ESI Scheme - An Introduction The Employees’ State Insurance Scheme is an integrated measure of Social Insurance embodied in the Employees’ State Insurance Act and is designed to accomplish the task of protecting ‘employees’ as defined in the Employees State Insurance Act, 1948 against the impact of contingencies of sickness, maternity, disablement and death due to employment injury and to provide medical care to insured persons and their families. The ESI Scheme applies to factories and other establishments viz. Road Transport, Hotels, Restaurants, Cinemas, Newspaper, Shops, and Educational/ Medical Institutions, etc., wherein 10 or more persons are employed. However, in some States threshold limit for coverage of establishments is still 20. Employees of the aforesaid categories of factories and establishments, drawing wages upto Rs. 21,000/- per month, are entitled to social ‘security cover under the ESI Act. The ESI Scheme is financed by contributions from employers and employees. The fate of contribution payable by employer is 3.25% and employees contribution is at the rate of 0.75% of the wages payable or paid to the employees (wef. 01.07.2019). Employees earning upto Rs.176/- per day as daily wages, are exempted from payment of their share of contribution. The main benefits provided under ESI Scheme are Sickness Benefit, Disablement Benefit, Dependants Benefit, Maternity Benefit and Medical Benefit. Besides, other benefits being provided to beneficiaries are Confinement Expenses, Funeral Expenses, Vocation Rehabilitation, Rajiv Gandhi Shramik Kalyan Yojana (RGSKY), Atal Bimit Vyakti Kalyan Yojna {ABVKY) and Skill upgradation training. Coverage In the beginning, the ESI Scheme was implemented at just two industrial centres in the country in 1952, namely Kanpur and Delhi. There was no looking back since then in terms of its geographic reach and demographic coverage. Keeping pace with the progress of industrialization, the Scheme today, stands implemented fully in 351 Districts, partially in 81 Districts and in 97 Districts Hqrs. in 34 states and Union Territories of the country. The Act now applies to over 10.33 lakhs factories and establishments across the country, benefiting over 3.43 crores insured persons/family units. As of now, the total beneficiary ‘stands at over 13.32 crores.Infrastructure Ever since its inception in 1952, the infrastructural network of the Scheme has kept expanding to meet the social security requirements of an ever increasing worker population. ESI Corporation has so far set up 154 hospitals (ESIC Hospitals 44 & ESIS. Hospitals 110) and 42 hospital annexes for inpatient services. Primary and out-patient medical services are provided through a network of about 1500/148 ESI Dispensaries/AYUSH units, and 980 Panel Clinics. The Corporation has also set up five Occupational Disease Centres, one each at Mumbai (Maharashtra), New Delhi, Kolkata (W.B.), Chennai (T.N.) and Indore (M.P.) for early detection and treatment of occupational diseases prevalent amongst workers employed in hazardous industries. For payment of Cash Benefits, the Corporation operates through a network of over 630/185 Branch Offices/ Pay Offices, whose functioning is supervised by 64 Regional/ Sub- Regional Offices. ESIC - A complete Social Security Organization for India’s workforce The ILO defines Social Security as “ the security that society furnishes through appropriate organization against certain risks to which its members are perennially exposed. These tisks are essentially contingencies against which an individual of small means cannot effectively provide by his own ability or foresight alone or even in private combination with his fellows. The mechanics of social security, therefore, consists in counteracting the blind injustice of nature and economic activities by rational planned justice with a touch of benevolence to temper it.” ESIC is the only Social Security Organisation in the country which covers most of the exigencies (provided in the list of ILO) which are sickness, medical care for the worker, maternity, unemployment, work injury, death of worker, invalidity and widowhood. The ESI Scheme is based on the Gandhian principle of “contributions as per their ability and benefits as per the requirement’. This principle entitles an insured person who is from the lower wage bracket of the society for a huge line up of benefits by paying the contribution as per the wages he/she