ESIC - Employee's State Insurance Corporation

Employees' State Insurance, abbreviated as ESI is a comprehensive social security plan by the Government of India to protect the interest of Indian workers, who are covered under the scheme. The scheme offers protection against the financial distress arising out of unemployment and health issues such as sickness, maternity, physical disability or death due to employment injury.

The scheme is a self-financed one with contributions made by both employer and employee, and it covers workers of all factories and establishment throughout India as defined in the ESI Act.

The ESI Act guarantees complete medical care and financial assistance to workers and their immediate dependent family members during unfavourable situations.

ESIC or Employees' State Insurance Corporation is an autonomous corporation, set up under the Ministry of Labour and Employment, Government of India, and is managed according to the rules specified in ESI Act, 1948.

It is one of the longest-running social security schemes of the government, which was first implemented at Kanpur on 24th February, 1952. The framework of the ESI Act, 1948 was made by Dr. B R Ambedkar and all the benefits provided to the employees are in accordance with ILO conventions.

The ESI Act was initially applicable to factory workers, but later on, it expanded its reach by including all establishments having a workforce of 10 or more persons, with a monthly salary not exceeding Rs. 21,000, and Rs. 25,000 for a person with a disability. Currently, the employee's contribution rate (w.e.f. 1.1.97) is 1.75% of the wages and that of employer's is 4.75% of the wages paid/payable in respect of the employees in every wage period.

The State Governments bear one-eighth share of expenditure on Medical Benefit within the per capita ceiling of Rs.900 per annum and all additional expenditure beyond the ceiling. As per the ESI Act, the medical expenditure incurred under the ESI scheme, is shared between ESIC and State Government in the ratio of 7:1.

There are few exemptions and exception in the ESI Act. 1948, which are listed below:

• The employee threshold for establishments located in Maharashtra and Chandigarh is 20 or more persons.

• Employees whose daily wage is within Rs. 176 are exempted from their own ESI contribution, and full contribution is made by the employer.

• The ESI Act, 1948 empowers ESIC to independently establish hospitals or collaborate with the state governments or private entities for the same.

• The functioning of ESIC is managed from its headquarter situated in New Delhi, along with 23 regional and 26 sub-regional offices. It has over 830 ESI centres throughout India for successful implementation of the ESI scheme.

• As on 31st March 2018, the ESIC infrastructural network consists of 154 ESI hospitals with 19,626 beds and an additional 42 hospitals with 371 beds.

• For out-patient services, it has 1500 ESI service dispensaries, over 2100 Panel Clinics, 307 diagnostic centres.

• The total number of beneficiaries of the ESI scheme stands at 13.32 crore from 10.33 lakh employer.

ESIC under Section 46 of the ESI Act has enlisted six major social security benefits to the registrant of the ESI scheme:

Medical Benefit

• The insured person and his family members are entitled to full medical benefits from day one of entering the insurance contract. The scheme doesn't have a cap on medical expenditure on the treatment, either of an insured person or his family members,

• The full benefits of the scheme are extended to the retired and permanently disabled insured persons and their spouses on payment of token annual premium of Rs. 120.

Sickness Benefit

• The insured person is entitled to cash compensation of 70% of wages payable, during the period of certified sickness, for a maximum period of 91 days in a year.

• In Extended Sickness Benefit, the insured is entitled to wages of up to 2 years at an increased rate of 80%, if diagnosed with a critical illness.

• Under Enhanced Sickness Benefit, the insured worker undergoing sterilization is entitled to full wage compensation for 7 days if they are a male, and 14 days if they are a female.

Maternity Benefit

• The insured women are entitled to a full wage during pregnancy, payable for a period of 26 weeks, extendable by one month under special circumstances.

Disability Benefit

• In the case of temporary disability, the insured person is entitled to benefit of 90% wage payable as long as the disability continues.
• Under permanent disability, the insured person is entitled to a monthly benefit of up to 90% wage payable, depending on the extent of financial loss and nature of the disability certified by a Medical Board.

• In case of death of the insured person due to employment injury, the dependent family members are entitled to the same benefits as listed under permanent disability.

Other Benefits

• The ESI scheme includes expenses for the rehabilitation process (both physical and vocational training), old age medical care, and funeral expenses of Rs 15,000.

Rajiv Gandhi Shramik Kalyan Yojana

Under this scheme, if an insured person under the cover of ESI for three or more years, becomes unemployed due to factory closure, workforce curtailment or permanent invalidity, then he/she is entitled to:

• Unemployment Allowance - 50% wage for a maximum of 2 years period.
• Full medical benefit for self and family during the period of unemployment.
• Vocational training for upgrading skills.

Atal Beemit Vyakti Kalyan Yojana

• Launched in July of 2018 on a pilot basis period for two years, the scheme offers cash compensation of 90 days once in a lifetime if you are unemployed. To avail the benefits of the scheme, the insured person should have completed two years of insurable employment. Entities Covered Under ESIC

• ESI scheme is a comprehensive plan to offer the benefits of quality healthcare to every stratum of society. The act is applicable to all registered and corporate organisations.

Under Section 1(5) of the ESI Act., entities that are covered under ESIC are:

• Shops.
• Hotels.
• Restaurant.
• Cinema Houses.
• Road-motor transport undertakings.
• Establishments engaged in the Insurance business and NBFCs.
• Port Trust and Airport Authorities.
• Warehousing Establishment.
• Private Medical and Education Institute (limited to few states/UTs).

