FACILITIES PROVIDED BY THE ESIS (Medical) Services.        

    

 FACILITIES PROVIDED BY THE DEPARTMENT OF Employees State Insurance Scheme (MEDICAL) SERVICES:-

The Medical Services are rendered by the Department of Employees State Insurance Scheme (Medical) Services popularly known ESIS (M) Services as per the memorandum of agreement by the State Government with ESI Corporation.

According to para 25 of the agreement the State Government and ESI Corporation whenever the rate of certification in the State exceeds the average of the country rate over and above 25%, then the State Government has to bear the entire exceeded expenditure on sickness benefit.

The Scheme started functioning from 27th July 1958 at Bangalore with a humble beginning with a strength of 12 ESI Dispensaries, 100 bedded ESI Hospital catering more than 48,000 beneficiaries with the wage limit of Rs.400/- p.m.

Now in Karnataka full medical care has been extended to about 7,73,000 Insured Persons and about 40,00,000 of their family members, headed by the Director through a network of 9 ESI Hospitals, 1 Diagnostic Centre, 3 ESI Annex Hospitals, 130 full time ESI Dispensaries, 7 Part time ESI Dispensaries and 12 Employers facilities Dispensaries +and through Government Hospitals and Primary Health Centres.

FACILITIES AVAILABLE IN THE DEPARTMENT

    1. Inpatient and Out-patient facilities
    2. Drugs and Dressings
    3. Laboratory Investigations and Imaging Services
    4. Artificial Limbs, Aids and Appliances
    5. Integrated family welfare, Immunisation and Child Health Care Services
    6. Ambulance Services
    7. Tie-up arrangement with private Hospitals and Nursing Homes where the ESI Hospital / Facilities are not available.
    8. Tie-up arrangement for Super Specialty treatment.
    9. Grant of Ex-gratia payment
    1. Re-imbursement of Medical Expenses.
    2. Medical Certification.
    3. Grievance Redressal Machinery.
    4. Medical Board.
    5. State Family Welfare Cell.
    6. ESI State AIDS Cell.

1. iN-patient and OUT-patient facilities:

In-Patient    – ESI Hospitals- referred from Diagnostic Centre and Dispensaries

Out-Patient – i. provided at Dispensaries
                     ii.ESI Hospitals and Diagnostic Centre (referred from Dispensaries)

DRUGS AND DRESSINGS

All Drugs and dressings (including vaccines and sera) that may be considered necessary and generally in accordance with the E.S.I.C drug formulary are supplied free of charge. There are two parts in E.S.I.C Drug Formulary, 1998 as follows:-

List of medicines for emergency kit for (a) Dispensary (b) Hospital

List of medicines to be supplied to the dispensaries in Service Areas.

LABORATORY INVESTIGATIONS AND IMAGING SERVICES:

Imaging and investigations including CT Scan, MRI, Echocardiography and laboratory facilities are provided free of cost to IP’s and their families at state level specialty hospitals or other institutions having tie up with E.S.I.Scheme.

2. ARTIFICIAL LIMBS, AIDS AND APPLIANCES:

Insured Persons and their family members are provided following artificial limbs, aids and appliances as part of medical care under the E.S.I Scheme:-

    1. Artificial limbs
    2. Hearing Aids
    3. Spectacles (Frame costing not more than
      Rs.100/-and replacement of frames not
      to be made earlier than 5 years) : to Insured Persons only

             4. Artificial Dentures, teeth : …………do…………….

             5. Artificial Eye : …………do…………….

    1. Wigs (replacement not earlier than 5 years) to female beneficiaries only
    1. Cardiac pacemaker
    2. Wheel Chair / tricycle
    3. Spinal supports (jackets, braces etc.,)
    4. Cervical collars
    5. Walking calipers, surgical boots etc.
    6. Crutches
    7. Hip prosthesis, total hip
    8. Intra Ocular Lens (IOL)
    9. Any other aid or appliances prescribed by the specialist as part of treatment.