is eaming. Each social security payments made under the ESI Scheme helps the insured person without putting any extra burden on his/her savings or earings, during emergent medicaland other contingencies. The benefits being provided by the ESI Scheme are:- 1. (a) The Sickness Benefit is paid to the insured person at the rate of 70% of the average dally wages up to 91 days in two consecutive Benefit periods. (b) Enhanced Sickness Benefit (for vasectomy/tubectomy) 100% of the average daily wages is payable for 14 days for tubectomy and 7 days for vasectomy extendable on medical advice. (©) The Extended Sickness Benefit is admissible at the rate of 80% of the average daily wages for 124/309/730 days as per the opinion of MR and Medical Board during ESB period of 3 years. 2. Under the Disablement Benefit, the insured person who becomes disabled due to employment injury is paid 90% of the average daily wages as long as temporary disablement lasts. For permanent total disablement, 90 % of the average daily wages is paid for whole life and for permanent partial disablement; the Insured Person is paid proportionate to the loss of eaming capacity as determined by the medical board. 3. Dependants’ Benefit is paid at the rate of 90 % of the average daily wages sharable in fixed proportion among all dependents if the insured person dies due to employment injury. This is payable to the widow for life or until her re-marriage, to the dependent male children till the age of 25 years and to the female children till their marriage. Besides it is also paid to the dependent parents, subject to conditions. In an endeavour to reach out to the beneficiaries and make the system more customer friendly, all benefits are being credited to the bank account of the beneficiaries through ECS System. 4. The Maternity Benefit is paid at the rate of 100% of the average daily wages up to 26 weeks in case of confinement and up to 6 weeks in case of miscarriage. This can be extended by one month on medical advice in case of sickness arising out of pregnancy, confinement or miscarriage. 5. One of the biggest benefits extended by ESIC is Medical Benefit which provides ‘Reasonable medical Care’ (Primary OPD services and In-patient secondary services) for self and family from day one of entering insurable employment which continues till the insured person remains in insurable employment. Super Specialty Treatment is provided subject to fulfilment of contributory conditions. Treatment is provided through Allopathy and AYUSH system of medicines. ESIC Dispensaries and Hospitals are providing the necessary medical treatment. Super speciality treatment is provided through in-house super speciality facilities available in some of the ESI Hospitals @or ESI-PGIMSRs or through large number of advance medical institutions on referral basis through more than 1000 tie-up hospitals across the country. In such cases, ESIC makes direct payment to the hospitals without putting any financial burden on the patient or his/her family. Medical Benefit is also extended to the widow/ spouse of the deceased/ retired/ ‘superannuated Insured Persons as well as to the widow/ spouses of Insured Persons who ceases to be in an insurable employment on account of permanent disablement, and also to the widows of Insured Persons who are in receipt of Dependants’ Benefit. 6. Retirement Benefit: 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/herself and his spouse subject to production of proof thereof, and payment of a nominal contribution of Rs. 120/- (Rupees ‘one hundred and twenty only) 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 of Rs.120/- (Rupees one hundred and twenty only) per annum for further period. This medical benefit is also admissible to an insured person and his/her spouse, who ceases to be in employment on account of permanent disablement caused due to employment injury on payment of similar contribution till the date on which he would have vacated the employment on attaining the age of superannuation, had not he sustained such permanent disablement. 7. Other Benefits include Confinement Expenses for an Insured Woman or an IP in respect of his wife in case confinement occurs at a place where necessary medical facilities under ESI Schemes are not available, for which Rs.5000/- is paid up to two Confinements. 8. ESIC has increased the Funeral Expenses from Rs.10,000/- to Rs.15,000/- in case of death of an insured person. 