FACILITIES PROVIDED BY THE ESIC.        

                               

  Facilities provided by the Employees State Insurance Corporation:

1. Registration of Employees and Temporary Identification Certificate (TIC) :

The employer taking any persons into employment shall be required to furnish certain particulars and details of workers and their families in the Declaration Form (Form 1), including the Temporary Identification Certificate (TIC) and complete it after obtaining the signature or thumb impression of the employee. He shall send the Declaration Form along with the TIC with a return of Declaration Form (Form 3) in duplicate to the Regional Office / SRO / LO within 10 days of the entry of an employee into the insurable employment.

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.

2. Allotment of Insurance Number:

The RO / SRO / LO shall allot an Insurance Number to each such person in respect of whom the Declaration Form has been received. The TIC with the Insurance Number marked thereon shall be detached and returned to the employer along with a copy of Form – 3.

Insured Person (IP):

IP means a person who is or was an employee in respect of whom contributions are or were payable under Section 2 (14) of the Act and who is, by reason thereof, entitled to any of the benefits provided by the Act.

An IP becomes entitled to cash benefits after completing nine months in insurable employment except in case of employment injury.

Preparation of the Documents:

The Regional Office / Local Office shall arrange to prepare a Permanent Identity Card in Form – 4 for each employee in respect of whom an Insurance Number is allotted and shall send such Identity Cards to the employer. Thus the office prepares following documents:-

      1. Permanent Identity Card (Form-4) sent to the IP through employer
      2. Medical Record Envelope (MRE) sent to ESI Dispensary / IMP Clinic where they are kept in filing cabinets Insurance number wise.
      3. Index Card (ESIC-2) only in Panel system area sent to Director /AMO.
      4. Index Sheet in duplicate one each for Director / AMO and RO.
      5. Permanent acceptance card (ESIC Med.7) only in Panel system are sent to IP.

3. Permanent Identity Card (Form-4):

The practice, in the past, was to issue a permanent Identity Card for IPs and a separate Family Identity Card for families. The Permanent Identity Card for IPs is issued within 3 months of entering in insurable employment and has all the essential particulars i.e., name of the IPs, Insurance Number, Dispensary / Local Office etc., to which IP is attached. Simultaneously, the Family Identity Card was also prepared showing particulars of the family.

Now, the procedure has been changed to issue of combined identity cards (form 4) in place of separate card for IPs and families. Identity Cards (now combined and formerly separate cards for IPs and families: are sent to employer who delivers these to such of the IPs who continue to be in the insurable employment on expiry of 3 months from initial entry into service.

The Identity Card is an important document and has to be produced while obtaining Medical Benefit, Certificates or Cash benefits. The AMOs / IMPs are to enter the identification marks of the IP in the space provided for the purpose in the Identity Card and the MRE on his first visit to the dispensary / clinic. Any loss of the Identity Card should be reported to the concerned L.O.

It has now been decided by the ESI Corporation to issue family photo identity cards to the insured persons joining insurable employment from 01.04.2001. Accordingly the employers are required to submit two copies of post-card-size photographs of the insured persons and members of his/her family who are eligible for medical benefit under the Act along with the declaration forms (Photos of children upto the age of five years not to be included). If the insured person does not want medical benefit for the members of his family, family photo is not required. In such cases photo of only the insured person in passport size need be submitted.

4. Certificate of Employment (ESIC-86):

If an IP or a member of his family requires medical care before his TIC is received back from Ro / SRO / LO, he can obtain a Certificate of employment from his employer on Form ESIC-86. This Certificate serves the same purpose as TIC. Insured Persons, who are issued Certificate of Employment, are not issued TIC. This Certificate will not have the Ins. No., but will have the reference of declaration form under which it was sent to RO / SRO / LO. This certificate should bear signature of a responsible official of the factory and rubber stamp of the factory.

The ESIC-86 can also be issued in cases where TIC is lost before receipt of Permanent Identity Card, but such ESIC-86 shall bear the Insurance Number.

5. Validity of Temporary Identification Certificate / Certificate of Employment:

The period of validity of TIC / Certificate of employment is 3 months from the date of entry of the IP into insurable employment (not from the date of issue of either of the documents to IP).

