) 2.To widow mother during life(2/5 DBR)3.To legitimate or adopted son and legitimate or adopted daughter till the age of 18 yr(2/5)4.Distribution does not exceed at any time of the full rate of DBR

150% of SBR (75% of wages) to be divided among the prescribe ratio)

The amount of DBR is reviewed vis-à-vis the cost of living index and increases are granted from time to time to compensate for erosion in its real value.

MATERNITY BENEFITContributory

conditionDuration Rate

Payment of contribution for 70 days in immediately preceding two consecutive contribution periods.

12 weeks of which not more than six can precede the expected date of confinement;6weeks for miscarriage and additional one month for sickness arising out of pregnancy confinement, premature birth of child or miscarriage

Double the SBR (approx full wages)Maternity benefits is continues to be payable even in the event of death of an insured woman during delivery or immediately following date of delivery for leaving child whole of period and in case child also dies ,during the said period until the death of child

FUNERAL BENEFITHE SHOULD BE AN INSURED PERSON ON

DATE OF DEATH.ACTUAL EXPENDITURE ON FUNERAL NOT

EXCEEDING Rs 5000/-AMOUNT IS PAID TO ELDEST SURVIVING

MEMBER OF THE FAMILY OR IN HIS ABSENCE TO THE PERSON WHO ACTUALLY INCURS THE EXPENDITURE ON THE FUNERAL.

REHABILATIONAL ALLOWANCEContributory

conditionDuration Rate

Entitlement to medical benefit or if disabled due to employment injury

For each day on which insured person remains admitted in artificial limb- centre for fixation/repair or replacement of artificial limb.

Double the SBR(full wage)

MEDICAL BENEFITContributory

conditionDuration Benefit

Insured person and his family is eligible from the date of entry of I.P. into insurable employment

Till the disability / disease last

Full curative and preventive medical care for I.P. and his/her dependants Including super specialty treatment

CONFINEMENT EXPENSESContributory

conditionDuration Rate

To an insured woman or an I.P. in respect of his confinement are not available in esi insitution

Up to two confinement only

Rs 2500/- per case.

Medical benefit to retired/disabled insured person and his/ her spouseContributory condition

Duration Benefit

Rs On payment of 120/- in lump sum for one year in advance(1)Retired I.P being insured for not less than five years.(2)By insured person who cease to be in insurable employment on account of disablement due to an employment injury

Period for contribution is paid

Full medical benefit for that period.

VOCATIONAL REHABILATIONAL ALLOWANNCEContributory

conditionDuration Rate

Not more than 45 years of age and disability not less 40% due to employment injury

All the days of training in vocational rehabiliational centre

Rs 123- per day or the amount charged by vocational rehabilatational centre whichever is higher

UNEMPLOYMENT ALLOWANCEContributory condition Duration Rate

An I.P. who has lost employment due to closure of factory, retrenchment or permanent invalidity and contribution in respect of him have been paid/payable for a minimum of three years prior to loss of employment.

Minimum12 monthDuringlifetime

60% of wages

SALIENT ACHIEVEMENTS OF RESURGENT ESIC

ESIC in the recent past has taken commendable strides forward as far as development of new innovative schemes, medical infrastructure and quality manpower is concerned. The cardinal body under the Ministry of Labour & Employment has moved ahead on the part of comprehensive inclusion with a corresponding focus on improving its competency in every respect. Here is an analysis of the major achievements as far as ESIC is concerned, with a key focus on the initiatives that stimulate mass welfare.

Facts that speak voumes (As on 31-03-2009)* ESIC today boasts of the largest medical infrastructure in

the country.* More than 1.29 crores Persons/Family Units have been

insured under the ESIC scheme.* ESIC today is an integral part of the lives of Approx, 5.00

crores of its beneficiaries.* ESIC has been able to involve over 3.94 lakhs employers

under the scheme.* ESIC today is represented by over 611 branch offices.* Tremendous reach with its 197 Pay Office.* Over 144 ESI Hospitals with 23,923 beds.* 42 ESI Annexes with 849 beds.* 1,388 ESI Dispensaries.* 7070 Insurance Medical Officers 1678 Insurance Medical

Practitioners.

Initiatives of ESIC – Standing by one and allHere is a list of initiatives that gives ESIC an

even more comprehensive reach:

Wage Ceiling limit for coverage under ESI Scheme has been increased from Rs. 10,000/- to Rs. 15,000/- per person per month 1.3.f. 1.5.2010.

