ESIC

Pragati (Insurance)

Benefits

October 30, 2013

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Introduction
Benefits : The insured persons, besides full medical care for self and family, are also entitled to a variety of cash benefits in times of physical distress due to sickness, maternity (in respect of insured women), temporary or permanent disablement etc. resulting in loss of wages or earning capacity. The section 46 of the ESI Act, 1948 envisages following five benefits 1. Medical Benefit 2. Sickness Benefit (SB) a. Extended Sickness benefit (ESB) b. Enhanced Sickness Benefit 3. Maternity Benefit (MB) 4. Disablement Benefit (TDB, PDB) a. Temporary Disablement Benefit b. Permanent disablement benefit 5. Dependants Benefit (DB)

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Benefit Bouquet
Panchdeep

Medical Benefit

Sickness Benefit

Maternity Benefit

Disablement Benefit

Dependent Benefit

Extended Sickness Benefit Enhanced Sickness Benefit Super-Specialty Sickness benefit

Temporary Disablement Benefit Permanent Disablement benefit

Medical Cash Benefits

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Other Benefit
Other Cash Benefits

Funeral Expenses Confinement Expenses

Conveyance Expenses Unemployment Allowance (Under Rajiv Gandhi Shramik Kalyan Yojana) Vocational Rehabilitation

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Benefit at glance
Benefit Contributory conditions Payment of contribution for at least 78 days in the relevant contribution period Continuous employment for a period of 2 years and payment of contribution for at least 156 days in 4 contribution periods. Payment for at least 78 days in the relevant contribution period Duration 91 days in any two consecutive benefit periods Rate

Sickness benefit

Standard benefit rate (not less than 50% of daily wages)

Extended Sickness benefit (ESB)

up to 2 years in deserving cases

150% of the standard benefit rate (not less than 70% of daily wages.

Enhanced Sickness Benefit

7 days for vasectomy and 14 days for tubectomy extendable in case of post operative complication etc. Till the temporary disablement lasts

200% of the standard benefit rate.

Temporary Disablement Benefit

No condition.

140% of the Standard Sickness Benefit rate (not less than 70% of daily wages) Upto 140% of the Standard Sickness Benefit rate.

Permanent disablement benefit

No condition

for life

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Benefit at glance
Benefit Contributory conditions Duration
To widow/widows for life or until remarriage. To legitimate or adopted son/ unmarried daughter till age of 18 years. Dependant's benefit No condition To legitimate infirm son. To legitimate adopted son/unmarried infirm daughter till infirmity lasts. To widowed mother 12 weeks of which not more than six can precede the expected date of confinement; 6 weeks for miscarriage and additional one month for sickness arising out of confinement, premature birth of child or miscarriage

Rate

Upto 140% of the Standard Sickness Benefit rate (not less than 70% of daily wages to be divided among the dependants in the prescribed ratio.

Maternity benefit

Payment of contribution for 70 days in immediately preceding two consecutive periods.

Double the Standard Benefit rate (Not less than full wages)

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Benefit at glance
Benefit Contributory conditions No condition . Deceased IP should be an IP on the date of death. No condition other than insurable employment of self/spouse. No condition other than insurable employment and a incapacity reference has been made by the Branch office or Regional office Duration Rate Actual expenditure on funeral not exceeding Rs. 5000/(wef 01.12.07) Rs. 2500 is paid as a lump sum grant towards confinement expenses to an insured woman, wife of insured person. Payable based on the travel mode recommended by the Medical referee or Medical board or the Actuals Funeral Expenses One time payment

Confinement expenses

payable for two confinements only

Conveyance Expenses

No duration

Rehabilitation allowance

No condition

For each day on which insured person remains admitted in Artificial limb centre for fixation / repair or replacement of artificial limb.

200% the standard sickness benefit rate but not less than full wages

Vocational Rehabilitation

Insurable employment upto 40% permanent disablement and below 45 years age.