9. Vocational Training in case of physical disablement due to employment injury for which the actual fee charged or Rs.123/- per day, whichever is higher is paid as long as the vocational training lasts. 10. Rajiv Gandhi Shramik Kalyan Yojana (RGSKY) is payable in case of involuntary loss of employment due to closure of factory, retrenchment or permanent ©invalidity due to non-employment injury and contribution for two years prior to the loss of ‘employment has been paid. This allowance is paid at the rate of 50% of the average daily wages for first twelve months and at the rate of 25% for the subsequent period of 13-24 months. Under RGSKY, in case of involuntary loss of employment, skill up gradation training is provided for duration of maximum 1 Year, so that the IP can enhance his/her skill and opt for other jobs. 11. Atal Bimit Vyakti Kalyan Yojana (ABVKY): In case of unemployment, cash compensation will be paid to the IP for 90 days. For this, the contribution of minimum 78 days in each contribution period should be paid in respect of the insured person, 02 years prior to the involuntary loss of employment. 12. In order to encourage employment of disabled persons, the Employers’ share of contribution in respect of such disabled employees is paid by the Central Government for initial ten years and thus the employers are exempted from paying their share of contribution upto 10 years in respect of all Permanently disabled persons imespective of their wages working in factories and establishments covered under ESI Act Brief description of Benefits, Contributory Conditions, Duration of Benefits and the Scale of Benefits 1. Medical Benefit One should be an insured | From day one of | Reasonable medical person under ESI Act. entering into | care, comprehensive insurable medical care & clinical employment. | investigation for IP and his/her dependent family members. 1(a) Medical care to ‘On payment of Rs.120/- per |On yearly basis. | Medical facility for Permanently disabled | annum primary and secondary care IPsWs who ceases to be (excluding SST) within ESI insurable employment due Medical institutions to IPIW. fo employment injury and his/her spouse till the date of superannuation. 4(b)Medical care to retired | To an IP who leaves the ‘On yearly basis. | Medical facility for primary and Insured Person insurable employment (on secondary care (excluding SST) attaining the age of within ES! Medical institutions superannuation, or retires to IP & hisiher spouse for whole under a VRS or takes life. This benefits also provided premature retirement after to the widow of deceased IP being insured for not less than Who had provided to the widow five years) on payment of Rs. of enrolled for this benefit. 120/- per annum @2. Sickness Benefit (On payment of contribution for | Upto 91 days | 70% of the average not less than 78 days in in any two daily wages. Corresponding contribution | consecutive period. benefit periods. 2(a) Enhanced Sickness _ As of Sickness Benefit. 7 days to an IP for | 100% of the average Benefit Vasectomy & 14 | daily wages. days to IW for Tubectomy, 2(b) Extended Sickness For 34 specified long term 124 to 309 days 80% of average daily Benefit |diseases. IP/IW should have _| which may be wages. |continuous insurable ‘extended upto two |employment for two years with | years (730 days) minimum 156 days contribution | on medical advise in four consecutive contribution | specified for long periods. term diseases. 3, Disablement Benefit 3(a) Temporary From day one of entering into. |» Not payable if Disablement Benefit insurable employment. Paid for| disability lasts for employment injury arising in |less thane 3 days the course & out of (excluding the day insurable employment. of accident). + Otherwise payable for the entire period, 'so long as the ‘temporary disability lasts. 