Setting up of Medical, Nursing, Dental Colleges and Para-Medical Schools in ESI Hospitals.

Enhancement of duration of Unemployment Allowance under Rajiv Gandhi Shramik Kalyan Yojana from 6 to 12 months and reduction in eligibility condition of five years insurable employment to three years.

Enhancement of the Permanent Disablement Benefit and Dependents’ Benefit in order to compensate the beneficiaries against erosion in the real value of these monthly benefits due to inflation.

Disabled persons working in factories and establishments covered under the ESI Act drawing wages upto Rs. 25000/- per month are coverable under the ESI Act and Employers’ share of contribution is paid by Central Government for three years.

For providing a smooth and hassle free process of disbursing the Permanent Disablement Benefit, Dependant Benefit and Maternity Benefit, ESIC has introduced the Electronic Clearance System (ECS). ESIC beneficiaries now receive benefits payments through their respective bank accounts.

INITIATIVES OF ESIC – A STEP FORWARD IN MEDICAL CARECeiling on reimbursement of expenses on

medical care to state governments has been increased from Rs. 1000/- to Rs. 1200/- per IP family per annum.

Super-speciality treatment to the beneficiaries are being provided and all expenditure on this outside the ceiling directly borne by ESIC.

Treatment under AYUSH i.e. Ayurvedic, Yoga, Unani, Siddha and Homeopathy also available in ESI Hospitals/Dispensaries.

To improve our medical services and improvements towards better delivery of services, state-of-the-art medical equipments like CT Scan/MRI has been provided at ESIC Hospital, Basaidarpur (New Delhi), Rajajinagar (Karnataka) and Andheri (Maharashtra).

Rate of confinement Expenses for confinement outside ESI Hospitals have been raised from Rs. 1000/- to Rs. 2500/- per confinement.

Enhancement of the reimbursement of Funeral Expenses from Rs. 3000/- to Rs. 5000/-

To facilitate early sanction of equipments for ESI Hospitals, SSMCs/SMCs at State level have been delegated powers to sanction equipments upto Rs. 15.00 lakhs per unit.

Project Sankalp for strengthening ESIC interventions on HIV/AIDS and family welfare launched at Mangalore (Karnataka).

ESI Beneficiaries have a choice to avail Super Speciality treatment in any of the networked tie up hospitals of ESIC on cash less basis.

REDRESSAL OF PUBLIC GRIEVANCES

ESI Scheme being multi-pronged service intensive Social Security program for workers, an estimated 10 lakh beneficiaries visit the service outlets at the grassroot level daily, either for treatment or for availing cash benefits. In such a highly interactive and dynamic service delivery system, there is sufficient scope for any inadvertent or willful harassment being caused to the beneficiaries.

Accordingly the ESI Corporation has set up the Public Grievances Redressal System at all levels i.e., Hqrs.Office/ Os/ SROs/ DOs/Branch Offices/ ESI Dispensaries/ESI Hospitals. To ensure expeditious disposal and speedy redressal of public grievances under the ESI Scheme various measures have been taken by the Corporation.

Grievances can be report I writing, over telephone through Toll Free Helpline No.1800-11-2526, by post or in person to any of the following Officers.

TOLL FREE HELPLINE:

In order to bring transparency in the system and to provide easy step to stake holders to access the information pertaining to ESIC and to make the ESI Scheme customer friendly, a Toll Free Helpline Number 1800-11-2526 is installed and activated since 01/02/2006 (Functioning all the working days from 9:30 A.M. to 5:30 P.M).

Advertisement has also been made in all national leading dailies in this connection. The system is functioning under the direct supervision of Public Grievance Cell and reviewed by the Insurance Commissioner & Director General. At present, System is operated manually, but efforts are being made to develop software and to launch 24x7 helpline for handling beneficiaries issues.

VIGILANCE RELATED ISSUESFor Vigilance related issues, employers and employees covered under the Scheme can contact the Regional Director, ESIC or their area or write to the:-

Chief Vigilance Officer / Director (Vigilance),

Employees’ State Insurance Corporation,Panchadeep Bhawan, CIG Road,New Delhi – 110 002.Tel: 011-23221105 (CVO)/ 23230145

(Director) 011-23234092 (Extn.293/311).

Thank You