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Employees’ State Insurance Scheme: Eligibility, Coverage and Benefits

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Published on June 12, 2023. EST READ TIME: 3 minutes

Imagine an employee, the sole breadwinner of his/her family, suddenly falls ill and requires urgent medical treatment. But the family can’t afford the cost of treatment at a renowned private hospital. Who can help? Say hello to the Employees' State Insurance Scheme (ESIS), a pioneering initiative by the Government of India aimed at providing healthcare and social security benefits to workers in the organised sector. This scheme offers a wide range of medical, cash, and other benefits to eligible employees and their dependents. So, what is ESI? Let’s find out.

What is the Employees’ State Insurance Scheme?

The Employees' State Insurance Scheme of India provides socio-economic protection to the workforce in the organised sector. It provides financial protection to employees against death or disability due to injury or sickness and maternity coverage. The insurance scheme also provides complete medical care to insured employees and their dependent family members.

Employees State Insurance Act, 1948

The ESI Act or Employees’ State Insurance Act, 1948, introduced by the Parliament, aims to financially protect employees in case of any eventualities at work, such as death, temporary or permanent disability of the insured, and to provide medical care to the insured and their families. The ESI Act provides medical and other benefits to employees working in factories, hotels, road transport, newspapers, educational or medical institutions, and shops, wherein 10 or more persons are employed. However, in Chandigarh and Maharashtra, the minimum number of employees for ESI coverage is 20. Under the Act, employees with a monthly income of up to Rs 21,000 are eligible for the social security scheme. But for a person with a disability, the monthly income can be up to Rs 25,000.

What is Covered Under Employees’ State Insurance Scheme?

• All non-seasonal factories with 10 or more employees

• Employees working in shops, restaurants, hotels, newspaper establishments, educational institutions, private medical institutions, road-motor transport undertakings, contract and casual employees of Municipal Corporations/Municipal Bodies, Non-Banking Financial Companies, Port Trust, Airport Authority, cinemas, including preview theatres, and more

• The State Government undertakings should have 10 or more employees

• The Central Government undertakings should have 20 or more employees

• As on 31st March 2022, the total number of beneficiaries was 12.04 crores, the number of insured persons was 3.10 crores, the number of employees 2.78 crores, the number of insured women 58.69 lakh, and the number of employers covered was 15.94 lakh

What Is Not Covered Under Employees’ State Insurance Scheme?

• Employees with a monthly income of Rs 21,000 or more are not covered.

• For people with disability, those with a monthly income of more than Rs 25,000 are not covered.

• In Maharashtra and Chandigarh, the minimum number of employees in an organisation should be 20, whereas, in other States and Union Territories, it is 10. Employees in organisations with less than the stipulated number do not qualify for ESIS.

Infrastructure of Employees State Insurance Scheme (ESIS)

Since its launch in 1952, the infrastructure network of ESIS has been expanding. Let’s look at the network:

• Inpatient services: 151 hospitals and 42 hospital annexes

• Primary & out-patient medical services: 1418 ESI dispensaries, 140 AYUSH units, 1017 Panel Clinics

• Occupational disease centres: 1 each in New Delhi, Mumbai, Kolkata, Chennai, and Indore

• Cash benefits: 627 branch offices, 185 Pay offices

Features of Employees State Insurance Scheme (ESIS)

Some key features of ESIS are:

• The health insurance scheme covers employees/workers earning less than or equal to Rs 21,000 per month.

• The benefits can be availed by the insured as well as dependent family members.

• While employers contribute 3.25% of their salary towards ESIS, employees contribute 0.75%.

• Any contribution due on the part of employers must be cleared within 21 days of the month.

• Under the scheme, 1/8th of the total medical expenses up to Rs 1500 per head must be paid by State Governments.

Benefits of Employees State Insurance Scheme (ESIS):

The benefits offered under the ESI scheme are:

• Sickness benefit

The insured employee can avail of cash compensation at the rate of 70% of the daily wage for a maximum of 91 days in two consecutive benefit periods.

• Medical benefits

The insured and his/her family can avail of full medical care from the day the person gets employed. There’s no limit on the treatment expenses.

• Maternity benefits

Women can avail of cash benefits at the rate of 100% of the average daily wages up to 26 weeks for confinement/pregnancy. This period can be extended further by one month based on the medical advice.

• Disablement benefit

In case of temporary disablement due to employment injury, the insured is paid 90% of the average daily wage till recovery. In case of permanent or total disability, the compensation is paid at the rate of 90% of the average daily wage for the entire life.

• Dependents’ benefits

If the insured suffers death due to employment injury, compensation at the rate of 90% of the deceased’s wage is given to the dependent family members per month. Children till the age of 25 years are eligible for compensation.

• Retirement benefit

If a beneficiary is covered under ESIS for at least 5 years, the medical expenses of the insured and spouse will be covered even after retirement with a nominal annual fee of Rs 120.

• Funeral expenses

Dependent family members can claim up to Rs 10,000 to perform the last rites of the insured.

When is ESI Registration Required?

ESI registration is compulsory for organisations with more than 10 employees. In the case of Chandigarh and Maharashtra, the minimum number of employees should be 20. The company should be registered with the Employee State Insurance Corporation (ESIC). To be eligible for the scheme, the employee’s monthly income should be less than Rs 21,000 and for people with disability, it should be less than Rs 25,000. While the employee/worker contributes 0.75% of the salary towards the scheme, the employer contributes 3.25%.