IMP / IMP shall prepare MRE on the basis of TIC / ESIC-86 indicating period of validity i.e., 3 months.

6. Revalidation of TIC:

    • By the Employers:- In cases where Permanent Identity Cards are not received by the employer from the RO / LO within 3 months from the date of entry of IP into insurable employment, the employer will revalidate the TIC by endorsing it as "REVALIDATED UPTO ………….." under signature of a responsible officer of the Factory with the rubber stamp of the factory affixed thereon, if the IP still continues to be employed in the factory. Such revalidation will be for a further period of 3 months from the date of expiry of the original period.
    • By Regional Office / Local Office:- Sometimes, employers send the declaration forms of the IPs to the RO / SRO / LO very late, say after expiry of 3 months or more from the date of entry of the IP into insurable employment. In such cases, the RO / SRO / LO will revalidate the TIC for a further period of 3 months from the date on which the employer certificates the IP to be in insurable employment.

Issue of Duplicate Permanent Identity Cards:|

  • i. The duplicate permanent Identity Cards are issued in case of loss, and defacement of an Identity Card. Now separate cards for IPs and families are replaced by combined Identity Cards even when only one is lost, defaced or destroyed, the other card being withdrawn and combined card issued. The IP should report the matter to the appropriate Local Office.

  • ii. When unserviceable Identity Card is retained at LO for issue of duplicate card, a certificate is issued this effect. Similarly a receipt is issued for the payment of prescribed fee for issue of duplicate card in cases of loss of card. These are valid for 30 days as Identity documents and enable the IP and his family members to obtain medical treatment. Local Office can extend this period of validity in case duplicate card is not issued within this period.
  • Duplicate Identity Cards can be misused by the persons who are not entitled to receive Medical Benefit. To check this and to enable IMO/IMP to detect impersonation, it is necessary that the particulars with regard to the issue of duplicate Identity Card are entered in MRE. Rubber stamp indicating "DUPLICATE CARD NO……ISSUED ON…….." may be affixed on MRE on receipt of information from LO about issue of duplicate card. This will enable seizure of the card and investigation, if any person produces the original card issued prior to the date indicated in MRE. The IMO will also record the identification marks of the IP on the duplicate Identity Card as per record on MRE.

  • 7. Cases of Impersonation:

    In case of an attempt at impersonation at the dispensary / hospital, it should be recorded on the MRE and intimated to the LO concerned enclosing the Identity Card for necessarily action.

    The Identity Card is retained by the LO. To avoid hardship to IPs in such cases, an intimation is issued to the IP through the employer to the effect that Identity Card bearing such Ins. NO. has been received by the LO and its ownership is under investigation. If the beneficiaries falls ill and wants his Identity Card, IP should come to the LO for issue of receipt (ESIC –139) for the Identity Card after establishing his identity. This receipt will be valid for a period of 3 months and will be issued under the dated signature of Local Office Manager.

    8. Change of Dispensary:

    IP may desire change of dispensary / clinic on grounds of change of residence or on some other grounds. The required change has to be applied for in Form ESIC-53. The change applied for may be from full-time ESI dispensary to other full-time ESI dispensary or from full-time ESI dispensary to part time ESI dispensary / panel clinic / Employers Utilisation dispensary or vice-versa.

    a) Change of dispensary on grounds of change of residence:

    The change from full-time dispensary to another full-time dispensary on grounds of change of residence can be sanctioned by IMO In charge of the dispensary to which IP is attached or IMO In charge of dispensary to which change is desired or by manager, local office. The change is intimated in form ESIC-54, copies of which are sent to the other dispensary, Lo, Ro, AMO / Director. If IP applied at the new dispensary, the IMO In charge will call for MRE of the IP from the old dispensary. If he applies at the old dispensary IMO will send MRE to the new dispensary.

    b) Change of dispensary on grounds other than change of residence:

    Change from full-time dispensary to part-time dispensary / panel clinic / employer’s Utilisation dispensary on any ground or from full-time dispensary to other full time dispensary on grounds other than change of residence are sanctioned only by Director / AMO. From ESIC-54 is sent to both the dispensaries, LO and RO. Besides this, in case of change to Employer’s Facility Dispensary / IMP Medical Acceptance Card may be sent by Director / AMO to dispensary along with ESIC-54 for filling the particulars and returned to his office by Employer’s dispensary / IMP. In case of change from Employer’s dispensary / IMP, Medical Acceptance Card is withdrawn from the cabinet of particular dispensary.