 

The expenditure on artificial limbs, aids and appliances is met from the shareable pool of expenditure on medical care.

3. INTEGRATED FAMILY WELFARE, IMMUNISATION AND MATERNITY CHILD

HEALTH PROGRAMME:

ESIC is implementing the integrated Family Welfare, Immunisation and Maternity and Child Health Programme in the form of child survival and safe motherhood programme. Now, it has been expanded to cover reproductive health and Sexually Transmitted Diseases.

The various services provided under the programme are in line with Government of India’s programme. The different formats / proforma for ante-natal, post natal, immunisation services etc., are same as adopted and circulated by Government of India from time to time.

At present various services provided are as follows:-

a. Family Welfare:

Insured persons and their spouses are provided facilities of Family Welfare viz. Vasectomy, Tubectomy operations, Intrauterine device insertion, medical termination of pregnancy, supply of condoms, distribution of oral pills etc.

b. Immunisation – Vaccination and Preventive Inoculation:

Vaccination and preventive inoculations are provided free of cost to IP’s and their families as per national immunisation schedule.

c. Maternity Services:

Antenatal Care, Confinement and Post Natal Care.

Antenatal and Post-Natal care and confinements facilities are provided free to insured women and wives of IP’s.

Medical Bonus of Rs.250/- per confinement is payable when confinement of insured Women or spouse of IP occurs at a place where facilities under the E.S.I Scheme are not available.

4. Ambulance Service or Reimbursement or conveyance charges:

a. Ambulance Service:

IP’s and members of their families are entitled to free ambulance service for visiting Specialist Centres, Hospitals etc., for Specialist consultation or admission or any investigation, provided that the patient is so ill that he / she is not able to travel by ordinary modes of conveyance. The facilities are available in Hospitals. Necessity for transport of sick persons by ambulance is to be strictly decided by IMO/IMP in accordance with the nature of disease and condition of the patient and whether or not transport by means other than an ambulance will be in the interest of the health of the patient. For emergency, ambulance services are provided round the clock.

Ambulance vans are provided as per prescribed Norms by the Corporation.

In case of areas having lesser number of IP’s arrangements should be made with other Organisations like District Hospitals Municipal Hospitals and Red Cross Society etc., to hire their ambulance for ESI Patients. Contractual arrangements may be made with private parties, in areas where own ambulance is not available and arrangement with other organisations is not possible.

b. Reimbursement of Conveyance Charges:

In the absence of availability of an ambulance and where needed in an emergency, any other quick form of transport may be used and amount so spent subject to the maximum rate prescribed by the Government / Transport authority (both ways) is reimbursed to IP’s.

To avoid hardship to IP and his family who have to go to any hospital or medical institution for admission, specialist consultation or investigation, but whose condition is not such as to need an ambulance, provision has been made for the payment of conveyance charges, if hospital / medical institution to which the case is referred to, is at an out-station or is at a distance of more than 8 kms from the ESI Dispensary or the clinic of the panel doctor. The charges are restricted to actual II class railway fare or cost of a single seat in public conveyance both ways whichever is feasible.

If the beneficiary is not in a fit condition to travel without escort for reasons to be recorded and so certified by IMO / IMP, the conveyance charges are also allowed for an escort.

The IMO / IMP should keep a separate account of such payments in the prescribed Register and send a quarterly statement of this expenditure to the Director/AMO by the 15th of the month following the quarter ending in March, June, Sept and December. The returns received from different areas in the State may be consolidated area-wise by the Director / AMO and quarterly statement sent to the Corporation.

The expenditure on conveyance charges forms part of the Medical Care under the E.S.I. Scheme and hence shareable between the Corporation and the State Government in the usual ratio within ceiling prescribed.

c. Domiciliary Treatment:

An Insured Person and his family members are entitled to free medical attendance by IMO / IMP at their residence when the condition of the patient is such that he / she cannot reasonably be expected to attend the dispensary / clinic.