Till such training lasts at a recognized centre / institute

As per the daily expense at the centre or Rs. 45 /whichever is more

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Benefit Claim Entry Trigger

Insured Person submits the claim form to the branch office. Employer submits Accident report at Branch office online or via post

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Benefit Claim Workflow

IP submits the claims at BO, ESIC

ESIC official creates the Claim form in the system through intranet
Claim is processed online

Eligibility Criteria/Contributory criteria is ascertained

Incapacity References (MR/MB)

Certificates will be reviewed

HIS

F&A

Benefit days, Amount to be paid will be calculated

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Benefits claim
Submit Benefit Claim
Manual Claim Submission

Generation of claim online and Processing of the claim

Claim entry by LDC Verification by UDC

Insured Person submits the claim to the Branch office

The claim form format is available on the screens for the LDC to input the claim form received from the IP online into the application. The Claim form will be checked and processed by the UDC. Certificates from HIS is reviewed and checked by UDC The benefit days and amount to be paid will calculated by the system and displayed to UDC. UDC submits the claim for managers approval

Claim approval reject/ recommendation

Upper Divisional clerk Insured Person Branch Manager Approves/Rejects/Recommends Branch manager recommends the claim for reference to MR/MB. Branch Manager may also refer the claims to RO/ Headquarters for approval of time barred claims or for special approval of ESB/TDB/PDB cases. On approval of the claim from the manager, the payment slip will be generated and forwarded to cashier (F& A) for making the payment.

Lower Divisional clerk Branch manager

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Exceptions to normal Process

Time barred Claims : Those claims which are submitted beyond the period of 12 months from the date of certificates are referred to the Regional Director or at the Headquarters (IC/DG) for approvals during the processing of benefit claims. It applies for all cash benefit claims. Incapacity References : References made to Medical Referee/Medical Board to know his opinion on the incapacity of the insured person to resume his work. While processing the claim, based on the certificates or the spell of the sickness, the branch office can recommend an IP for a medical examination by an MR/MB. The reference can be made through the screens available in the application.

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Benefit Claims Exit Triggers

Payment of the Claims (The processing of the claim may be held in case of any
references to Medical Referee/Medical board for medical examination or to RO/Headquarters for approvals)

Payment Slip is generated for the benefit claims, on the approval from the branch manager and forwarded to F&A for payment. The benefits paid per day are recorded and will be sent to F&A . F&A Interface will be populated and the F&A will update finance records Claim Rejection If insured person failed to satisfy the eligibility criteria, the claim will not be processed and rejection slip is generated

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Process related Reports

Reports from BO Monthly progress report Statement to P.L.B Data Statement of P.D.B Cases Statement of E.S.B Cases Statement of Excess Payment Statement of Waiver or Recovery of Excess Payment

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Process related Reports

Reports from RO Return on Disposal of Long term Benefit Return on waiver of recovery from Insured Persons, beyond the power of RD Return on waiver of excess payments made to Insured Persons by the Regional Director Half Yearly Report of ESI Beneficiaries with Disability for Whom Employers Contribution is to be Paid by Ministry of Social Justice(Region Wise Statement) Half Yearly Report of ESI Beneficiaries with Disability for Whom Employers Contribution is to be Paid by Ministry of Social Justice (Disability Wise Statement)

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Claim Verification & Recovery

Abstention verification : Enquiries regarding IPs abstention from work are filled and submitted by the employer through the ESIC employer portal.

Excess or wrong payments: An excess or wrong payment may be paid to the IP/Beneficiary due to false declaration by insured person. Such excess or wrong payments made may come to the notice on receipt of reply to abstention enquiry. These excess payments are recorded and further steps to recover the amount is taken. The System generates an alert and prompt when future claims by the IP is received when the excess paid amount is recovered.

The application provides the option to generate B19 and refer to recovery branch to initiate recovery procedure if no further claim from the IP is received.
The application also provides the option to refer the non-recoverable excess payments to Regional office/ Headquarters for waiver of recovery
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Screens

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Screens

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Screens

claim form

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Screens

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Screens

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Screens

IP details & Certificates

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Screens

Contribution details & Benefit Days calculated

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Screens

Incapacity reference (RM1)

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Thank You

October 30, 2013

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