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MEDICAL BENEFITS

What is medical benefit?

Medical benefit means medical care to the IPs and their families. Medical benefit is provided in kind through a network of hospitals and dispensaries coming under the administrative control of the State Government and through ESIC Model Hospitals and Hospitals coming under the administrative control of the ESI Corporation. This benefit is uniform to all according to their requirement without disparity or linking it to their wages and contributions paid. It is the only health insurance scheme in the world, which has no upper ceiling on expenditure on medical care of beneficiaries.

What are the eligibility conditions to become entitled to medical benefit?

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 continue 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 under ESI coverage for at least two 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 2 years for self and family.

Whether the family members of the IP who are staying in a different place from that of the IP avail medical care in their place of residence ?

In case the family members of the IP are staying in a different town / city from that of the IP, and this fact is declared online by the employer, they can avail medical facilities of ESI Scheme in a dispensary located near their residence with the pehchan card. (the IPs are given a set of two pehchan cards).

What is the procedure to avail medical benefit when an insured person leaves station for a temporary period ?

While leaving the station, the insured person may obtain a certificate of employment from his employer in Form ESIC – 105. Based on this certificate and pehchan card, the insured person can avail medical benefit in any ESI Dispensary/Hospital across the country. On the basis of the Pehchan card, the insured person and his /her family can avail medical benefit in any ESI Dispensary/Hospital after the computerisation process is completed.

How are medical treatment administered to the beneficiaries if any of the 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.