Conveyance allowance for Domiciliary visit:

i) For the domiciliary visit, the IMO’s are paid conveyance allowance. The quantum of this allowance is decided by the State Government in consultation with the Corporation.

ii) The IMPs are not paid any domiciliary conveyance allowance. In their case, it is included in the capitation fee upto a distance of 5 km, between the clinic of IMP and IP’s residence.

The IMOs / IMPs are required to maintain record of domiciliary visits in a register month-wise. The columns in this register are given under the chapter "Sickness Absenteeism and Recording".

c. Hearse Van:

A dead body van / hearse van may be provided on contractual basis in each E.S.I. Hospital.

5. Tie-up arrangement with private Hospitals and Nursing Homes

where the ESI Hospital / Facilities are not available.

(a) In order to give better treatment to the IP’s and their family members the Department is having a tie-up arrangements with Private Hospitals and Nursing Homes where there is no ESI Hospitals in the following places.

    • K.G.F
    • Tumkur
    • Hospet
    • Karkala
    • Hulikote
    • Manipal

(b)The Department has got tie-up arrangements with Private Hospitals and Nursing Homes in the following places where there is ESI Hospitals:

    • Mysore (If the facilities are not available in the ESI Hospital)
    • Mangalore (If the facilities are not available in the ESI Hospital)
    • Hubli (If the facilities are not available in the ESI Hospital)
    • Davanagere (If the facilities are not available in the ESI Hospital)
    • Belgaum (If the facilities are not available in the ESI Hospital)
    • Shahabad (If the facilities are not available in the ESI Hospital)

Beds are also reserved for IP’s in Government and other Private Hospitals in the State.

6. Tie-up arrangement for Super Specialty treatment.

In case super-specialty / specialty treatment is not available in ESI Institutions for illness like heart surgery, neurosurgery, bone marrow transplantation, dialysis, cancer treatment, etc tie-up arrangements had been made with the reputed hospitals possessing these facilities. The Corporation has decided to keep Rs.50/- per I.P family unit per annum out of the ceiling of Rs.600/- with Regional Offices as a corpus. This fund is to be utilised for deposit / reimbursement for such treatments against the sanction by the Director of ESIS (M) Services.

The following Institutions are having tie-up arrangements for Super Specialty treatment:

( i ) Autonomus Organisations headed by State / Central Government:

    • Jayadeva Institute of Cardiology, Bangalore.
    • Kidwai Memorial Institute of Oncology, Bangalore.
    • NIMHANS, Bangalore.

(ii) Private Hospitals

    • M.S.Ramaiah Hospital, Bangalore.
    • Bangalore Kidney Foundation Hospital, Bangalore.
    • K.C.T.R.I. Hospital, Hubli.
    • Bharath Cancer Hospital, Mysore.

7. Grant of ex-gratia payment:

In the event of death, marked disability, loss of limb, or part of limb of an Insured Person or family member due to adverse reaction of drug / injection an ex-gratia payment upto Rs.5,000-/ may be allowed.

8. Reimbursement to employers under Regulation 69:

Reimbursement of medical expenses for providing Emergency Treatment / First aid to the Employer is provided under Regulation – 69.

Under Regulation – 69, every employer has to arrange for First-aid Medical care and transport of accident cases till the injured IP is seen by the IMO / IMP and such employer is entitled to reimbursement of expenses incurred in this regard upto the maximum of scale prescribed from time to time. However, reimbursement is not permissible, if the employer is required to provide such medical aid free of charge under any other enactment.

The cost of provision of such emergency treatment would be reimbursed to the employer by the Director / AMO (ESI Scheme) of the respective State and, therefore, all claims duly supported by relevant receipts and vouchers should be sent to the Director for verification and payment.

9. Reimbursement of expenses incurred in respect of medical

treatment under regulation-96 A.

