Employee State Insurance
Key
Features and Benefits of ESI:
There are a number of
attractive features and benefits that are offered by the Employee State
Insurance Corporation. Not only does it provide medical benefits but it also
comes with a level of financial security in times of financial hardship like unemployment,
etc. Some of these are listed below:
1. Medical Benefits:
The Employee State Insurance Corporation takes care of an individual's medical expenses by providing reasonable medical care. This cover comes into effect from day one of the individual's employment.
Medical Benefit means Medical care of IPs and their
families, wherever covered for medical benefit. The Standard medical care
consists of out-door treatment, in-patient treatment, all necessary drugs and
dressing, pathological and radiological specialist consultation and care,
ante-natal and post natal care, emergency treatment etc., Out-door medical care
is provided at the state Insurance Dispensaries or Mobile Dispensaries manned
by full-time doctors (service’ system) or at the private clinics of Insurance
Medical Practitioners (Panel System)
Insured
worker and members of his family are eligible for medical care from the very
first day of the worker coming under ESI Scheme. A worker who is covered under
the scheme for first time is eligible for medical care for the period of three
months. If he/she contributes at least for 78 days in a contribution period the
eligibility is there up to the end of the corresponding benefit period.
A worker is also eligible for extended
sickness benefit when he/she is suffering from any one of the long term 34 diseases
listed in the Act. This is admissible after the worker has been under ESI these
conditions are satisfied medical benefit is admissible for a maximum period of
730 days for the IP and his/ her family.
2. Sickness benefits:
Sickness signifies a state of health
necessitating Medical treatment and attendance and abstention from work on
Medical grounds. Financial support extended by the corporation is such a
contingency is called sickness Benefit Sickness Benefit represents periodical
payments made to an Insured Person for the period of certified sickness after
completing 9 Months in insurable employment.
To qualify for this benefit,
contributions should have been payable for at least 78 days in the relevant
contribution period.
} The Maximum duration for availing sickness
Benefit is 91 days in two consecutive benefit periods
} Standard benefit rate – this rate corresponds
to the average daily wage of an Insured person during the corresponding
contribution period and is roughly half of the daily wage rate.
Extended Sickness Benefit
Ø The daily rate of Extended Sickness Benefit is
40% more than the standard Sickness Benefit rate admissible
Ø After exhausting sickness Benefit Payable for
91 days the Extended Sickness Benefit is payable upto further period of 124 /
309 days that can be extended upto 2 years in special circumstances
Ø Cash
Benefit paid for prolonged illness (Tuberculosis / Leprosy, Mental and
Malignant diseases) due to any of the 34 Specified diseases
Ø The IP should have been in continuous employment
for a period of 2 years and should have contributed for atleast 156 days in 4
preceding contribution periods
3. Maternity benefit
Maternity Benefit is cash payable to an
Insured women for the specified period of abstention from work for confinement
or mis-carriage or for sickness arising out of pregnancy, “confinement”
“premature birth of child or miscarriage” “confinement” connotes labour after
26 weeks of pregnancy whether the result issue is alive or dead, “Miscarriage” means expulsion of the contents
of a pregnant uterus at any period prior to or during 26th week of pregnancy.
§ Criminal
abortion or miscarriage does not, however, entitle to benefit.
§ The
contribution condition is the same as for Sickness Benefit.
§ The daily benefit rate is double the sickness
Benefit rate and is thus roughly equivalent to the full wages.
§ Benefits
are paid for Sundays also.
§ For
a total period 12 Weeks beginning not more than 6 weeks before the expected
date of child birth, if the insured women dies during confinement or within 6
weeks thereafter, leaving behind the living child, the benefit continues to be
payable for the whole of the period. But the child also die during that period,
the benefit will be paid upto and including the day of the death of the child.
§ For
Miscarriage For the period of 6 weeks following the date of miscarriage
§ For
sickness arising out of pregnancy, confinement, Premature birth of child or miscarriage:
For an additional period or upto four weeks. In all the cases, the benefit is
paid only if the insured women do not work for remuneration during the period
for which benefit is claimed. There is no waiting period.
4. Disablement benefits
Temporary disablement
} In
case of temporary disability arising out of an employment injury or
occupational disease.,
} Disablement benefit is admissible to insured person for the entire period so certified by an Insurance Medical officer / Practitioner for which IP does not work for wages.
} The
benefit is not subject to any contributory condition and is payable at a rate
which is not less than 70% of daily average wages.
} However, not payable if the incapacity lasts
for less than 3 days excluding the date of accident.
Permanent disablement
} In
case an employment injury or occupational disease results in permanent, partial
or total loss of earning capacity,
} Periodical payments are made to the IP for
life at a rate depending on the actual loss of earning capacity as may be
determined and certified by a duly-constituted Medical Board.
} The
rates of Disablement Benefits are determined in accordance with the provisions
of Rule 57 of ESI (Central) Rules, 1991.
} In order to product erosion in real value of
the periodical payments of Permanent Disablement benefits, against rise in the
cost of living index, periodical increases are granted, based on actuarial
calculation
} Commutation
of periodical payments into lump sum (one time payment) is permissible where
the permanent disablement stands assessed as final and daily rate of benefit
does not exceed Rs. 1.50. Per day.
} Commutation of Permanent Disablement Benefit
into lump sum payment is also allowed in case the total commuted value does not
exceed Rs.10000/- (The ceiling is now being raised to Rs.30000/-).
5. Dependents benefits
Dependents Benefit is a monthly pension
payable to the eligible dependents of an insured person who dies as a result of
an Employment Injury or occupational disease Beneficiaries and Duration of
benefit
a)
Widow / widows during life or until
remarriage
b)
Legitimate or adopted son until age 18 or if
legitimate son is infirm, till infirmity lasts.
c)
Legitimate or adopted unmarried
daughter until age 18 or until marriage, whichever is earlier, or if infirm,
till infirmity lasts and she continues to be unmarried. In the absence of any
widow or legitimate child, the benefit is payable to a parent or grandparent
for life, to any other male dependent until age 18 or to an unmarried or
widowed female dependent until age 18.
The total divisible benefit is equivalent to the temporary disablement benefit rate (roughly 70% of the wage rate).
} The widow / widows share 3/5th of the benefit and the legitimate or adopted son and daughter 2/5th each of the benefit. If the total benefit so divided exceeds the full rate, there is a proportionate reduction in the respective shares of the beneficiaries.
} The amount of pension paid to the dependents
of a deceased insured person 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.
OTHER BENEFITS
} Funeral expenses:
Funeral Expenses are in the nature of lump sum payment up to a
maximum of Rs.2500/- made to defray the expenditure on the funeral of deceased
IP. The amount is paid either to the eldest surviving member of the family or,
in his absence, to the person who actually incurs the expenditure on the
funeral.
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