Documents Necessary for ESI Online Registration

The documents required for ESI online registration are:

• Certificate of registration under the Shops and Establishment Act or Factories Act.

• Certificate of Registration for private limited companies and partnership deed for partnership companies.

• Articles of Association and Memorandum of Association of the company.

• List of all employees and their monthly compensation details.

• List of directors, shareholders, and partners of the company.

• Address proof and PAN Card details of employees and the company.

• Cancelled cheque of the establishment’s bank account.

• Attendance registers of the employees.

• Employer’s Registration Form (Form No.1) must be downloaded, filled and uploaded on the ESIC website along with the above-mentioned documents.

Procedure For ESI Registration

1. Visit the official website of ESI and click on Employer Login.

2. Then click on Sign up.

3. Fill up all the mandatory fields like company name, employer name, state, etc., and submit.

4. You will receive an email confirmation containing your username and password details.

5. Now log in to the ESIC portal again with the username and password and click on “New Employer Registration.”

6. Pick “Type of Unit” from the drop-down menu; click on “Submit.”

7. Fill in the details required for the “Employer Registration Form 1”; submit it along with all necessary documents.

 

8. Then, you will be redirected to Payment of Advance Contribution. The employer needs to enter the amount for 6 months’ advance contribution and choose the payment mode.

9. Once the payment is successful, you will receive an ESI Registration Letter (C-11) containing the 17-digit ESIC registration number.

The Registration Letter (C-11) is proof of employer registration.

How To Apply for an ESI Card (Pehchan Card)?

The ESI Card or the Pehchan Card contains all the details of the insured person and dependents, such as name, address, ESI insurance number, date of birth, photograph, etc. To apply for the card online, just follow the below process:

• Log in to the ESI website with your username and password.

• Under the Employee section; click on the e-Pehchan card.

• Select the unit details and click on View. You will be able to see the details of all employees. You can also search by the respective employee’s ESI number.

• The same page will have `View Counter Foil’. This ‘Counter Foil’ denotes the ‘e-Pehchan’ card.

• Scroll down on the same page and click on ‘Print’. You can also download it as a PDF document.

• The respective employee has to sign and paste photographs of dependent members; the photos should be attested and stamped by the employer or the ESIC official.

The ESIC will issue the magnetic smart card and dispatch it to the employee’s address, or you may collect it from the ESIC branch.

Employees State Insurance Scheme Hospital List

The complete list of hospitals with which ESI has tie-up is available on the ESI website.

Progress of 2nd Generation Reforms of ESIC (ESIC: 2.0)

In 2015, several Health Reforms initiatives of the scheme were launched:

• Health Records of ESI beneficiaries (insured persons and family members) stored in electronic format. The beneficiaries can access the health records online without visiting the hospital for any information.

• 24*7 Helpline (1800 11 3839)

• VIBGYOR – Operation Indradhanush: Bedsheets to be changed every day according to VIBGYOR (i.e., a colour pattern or different colours for each day of the week)

• Special OPD for senior citizens and differently-abled persons

• Quality check on medicines

• Pathological and X-ray facilities on the PPP model

• Regular Inspection of ESIC hospitals by an ESIC member

• Creation of special departments — CT, ICU, MRI, CAT-Labs, dialysis.

• Behavioural training of doctors and para-medical staff, feedback system for indoor patients, queue management system, special child and mother care hospitals, Yoga, Ayush, ‘May I Help You’ counters, etc.

Do’s and Don’ts of the ESI Scheme

It’s very important for employees to be aware of the Do’s and Don’ts to avail of the benefits of the ESI scheme:

• An employee must ensure the ESI card/Pehchan card or e-Pehchan card is not damaged or lost, as the card needs to be presented while availing of treatment at ESI hospitals or dispensaries.

• If the card gets lost, an employee should inform the ESIC branch office or dispensary about it.

• If an employee moves to another organisation, he/she should inform the new employer of the ESI registration number.

• Follow the instructions of the doctor.

• The Pehchan Card should not be lent to any individual who is not insured.

How To Claim ESI Benefits?

The process to claim ESI benefits, whether medical or cash benefits, is as below:

• Install the UMANG app on your smartphone.

• Log in to your account using the ESIS insurance number.

• Generate OTP and enter it to log in.

• Under `Services’, select `Make a Claim.’

• Provide the mandatory details and submit the required documents

• Once the claim request is submitted, the concerned person from ESI will get in touch with you.

ESI Head Office and Helpline Number

ESI Head Office: Employees’ State Insurance Corporation Panchdeep Bhawan Comrade Indrajeet Gupta (CIG) Marg, New Delhi – 110 002

Phone Number: 011-23234092/93/98, 23235496, 23236051, 23236998, 23235187.

Toll-Free/Help Desk Number: 1800-11-2526

Medical Helpline: 1800-11-3839

Email Address:

• For Grievances/Suggestions: pg-hqrs@esic.nic.in
• For IT Related Issues: itcare@esic.nic.in

Conclusion

By contributing a percentage of their wage to the ESI scheme every month, employees are eligible for several benefits such as sickness, medical, maternity, etc. However, there are some ESIC eligibility criteria which one should be aware of before enrolling for the scheme. Those not eligible for the scheme should buy individual health insurance or family health insurance for financial security during medical emergencies.

Disclaimer : The above information is for illustrative purpose only. For more details, please refer to policy wordings and prospectus before concluding the sales

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