     

    9. Change in Name / Date of Birth of IP and family member:

    This is to be got done through LO / RO in Form ESIC-53 and ESIC-54.

    10. Treatment of family members of Insured Persons:

    The family members of an Insured Person who reside at the place of work or at a place other than the place of work of the Insured Person or who move along with the Insured Person on leave or temporarily transfer will be provided medical care as under:-

     i) The family members can get treatment along with Insured Person at the station where
     the Insured Person is posted permanently / temporarily.

     ii) The facilities of medical benefit under ESI Scheme will also be provided to the family
    members of IP where the IP works and resides at one station and his family resided at another station but both
    the places are implemented centres and located in the same State. 

    iii)
    Where the member of the family moves along with the Insured Person from his place

    of duty either on leave or on temporary transfer to any other station which is an

    implemented center in the same state or in a different state at the scale prescribed by

    respective State Governments at outstations.

    iv) The family members, excluding IP are to be treated as one unit. The family members

    shall have no option to get treatment at more than one station i.e. some members of

    the family getting treatment at one place and the remaining members at another

    place.

    v) The family members of IP shall get only such type of medical care as is available in

    the area where they reside. This is irrespective of the fact whether the type of

    medical care available to family at the place of duty of IP is inferior or superior to the

    type of medical care available to the family members at the area where IP resides.

    vi) The capitation fee to the IMP shall be paid at a rate of Rs.60/- per family unit per year.

    vii) In the declaration form, the IP shall have to mention the name of ESI Dispensary /

    clinic of IMP from where the IP and member of his family shall get treatment.

    viii) For obtaining medical benefit by the beneficiaries separate TIC / Identity Cards, etc,

    will be issued for the IP and members of their family (marker "only for family

    members not residing with IP").

     

    1. Reciprocal Medical Arrangement: Treatment of insured persons and their
      1. families working in one state and residing in the adjoining state.

        There are cases where an IP works in one State and lives with his family in the adjoining State. The responsibility of making medical arrangements will rest with the State in which the covered factory is situated. Since the IP and members of his family can be attached to same dispensary or panel Doctor in the State of residence, it has been decided that where the two concerned states agree on reciprocal basis to provide treatment to such Insured Persons and their families, from the other state, the Corporation will agree to attaching the IP and his family to a dispensary falling in the adjoining State of their residence. The procedure regarding sharing for expenditure on Medical Care of such Insured Persons and their families will be governed by the agreement between the two States.


        12. Medical Treatment to Insured Persons and Families at out-stations:

        Temporary Residents:

        An IP, who moves from his normal station to another station in the same State or another State where also the medical benefit provisions of E.S.I.Scheme are in force, either on authorised leave or on temporarily duty, (for a period not exceeding three months), will be provided medical treatment at the new place also (temporarily resident).

        A temporary resident, before proceeding to a temporarily residence, shall obtain on request a certificate of entitlement on Form ESIC-105, from his employer. The employers shall also indicate on Form ESIC-105 whether the members of family of IP are also moving along with the IP. This certificate of entitlement will be valid for a maximum period of 3 months only from the date mentioned therein. Any IP who does not possess ESIC-105 or the document referred or the document referred to in para below cannot avail Medical Benefit at his temporarily residence.

        A memorandum from employer sanctioning leave or tour indicating Name, Address, Insurance Number, Employer’s Code Number and period of leave or tour can be accepted in lieu of ESIC-105. This will be treated by IMO / IMP in the same way s ESIC-105.

        A temporary resident can claim treatment at any State Insurance Dispensary / Clinic of a panel Doctor at his temporary residence on the production of Form ESIC-105 and Identity Card and he should be accepted by the IMO / IMP on his list only if IP actually needs medical treatment at that time. IMO / IMP will get the signature of the IP on ESIC-Med.10 (on the reverse of ESIC-105), complete it and put his signature in token of his acceptance of the temporarily resident. This card is to be retained by the IMO in service areas, but sent to Director by IMPs in panel areas and also by Employer’s Utilisation Dispensaries for payment of capitation fee for one quarter.