3(b) Temporary * No contributory condition | For wholelife. ‘+ For permanent total disablement Disablement Benefit are there. -90% of average dally wages. * Paid for permanent disablement, whether total or partial, caused by accident or an occupational disease arising out of and in the course of insurable ‘employment. For permanent partial disablement proportionate to the loss of earning capacity as determined by the medical board. This can be commuted into lumpsum in case the daily rate benefits uptors.10 or the total ‘commuted value does not exceed s.60,000/-4{a)Dependants’ Benefit | From day one of entering into |For life to the widow | 90% of average daily insurable employment in case |or until her re~ wages shareable ‘of death due to employment |marriage and to each] among dependents in injury. legitimate or adopted] fixed proportion. |son upto the age of 125 years. To each legitimate or adopted} unmarried daughter until marriage. For infirm chit til infirmity lasts, 4(b) Medical care tothe |For widow in receipt of Yearly basis. Medical facility for primary and widow in receipt of Jdependant benefit. secondary care (excluding SST) Dependant Benefit within ES! Medical institutions on yearly payment of Rs.120/-to the widow of deceased IP who is in receipt of dependent benefit. 5. Maternity Benefit 170 days contributions payable | + 26 weeks upto two | 100% of the average in the immediately preceding 2| surviving children | daily wages. consecutive contribution and thereafter. periods + 12 weeks for 3 rd surviving child and onwards. + 6 weeks in case of miscarriage. + 12 weeks for the Commissioning mother. + 12 weeks for the ‘adopting mother. 6. Confinement Expenses | An Insured Woman or an Upto two: Rs.5,000/- per case Insured Person inrespect of | confinements. subject to two cases. his wife shall be paid medical bonus on account of confinement expenses at a place where necessary medical facilites under the ESI Scheme isnot available.7. Funeral Expenses + IP should have been eligible | One time payment | Actual expenses for any of the benefit under | for defraying subject to maximum ESI Scheme. ‘expenses on Rs.15,000/- only. + On production of a death funeral of an certificate by the eldest Insured person. surviving member! dependents/any person who actually incurs the ‘expenditure on funeral. 8. Unemployment Allowance | + insurable employment for | Unemployment —_| « Unemployment allowance at Under Rajiv Gandhi Shramik | the last 2 years with 78 days | Allowance fora | the rates of Kalyan Yojana(RGSKY) —_| contribution paid/payable | maximum period of | (a) 50% of last avg. daily wages in each contribution 24 months during | for 0- 12 months period. the entire insurable | (b) 25% of last avg daily wages + Involuntary unemployment | employment. for 13-24 months. rendered due to closure of + Vocational training for duration Factory/Establishment, Upto 1 year for upgrading skills of retrenchment or Person receiving unemployment permanent disablement allowance. due to non- employment + Medical care for self and family injury not less than during receipt of unemployment 40%. allowance. + Entire fee charged by Government approvediaccredited institutions reimbursed by ESIC. 9. Vocational Rehabilitation | Notmore than 45 years of age | Training in any field | Conveyance charges ‘Allowance under Rule 60 | and disability not ess inaGovt.Institution | atnormal rate/second class than 40% due to JorGovt.accredited | railway/bus fare as applicable. Employment Injury. Institution as perthe | - Expenditure charged by the norms of the center or Rs. 123/- per day, Vocational whichever fs more. Rehabilitation Centre/institution. 10. Atal Bimit Vyakti Incase of unemployment, cash | 90 days Kalyan Yojana compensation will be paid to the insured Person subject to 2 years of service completed by IP and contribution for not less than 78 daysin each contribution period.+ Public Grievance Module 2.0 The Insured Persons, Employers and General Public can lodge their grievance/complaints online through this module anytime, anywhere in the following manner:- 1. Log on to ‘www.esic.in or & www.esic.nic.in’. 2. Click on Public Grievance. 3. Fill up necessary information write grievance/ complaint. 4. Submit. 5. Online grievance number will be generated. 6. Track the status of the grievance/complaint through grievance number. + IVR HHelp Desk Facility for ESIC Toll free No. 1800-11-2526: Facility to attend to callers’ queries and also to receive complaints / grievances and redress the complaints. Unique ticket number given to complaints requiring longer period and forwarded to PG Portal of ESIC for early redressal. For any other information about the ESI scheme, individuals or organizations may log on to ESIC website: www.esic.nic.in, www.esic.in, www.esichospitals.gov.in or contact any of the officers of ESIC offices/ establishments. Grievances can also be reported in writing, over telephone through Toll Free Helpline, by post, Email or in person to any of the following officers. Branch Office Level : Branch Manager