Note: If you are employed in a seasonal factory or mine, then you are not eligible for ESIC benefits.

Anybody, those who are working in a factory or establishment as defined in the ESI Act, and whose monthly pay (Basic+ Dearness Allowance) is less than Rs 21,000 are eligible for enrolling in the ESI scheme [Rs. 25,000/- per month in the case of persons with disability].

• Registration Certificate of the company obtained under Factories Act or Establishment Act.

• Partnership Deed/ Trust Deed/ Memorandum of Association and Articles of Association of the company.

• Certificate of commencement of production or GST number.

• PAN Card and Proof of Address of the company.

• Copy of bank statement/ Cancelled Cheque.

• List of all Directors/Partners and their phone number and email address.

• List of shareholders of the company.

• A list of all employees working with the company along with PAN and joining details.

• Compensation details of all employees.

• Digital signature of Proprietor/ Director/ Partner.

• ESIC Card is a health card given to all those beneficiaries who have enrolled with the ESI scheme. It's a magnetic smart identity card, also called Pehchan Card.

• This card needs to be produced to avail all the medical services on ESI network hospitals and dispensaries. The card contains details like:

• Insured person number, name, father's name, address, biometric details (fingerprint), photo and a family photograph.

• ESIC provides two sets of cards to the employee, one for self-use, and other for dependent family members.

• It offers seamless access to medical services across network hospitals, without carrying documents.

• The card stores the medical history and treatment of the insured and can be beneficial during emergency situations.

• In the case of a change in jobs, you just need to inform the insurance number to your new employer and can continue using the facilities.

• This card is used to claim all the benefits offered under the ESI scheme.

• Biometric authentication makes it a very secure card, thus preventing frauds.

The process to obtain ESIC or Pehchan card is very easy and hassle-free. Below is the process to obtain the Pehchan Card.

• Obtain print counterfoil form from your company/employer, which is available in ESIC portal.

• Print counterfoil form is your ESI application form, in which you need to sign and paste a family photograph.

• Attest this counterfoil form from your employer/company.

• Bring your dependent family members and counterfoil form to nearest ESIC office for biometric collection, verification and photographs.

• Within 30 days of the verification process, you will get two sets of cards by courier or can collect it from the office, as intimated by officials.

In case for an issue of duplicate ESIC smart card, the employee needs to submit the duly filled Form 72.

ESIC benefits are categorised into two types:

Medical Benefits

• Medical benefits are only for employees along with dependent family members, and can be only be availed in ESIC network hospitals and dispensaries.

  • Under medical benefits, there are cases where the treatment specified by doctors of ESIC hospital is not available and refer you to any non-ESIC network hospital, then you can claim your bills later.

  • If you take admission to a non-ESIC network hospital, but the specified treatment is available in the ESIC network hospital in your region, then your claims will be marked invalid.

  • In emergency situations like a road accident, the insured person can be admitted to a nearby private hospital for treatment in case there are no ESI network hospitals nearby.

  • Under Regulation 96 of ESIC, the claims for reimbursement of medical expenses incurred in a non-ESIC network hospital are handled by - the State Government machinery and the time limit for submission of such claims is one year.

  • All the reimbursement claims are processed according to the ESIC approved rates and can be lower than the actual bill. You will have to visit your nearest ESI centre for more details on making medical benefits claim.

Cash Benefits

• Cash benefits are claimed in the event of sickness, maternity, loss of employment, physical disability, and death of the insured person from employment injuries.

• Form 9: To make claims for sickness, temporary disability, and maternity benefits.

• Form 14: To make claims for permanent disability benefits.

• Form 15: To make claims for dependent family member benefits.

• Form 16: For claiming periodical payment of dependent benefits.

• Form 19: To claim maternity benefits and for notice of work.

• Form 20: To avail maternity benefits after the death of the insured women, leaving behind the newborn.

• Form 22: To make claims for funeral expenses of the insured person.

• Form 142: For making claims for conveyance allowance.

The claim for unemployment allowance under the ESI Act should be submitted within three months of losing the employment status. You need to submit Form (US-1) to the branch office, supported by the necessary documents for proving unemployment.

The forms are available for download on the ESIC employee portal.

Claims status can be checked online through ESIC Employee Portal.

All the states have different rules and regulations for the number of employees required for ESIC Registration .

The total number of employees required under ESI Act for factories is 10 or more for pan-India basis.

For establishments, the number of employees varies from state to state, and the following snapshot shows the minimum number of employees required:

Employee State Insurance Corporation has played an instrumental role in providing access to quality health care services to millions of workers in the organized sector. Since its inception, it has played a pivotal role for overall social development and human security, helping to provide the right standard of living to the beneficiaries of the scheme.

For employees, the benefits are many, right from the full medical benefit to sickness benefit, disability benefit, maternity benefit, unemployment benefit and death benefits. The schemes fulfil the aspiration of millions of workers, in the hour of distress.

For employers also, the ESI scheme is a boon, as it freed them from the worry of workers during their health distress. Further, the ESI scheme is very economical for organisations compared to any regular social security schemes offered by insurance companies.