Regulation – 96 A reads as follows: - Claims for reimbursement of expenses incurred in respect of medical treatment of IP and his family may be accepted in circumstances and subject to such conditions as the Corporation may be general or special order specify.

The following conditions have been laid down under this Regulation: -

    • Full authority is vested with the State Government concerned to reimburse expenditure in respect of medical treatment of IP and his family.
    • It may be left to the discretion of the State Government to decide the Authority within their machinery who will approve the expenditure in question; and
    • Time limit for submission of the claims for reimbursement is one year.

The State Government has to keep in view the following points while considering the cases of reimbursement of expenditure on Medical Care:

i. Whether such facilities for which reimbursement is recommended are not
    available in the ESI Hospitals.
ii. Whether the hospital, where the IP was referred or proposed to be referred was / is the nearest
     hospital having required facilities / services.

A list of Types of cases for which reimbursement is permitted is given below:-

    1. Reimbursement is permissible in case of failure of the mobile dispensary van due to technical defects or otherwise to adhere to its schedule timings or where IP attached to such a dispensary sustained serious injuries or suffered from serious illness during off hours of the dispensary.
    2. IPs and their family members had to resort to private treatment during the off hours of ESI dispensary / Emergency Centre due to unavoidable circumstances.
    3. Medicines prescribed by IMO / Specialist were out of stock in the ESI Dispensary/ Hospitals thereby compelling the IPs to make purchases from the market.
    4. Medicines prescribed by Specialist and not provided by the IMO / IMP and where specialist considered such special Medicines absolutely necessary for the treatment of the beneficiaries as no substitute medicine was considered equally efficacious whether as an out patient or in-patient.
    5. Special appliances prescribed by Specialist such as Spinal supports, Cervical Collars, Walking Calipers and Crutches, etc., if considered necessary as part of the treatment.
    6. Where an IMO / IMP failed to make domiciliary visit requested by an IP thereby compelling the IP to make private arrangement for treatment. Under the panel
    7. system such cost is recoverable from the IMP if recommended after investigation by the Medical Service Committee / State Grievance Cell / State Scrutiny Committee / Hospital Scrutiny Committee.
    8. Serious cases of accident or illness admitted directly into recognised hospitals where owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal his identity; as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer.
    9. Serious cases of accident / illness where a beneficiaries was admitted directly at a private hospital or in a non-recognised hospital where admission in a hospital recognised under the scheme would have seriously jeopardised his health like sudden heart attacks, fracture of the spine, cerebral haemorrhage, etc.
    10. Expenditure incurred on investigation for blood transfusion.
    11. Mental cases that may have incurred expenditure either as an outpatient on specialised Therapy such as ECT etc.
    12. Serious cases of accident and illness admitted to recognised hospitals where all the reserved ESI beds were occupied.
    13. Reimbursement of conveyance charges incurred by IP where ambulance or any other transport under the scheme is not available owing to some reason or the other and where in the opinion of the IMO / IMP such a patient was non-ambulatory.
    14. In respect of Specialised examination, laboratory test, X-ray, other imaging services etc., recommended by specialist, but where the IP either due to the break down in the machinery or where the nature of the examination of the Laboratory Tests was such that it was beyond the scope of the facilities available in the recognised laboratory / hospital.
    15. In addition to above types of cases, reimbursement may also be allowed in other cases depending upon the merits of each case and the circumstances under which expenditure was incurred.

10. General Principles of MEDICAL Certification:

Broadly, the principles governing the issue of certificates for sickness (including sickness arising out of pregnancy / confinement and enhanced sickness and ESB) and Temporary Disablement are similar. Even the Forms used and procedure for issue of these Forms are similar. Hence, these have been dealt with together. Distinctive features of certification for temporary Disablement, ESB, Maternity etc., will be taken up separately.