        If a temporary resident will be previously in a panel area, his original IMP will also be entitled to the capitation fee for the quarter unless an exit card has been issued.

        A temporary resident will be provided Medical Benefit in the same way and on the same scale as other IP’s in the area. As all benefits will be admissible to a temporary resident, certificates, if justified, should also be issued to enable him to claim cash benefits from Local Office to which IP is allotted at his permanent place of resident. IMO will prepare the MRC in ESIC-Med:3 and keep them separately.

        The MRC of a temporary resident after the expiry of the period of IP’s stay shall be sent through the Director of the state to the Director of his permanent place of resident who will pass on the same to the ESI institution (to which the IP is attached) where it will be placed in his MRE. In service areas, IMO sends MRE directly to IP’s permanent dispensary. If an IP wants to return to his original place of resident before issue of Final Certificate, he should be issued a statement by IMO/IMP of temporary resident giving details of certificate issued to enable follow-up action by IMO/IMP of original place of resident. The IP shall get specimen signature of IMO/IMP on Medical Certificate verified by the nearest Local Office Manger and send it to his Local Office.

        A temporary resident whose stay at a place is less than 24 hours should also be given medical treatment by the IMO/IMP, but the procedure detailed in the above paragraphs need not be followed. As the treatment is of the nature of emergency treatment, no capitation fee will be payable to the IMP/Employees facility utilisation dispensary.

        If an IP’s stay at a temporary residence is for a period of more than 3 months, he will not be treated as temporary resident, but will be entitled to Medical Care at the new place only as provided for change of dispensary/doctor/IMP/region.

      2. Medical treatment to Insured Persons who move to another implemented area
        within the same state or another state after leaving employment during the subsistence 
        of their entitlement to Medical Benefit.

    The following procedure will be followed to provide Medical Care to an IP who moves to another implemented area within the same state or another state after leaving his job, but within un-expired period of entitlement to Medical Benefit under the Scheme:-

    a) The IP will intimate to the Regional Office (RO) of his area, directly or through his Local Office (LO), his intention to go to another area. The application should state all the necessary particulars, viz. Employers name, Code No. and IPs name and Insurance Number etc.

    b) The RO will verify the facts and work out the period of entitlement to Medical Benefit and inform the new RO, where the IP intends to move. Copy of this should be given to IP in Form ESIC-50 which will be suitably modified for this purpose. Intimation of this fact will also be sent to

    the director of the area to which the IP moves. Along with this intimation the RO will issue another intimation (by an Exit Card) to the Director/Dispensary requesting removal of the name of the IP from the list of IMP/Dispensary to which the IP has been attached.

    c) The new RO on receipt of intimation from the old RO should intimate the same to the director of the new area.

    d) The IP will produce the card in Form ESIC-50 to the new IMO/IMP who will provide necessary Medical Benefit and also prepare a MRC on Form ESIC-Med.3. The period of entitlement given in Form ESIC-50 will also be noted on this card. Medical Benefit will be stopped on expiry of this period. The Form ESIC-50 will be retained by the IMO/IMP.

    e) the Medical Record of the IP after the expiry of the period of entitlement indicated in Form ESIC-50 will be sent to the Director of the original area who will then place the card in the IP’s MRE.

    f) In panel areas, capitation fee in respect of such temporary entitlement will be payable for one quarter even if the IP joins the new Panel Doctor’s list after the first day of the quarter. If the IP has moved from the Panel area, his original IMP will also be entitled to capitation fee for the quarter.

    13. Inter-Regional Transfer with different employers:

    If an IP moves from one region to another region and in doing so changes his employer, then the IP will approach the LO of his new place of posting and present his Identity Card. The LO will retain the Identity Card and issued to the IP a certificate in Form ESIC-98 indicating the name as well as the LO and dispensary opted by him so that it may be possible for him to obtain medical treatment during the period he may be without the Identity Card. The LO will send third Identity Card along with a request to the old RO of IP for transfer of documents. The RO will direct the Local Office to which the IP was attached earlier for immediate transfer of the documents direct to the new Local Office.