Dispensary Level _: Insurance Medical Officer Incharge Hospital Level: Medical Superintendent/Deputy Medical Supdt. Regiona/Sub- _: (}) Regional Director/Director/Joint Director/Dy. Director (VC) Regional Level __: (i) Public Grievance Officer Corporate Level _;: (I) Director General (ii) Medical Commissioner (ii) Insurance Commissioner (iv) Director (Public Grievances) * Suvidha Samagam In order to deal with oral, written complaints/suggestions and grievances, Suvidha Samagam is. being held regularly in various field offices i.e. at RO/SRO/ESIC Hospitals on 2nd Wednesday of every month and at Branch Office on 2nd Friday of every month. Address: ES! Corporation, Panchdeep Bhawan, CIG Marg, New Delhi-110002 Website: www.esic.nic.in, | www.esic.in, | www.esichospitals.gov.in E-mail: pg-hars@esic.nic.in, Phone: 011-23234092/93/98 Fax: 011-23234537 Toll Free Number: 1800 11 2526 + Medical Helpline Number: 1800 11 3839 @ @SALIENT ACHIEVEMENTS, + Dispensary-Cum-Branch Offices (DCBO) has been set up for outpatient services and cash benefit payments to the IPs at one location. + Dispensary-Cum-Branch Offices to empanel IMPs/Pharmacies/Diagnostic centres in respective districts. For this purpose, Mobile based software is now ready for monitoring the delivery of primary care to IPs. + To make ES! Scheme more attractive, Atal Bimit Vyakti Kalyan Yojana launched to provide unemployment allowance upto 90 days. * Started intensive monitoring of SST bills pending for payment at ESIC Hospitals and Regional Offices which is yielding good results. . Finalised rate contracts for essential drugs. + Procurement of secondary and tertiary care equipments under way. + ESI Scheme implemented in Andaman & Nicobar Island and All North-Eastern States except Arunachal Pradesh = & Union ‘Territory + of-~—Lakshadweep. + ESI Scheme now stands implemented in 529 Districts of the States, where industrial’ commercial clusters are located. + ESIC approved its investment policy and appointed consultant for selection of Portfolio Managers, Custodians & Concurrent Auditors. + The Corporation approved proposal for formation of State Autonomous Body(SAB)Employees’ State Insurance Society + in’ ~—sthe~—sStates. + ESIC bagged the prestigious “India Pride Awards” in the Best Autonomous Organisation Categories for playing a vital role towards the development of the country. ESIC made ‘an exponential growth in extending coverage to the record no. of employees and employers. New initiatives during last 1 year. + Number of Insured Persons under ES! Scheme has gone up to 3.43 crores and the beneficiaries has touched a figure of 13.32 crores at the end of March, 2018. + During the F.-Y. 2017-18, ESIC has disbursed Rs. 642.84 crores as benefits in cash. The number of Cash Benefit payments has gone up to 36.97 _ lakhs. * During the F.Y. 2017-18, an expenditure of Rs. 6867.73 crores was incurred on Medical Benefit. + Launched ESIC- ‘Chinta Se Mukti’ Mobile App on UMANG Platform-Insured Persons can view their contribution history, personal profile, claim status and also their entitlement to benefits through this Mobile App. Grievances can also be lodged through this App. Besides, IPs can also view knowledge bank on health topics and audio-visuals on benefits under ES! Scheme.ESIC VISION 2022 + The expansion of ESI Scheme in each district of the Country with target of covering 10 crores workers in a phased manner. + Expanding the network of secondary and primary medical care centres and improving the quality of medical benefits. + Upgradation of existing ES! Hospitals with modem equipments and adequate number of Specialists and IMOs. * Strengthening public grievance redressal mechanism to inculcate accountability and improve responsiveness of ESIC. + Health Pass Book for IPs. * ESIC Toll Free No. gets IVR/Help Desk Facility- ESIC has started a landmark facility with “Launching of IVR(Interactive Voice Response)/Help Desk for ESIC Toll Free No.