While issuing certificates for Sickness, the definition of the term "Sickness" as defined in Section 2(20) of ESI Act must be kept in mind. Under this section, "Sickness" means a condition which requires medical treatment and attendance and necessitates abstention from work on medical grounds. This definition enjoins that before a sickness certificate can be issued, two

conditions must be satisfied, namely (i) that a person requires medical treatment and attendance and (ii) that his condition temporarily necessitates abstention from work on medical grounds. This

needs a little clarification for the guidance of the IMO’s / IMP’s. There may be cases who require medical treatment and attendance but not abstention from work, e.g., cases of simple diseases like a small abrasion. There may be cases who require abstention from work, but not medical

treatment and attendance e.g. cases of such diseases where no further active treatment is indicated or possible and there is a permanent disability. Thus it is clear that both these conditions are satisfied before issuing a medical certificate. As this is also the language of Forms 8,10 & 11, these conditions apply even when issuing certificates for E.I. cases also.

IPs are issued medical certificates for Sickness, Employment injury and Maternity free of charge by IMOs / IMPs whenever abstention from insurable employment and issue of such certificates is necessary. Death certificate is also issued. Family members are also issued certificates wherever required.

Section 46 (1) of the ESI Act read with ESI (General) regulation 54 to 61, 87 to 89B, 94 and 107 provide for issue of Medical Certificates (Regulation Certificates) and lays down the procedure for Forms to be used in respect of sickness, Employment Injury, Maternity, Miscarriage and Death. The following chart shows the certificate forms prescribed under ESI (General) regulation, 1950 i.e. Regulation Certificate and certificate prescribed for administration purpose i.e., Non-regulation certificate.

(a) Regulation Certificates

Sl.No.

Regulation

Form No

Type of Certificate

Purpose & Remarks

1

57

Form – 8

First Certificate

Issued on first examination to certify medical attendance & treatment and abstention in case of sickness, EI, Sickness arising out of pregnancy / confinement. It certifies only the day of examination, 24 hours, (3 days in case of mobile dispensary) but back period may be covered in genuine cases.

2

57

Form – 8

Combined First & final Certificate

Issued for short spell upto 3 days, 24 hours (3 days in case of mobile ESID) but back period may be covered in genuine cases.

3

58

Form – 9

Final Certificate

Issued in cases where first certificate was issued / directly admitted when the IP is found fit for duty on same day or any other day not later than the 3rd day after date of examination.

4

59

Form – 10

Intermediate certificate

Issued on 8th day after the first certificate and at intervals of 7 days till IP is fit for duty.

5

61

Form – 11

Special Intermediate certificate

Issued where prolonged abstention is required after 28 days of first certificate, when repeated examination is not required and abstention for 14 to 28 days is required, ESIC Med. 11 for the same period to be issued from separate book.

6

79

Form – 17

Death certificate

Issued after receipt of accident report resulting in death and on identification of the body of the deceased. Meant for claiming funeral expenses and dependants’ benefit.

7

87

Form – 20

Certificate of Pregnancy

Issued on confirmation of pregnancy of an Insured woman.

8

88 (i)

Form – 21

Certificate of Expected confinement

Issued where expected date of confinement is within next 50 days. ESIC Med.11 from separate book for 84 days is to be issued simultaneously.

9

88 (iii) / 89

Form – 23

Certificate of confinement / miscarriage

Issued if signs of recent confinement / recent miscarriage are present. Issued within 30 days of confinement or miscarriage. ESIC Med.11 for 84 days for confinement and 42 days in case of miscarriage.

10

89 (A)

Form – 24 (B)

Maternity Benefit Death Certificate

Issued on death of Insured woman after miscarriage / confinement during the maternity benefit period.

11

107

Form – 26

Life Certificate

Issued at 6 months intervals to insured persons in receipt of permanent disablement benefit.

(b) Non-Regulation Certificates

Sl.No.

Form No

Type of Certificate

Purpose & Remarks

1

ESIC MED.8

Certificate for IPs suffering from ESB

Issued to IPs suffering from a disease for which ESB is payable.