    On receipt of documents from the old Region, the new Regional Office / Local Office will allot a new Insurance Number to the IP and prepare a fresh Identity Card. The Identity Card will be supplied to the IP. The MRE will be sent to the relevant IMP / Dispensary. In the case of Panel System, a Medical Acceptance Card in form ESIC-Med. 7 will be prepared and sent to the new employer for delivering the same to the IP.

    The above procedure will also apply with necessary modifications where an IP moves from one station to another in the same Region and change of Insurance Number is involved.

    Medical Benefit after contribution ceases to be payable:

    This governed by Regulation 103-A which reads as follows:-

      • A person on becoming an IP for the first time shall be entitled to Medical Benefit for a period of 3 months provided that where such a person continues for 3
      • months or more to be an employee of factory or establishment to which the Act applied, he shall be entitled to Medical Benefit till the beginning of the corresponding benefit period.
      • Person in respect of whom contribution has been paid in a contribution period for not less than half the number of days in the said contribution period shall be entitled to Medical Benefit till the end of the corresponding benefit period.
      • An IP whose title to Medical Benefit has ceased under this Regulation shall again be entitled to Medical Benefit from the date of his re-employment as an employee under the Act in a Factory or Establishment to which the Act applied, if he produces a certificate from the employer in the Form ESIC-37. Such an IP, shall, unless he is covered by Sub-regulation (2) be entitled to medical benefit till the commencement of the benefit period corresponding to the contribution period in which he is re-employed.
      • An employer shall, on demand, issue the certificate referred to in Sub-regulation (3) to an employee who has been employed by him after cessation of his previous insurable employment.
      1. Procedure for enforcement of Dis-entitlement and re-entitlement to Medical Benefit:

    As dis-entitlement and re-entitlement depend upon the contributory condition, this is operated by the R.O. Cases entitled to Medical Benefit on the basis of Temporary Identification Certificate or Certificate of Employment or certificate of entitlement, get automatically disentitled on expiry of validity of these documents unless they produce permanent Identity Cards. Cases having Permanent Identity Cards remain entitled to Medical Benefit till disentitled in accordance with the procedure.

    The R.O. keeps a check on entitlement to Medical benefit on the basis of the contribution / return of contribution / ESIC-37 / ESIC-166 / ESIC-86 received from the employers. The R.O. sends the Exit Card / Exit List and re-entitlement list / Card to ESI Dispensaries and AMO / Director (who in turn sends this to IMP in Panel area), Periodically indicating the date from which the IP would become disentitled / re-entitled to Medical Benefit. Earlier, IPs were categorised as ‘X’, ‘E’, ‘N’ & ‘NN’

    X’ Disentitled : Where the contributions have been paid in a 
                             contribution period for less than half the number of 
                             daysin the said contribution period. 

                 ‘E’ Clearly entitled : Where the contribution for half the number of days 
                                                  or
      more in a contribution period have been paid.

                  ‘N’ Allowed to be : Where contribution was due but has not been entitled received.

            ‘NN’ to be disentitled : Where contributions has not been received in two consecutive contribution periods.

    IPs falling in the categories ‘X’ & ‘NN’ to be treated as debarred.
    The above categorisation of IPs has been amended by Instruction NO.4/94 dated
    20.10.1994 issued vide letter No.R-37/14/1/87-Ins. II, which is modified as under.

     E’ Clearly entitled : Where the contribution for half the number of days or  
                                    more in a contribution period have been paid.

      ‘S’ Allowed to be : Where the contributions have been paid in a
                                    entitled contribution period for less than have the number of
                                    days in the said contribution period and IP continues to
                                    be in insurable employment in the following
                                    contribution period i.e., current contribution period.

           ‘X’ Disentitled : Where the contributions have been paid in a
                                     contribution period for less than half the number of
                                     days in the said contribution period does not
                                     continue to be in insurable employment.

          ‘N’ Not entitled : Where the contributions has been received or where
                                     Return of contribution has been received but the
                                     insurance number, name of the IP does not appear in it.