-1800- 11-2526. + User friendly Audio-Visual Clips on ESIC- To educate and spread awareness about ESI Benefits among the stakeholders, mainly the workforce, ESIC produced seven Audio- Visuals using into graphics and simple language. These Audio-Visuals are already available on You Tube(Employees’ State Insurance Corporation You Tube Channel). The Audio-Visual clips will help all the stakeholders, IPs & their family members, employers and employees to understand the various benefits being provided under ESIC Scheme. + Relaxation in the eligibility conditions for availing Super Specialty Treatment- ESI Corporation approved the proposal for relaxing the eligibility conditions for availing Super Specialty Treatment from earlier insurable employment of 02 years to 06 months with contribution requirement of only 78 days. Besides, the eligibility for availing Super Specialty Treatment for dependants of Insured Person has now been relaxed to insurable employment of 01 year with 156 days (78 days in each contribution period) of contributions. Insured Women shall be eligible for SST in case it arises due to or out of Matemity if she is in receipt of Maternity Benefit. This relaxation will immensely help the Insured Persons and their beneficiaries to avail Super Specialty Treatment free of cost as per revised eligibility. * Modified Employers’ Utilization Dispensary [MEUD] In addition to existing options, wherever ESIC Medical Services are not adequate particularly in the newly implemented areas, ESIC has planned to open Modified EUD with the active participation of employers to strengthen the medical services delivery mechanism. * Modified Insurance Medical Practitioner(IMP) Scheme, 2018 ESI Corporation has given in principal approval to Modified Insurance Medical Practitioner(IMP) Scheme, 2018 to make IMP Scheme more attractive on pilot-basis. ®This scheme may further be expanded in the new areas as well as exiting areas as per need. In an area, where ESI does not have its medical establishment, or in newly implemented area, Primary Medical Care is provided cashless through tie up arrangement, with Insurance Medical Practitioner(IMP). ESIC shall utilize the services of private practitioners (as IMPs) for delivery of primary care services (except for lab tests & medicines) to IPs. + Enhancement in Funeral Expenses ESIC has enhanced the Funeral Expenses from Rs. 10,000/- to Rs. 15,000/-. It will be paid on production of a death certificate by the eldest surviving member/dependants/any person who actually incurs the expenditure. * ESIC to allow Non-Ps to avail medical services from its underutilized Hospitals: ESIC has decided to allow Non-IPs to avail medical services from underutilized ESIC Hospitals after levying User Charges at a subsidized cost of Rs.10/- for OPD consultation, at 25 % of CGHS package rates for IPD and to provide medicines on actual rate initially for one year on pilot basis. + Exemption limit for payment of employees’ share of contribution Decision to enhance the exemption limit for payment of employees’ share of contribution from Rs.137 to Rs.176 has also been taken. Social Media Tools: + ESIC has made its strong presence felt on Social Media Handles through Facebook (www.facebook.com/esichq), Twitter (www.twitter.com/esichg) and other such handles like Pinterest, Instagram, G+ & Youtube. The visitors post their Grievances, Feedback and comments on other issues related with ES] Scheme enthusiastically. Medical Education and ICT * 6 Medical Colleges have been established by ESIC at Rajaji Nagar, Bengaluru (Kamataka), Gulbarga (Karnataka), Chennai (Tamil Nadu), Sanatnagar (Hyderabad), Faridabad (Haryana) & Joka (West Bengal), in which around 600 students have been enrolled in the under graduate courses of medical science. + Two Dental Colleges at Rohini (Delhi) and Gulbarga (Kamataka) respectively have been established by ESIC where the total number of seats is 100. + The post graduation in medical education for 108 seats is provided by ESIC Hospitals at Andheri East (Mumbai), Rajaji Nagar (Bengaluru), Joka (Kolkata), Manicktala (Kolkata), Chennai & Basaidarapur (New Delhi). @ESIC AT AGLANCE ras nm [ma | wom | mae | mew | mew | an No. of IPs covered under | 471990958 18582000 19547620 20343800 | 21361880 31962910 34331300 besser Yecotawndvonen | aera | arma | amaws | mer | wear | anne | ee Wp. of Begeietoen cove) Geaci717 72098160 ‘75844766 7e933944 | 82884004 | 124016091 | 139205444 peepee weet Scotemenscowea | ston | sxaer | mao | race | rare | sonse | snrn Ss arcana | coe hte | dc. 9 No. of implemented 807 810 815 830 836 ‘51 district | district Hqrs. : Hars. areas | and partially esate Teatrewwaicone Tsasas | somnes | soma | saese | verze | snncase | cooar Teal epenatron an ‘benefit (Rs. In 2686.62 4058.13 4859.90 5714.34 6112.97 6256.57 6867.73 ‘etl egndtr oa memacrooncsh| aaias | raisr | mes | anisr | nase | wove | sam @ wird or ter fre Ee cee cee «Siena tngn Sows