2

ESIC MED.8A

Record of Progress of IP suffering from ESB

Issued to the IPs suffering from a disease for which ESB is payable. The progress of the disease is given at periodical intervals.

3

ESIC MED.11

Certificate of Information of Sickness / Maternity / Miscarriage for the Employer

For information to employer to regulate leave and make alternate arrangement. Issued for corresponding period from separate book along with Forms 11, 21 & 23. Also issued as duplicate of lost certificate for information to employer, Quarantine & court purposes.

4

ESIC MED.12

Death Certificate

Issued in case of death for cases not covered by regulation certificate on identification of body of deceased and used for claiming funeral expenses only.

5

ESIC MED.13

Certificate for inpatients in Hospitals

Issued to IPs undergoing in-patient treatment by IMP of ESI Hospital at weekly intervals at the request of IP along with ESIC-Med.11 from separate book for claiming periodical payments.

6

Section 2(6A) & 80 (i) (iv)

Certificate of infirmity (Proposed)

Issued by Medical Referee for claiming dependant’s benefit & for Medical benefit beyond 21 years of age of the dependant.

11. GRIEVANCE REDRESSAL MACHINERY:

Grievance redressal machinery is functioning in the ESI dispensaries/Hospitals and Directorate of ESI (Medical) services.

Vigilance Committees have been constituted for ESI Hospitals in the State.

A state level Grievance cell is established in the Directorate consisting of the following officers



Dr.H.B.Lingamma,  
Director, ESIS (M) Services.
Chairperson
Dr.(Mrs) N.Khan,
Deputy Medical Commissioner ESIC
Member
      1. Dr.H.B.Lingamma,                                       - Chairperson
      2. Director, ESIS (M) Services.

      3. Dr.(Mrs) N.Khan,
      4. Deputy Medical Commissioner ESIC             - Member

      5. Sri Venkatesh, Joint R.D
      6. Complaint Officer, ESIC                               - Member

      7. Dr. Venkatachalapathy,                                - Member
      8. Dy.Director, ESIS (M) Services.

      9. Dr.D.O.Gangadhara Swamy               

                                Asst Director/Complaint Officer

                                State Grievance cell.                                   - Member Secretary 

The committee meets on the 3rd working Friday of every month to hear complaints relating to administration of medical benefits.

If there is any problem in the hospital/dispensary, you can contact the Superintendent / Administrative Medical Officer or Dr.D.O.Gangadharaswamy, Complaint Officer State Grievance Cell, Directorate of E.S.I.Scheme (Medical) Services, Rajajinagar, Bangalore-560 010. Telephone No. (080) 3325578.

12. STATE FAMILY WELFARE CELL

The State Family Welfare Cell was established on 23-5-1997 at Directorate. The work profile of the Assistant Director is mainly to the Family Welfare immunisation and implementation of National Health Programmes.

13. ESI STATE AIDS CELL

ESI State AIDS cell was established in the month of March 2000, Assistant Director / Programme Director is assisting in implementation of National AIDS Control Programme in the Department and also Blood Transfusion Services.

14. MEDICAL BOARD

Medical Board meeting for the workers residing at Bangalore will be held on 2nd and 4th working Thursday of every month at Directorate of ESIS (M) Services, Bangalore - 10. Medical Board meeting for the workers residing outside Bangalore be held on 2nd working Wednesday of every month at ESI Hospital, Rajajinagar, Bangalore - 10. The Director is the chairperson for the Medical Board. The other members of the Medical Board are Deputy Medical Commissioner, (SZ), two Senior Surgeons and Specialist of the concerned medical specialty. The board will decide the benefits to the Permanent disabled IP’s.

The employer shall deliver the TIC to the employee to when it relates after obtaining his signatures or thumb impression. The employee can avail of medical treatment on production of this TIC which is valid for 3 months and can be revalidated till a permanent Identity Card is issued.

 
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