    According to the above procedure, the exit list of the ‘X’ category will be prepared first

    and sent to all concerned as is being done now. Exit list in respect of the category ‘N’ will be sent

    separately after completing the posting in the ESIC-38 register so as to reach AMO / Director /

    Dispensary concerned, 15 days before the start of the corresponding benefit period.

    Action by IMO / IMP on receipt of Exit Cards / Exit List:

    The IMO /IMP on receipt of Exit Card / Exit List should take out the MRE along with

    MRC of the debarred IPs from the regular run and place them in a separate "Exit" run. Before

    doing so, he should write in the red ink on the MRE / MRC "Dis-entitled to Medical Benefit from

    …………" It may be clarified that as and when an IP becomes debarred from the Medical Benefit,

    his family automatically becomes debarred. To ensure a fool-proof method, an IP or member of

    his family who reports to the dispensary for treatment should first report to the card room. The

    clerk managing the Card section should take out the MRE from the "Entitled run". If the MRE is

    not found in the "Entitled", it is presumed that the IP is under "Exit". He may have a cross check

    with the Exit run.

    Re- Entitlement:

    The re-entitlement can be in either of the two ways:-

    (1) By Regional Office:

     

    In cases where the Exit Card is issued for non-receipt of contribution and where the return of contribution (RC) is subsequently received the Regional Office would prepare a re-entry card/list if the IP is otherwise entitled to Medical Benefit and send it through the Director or director to the IMO/IMP who on receipt of this, will take out the MRE from the "Exit" run, write on it in red ink "Re-entitled from………….on the basis of…………….and place it in the "Entitled run".

    (2) By IMO/IMP :

    (i) On the basis of ESIC-37 (Annexure 2.8): An IP may, at time, report to the IMO/IMP for treatment and insist on getting Medical Benefit on the grounds that he is continuing in service and his contributions are being regularly deducted. Such an IP may be advised to contact his employer to obtain From ESIC-37-certificate of re-employment/continuing Employment. In the meanwhile, for the day, the IP/his family should be provided with necessary Medical Benefit. The IMO/IMP himself re-entitles the IP on the basis of ESIC-37 when received, for 9 months from the date indicated therein. This card has to be completed on its reverse ESIC-Med.7 and sent to the Regional Office under intimation to Director for necessary action every month. The MRE should be taken out of "Exit run" and placed in "Entitled run" after an entry in red ink "Re-entitled on the basis of "ESIC-37".

    (ii) On the basis of declaration of IP(ESIC-166) :

    If for any valid reason the IP is not able to produce ESIC-37 from his employer, in order to avoid hardship to the IP, Regional Office/LO/IMO in service areas have been authorised to restore the Medical Benefit on the basis of a declaration to be made by the IP in Form ESIC-166 (Annexure-2.9). it should, however, be made clear to him that in case of his declaration being proved false, he will render himself liable to prosecution. In Panel areas, the benefit may be similarly restored by the Regional Office / Local Office.

    The Benefit will be restored only for a period of 3 months from the date of declaration. Thereafter the IP will stand debarred from Medical Benefit automatically, unless ESIC-37, entitling the IP is received in the meantime or regular re-entry card / list is received.

    In order to ensure that Medical Benefit is stopped on the due date, a rubber stamp with the words "Restored upto ….. " should be affixed on the MRE which should then be placed in the entitled run.

    When the Local Office / IMO restores Medical Benefit to the IP on the basis of IP’s declaration (ESIC-166) he will forward the same to Regional Office under intimation to Director and simultaneously issue the entitlement slip (ESIC-166) to the IP. When the Regional Office /

    Local Office restores the benefit, they shall issue ESIC-166 to the IP who will hand it over to his

    IMO / IMP. This will be sent by the IMP to the Director after the commencement of treatment. The Director will make necessary entries in the Medical Acceptance Card.

    For ensuring timely exit action in respect of IPs entitled on the basis of ESIC-86, ESIC-166, T.I.C. ESIC-37, ESIC-105, ESIC-48, ESIC-50 and ESIC-51, a separate watch register is to be maintained indicating date upto which benefit is restores, unless re entered in the Regional Office list.

     

     

      

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