Article (November-2016)

Articles

Benefits under ESI Scheme

M.S. Dhaiya

Designation : -   Director ESIC (Rtd.),

Organization : -  

01-Nov-2016

10000+ View        

Employees' State Insurance Scheme is a unique and unparalleled Social Security Scheme. Unique and unparalleled because no Social Security Scheme in the world provides as many benefits as ESI Scheme in India.


The advent of Social Security is as old as trade Union Movement. The workmen in Industry or elsewhere did not get anything else than their wages. With the dawn of Trade Union Movement the bargaining power of the workers increased and thus slowly trickling of benefits started. Health hazards in the Industry made it imperative to have some Medical / health Insurance and it culminated in the Schemes like ESI.


On the demand of Trade Unions in 1920s and 30s, the Government agreed to get the demands studied and a committee under the Chairmanship of Sh. B N. Adarkar was set up only  in March 1947, just before Indian independence. He was appointed by the Government of India to create a Health Insurance scheme for industrial workers. A year later the report he submitted became the basis for the Employment State Insurance (ESI) Act of 1948.


Employees' State Insurance Act, 1948 was promulgated to safeguard the workmen in the contingencies like sickness, maternity, disablement and death due to employment injury and to provide medical care to insured persons and their families. The Scheme was started on 24th Feb, 1952 by the then PM at Kanpur and Delhi simultaneously with few thousand workers. Now the Scheme covers more than 2 Crore workers and total beneficiaries over 8 Crore in India and is operational in all States and UTs. The ESI Scheme applies to factories and other establishments wherein 10 or more persons are employed. Employees of the aforesaid categories of factories and establishments, drawing wages up to Rs.15, 000/- ( Now, it is proposed to extend the limit to Rs. 21,000/-. The notification has also been issued on 6.10.16.) a month as defined under Section 2(9) of the ESI Act.


The ESI Scheme is financed by contributions from employers and employees. The rate of contribution by employers is 4.75% and that of employees is 1.75% of the wages payable to an employee. Employees, earning less than Rs.137/- a day as daily wages are exempted from payment of their share of contribution. The employer, once allotted an ESIC Code number in respect of a factory/ establishment can login through the employer page on the web portal and register the employees. Each employee is allotted an insurance number, which is unique and will be valid throughout the life of the employee despite  changes in the jobs. On registration every insured person (IP) is provided with a 'Temporary Identification Certificate' (TIC) which is valid for a month. In the meantime s/he is required to register himself at an Enrolment Centre with his Photo and Finger prints with family to obtain a permanent Pehchan Card in Duplicate, one for him and other for the family. In case of loss a Duplicate card is issued on payment of  Rs.25/- at the designated Branch Office.

Benefits available under the Scheme:
(a) Medical Benefit: Reasonable medical care is provided to an Insured person and his family members from the day he enters insurable employment. However a ceiling of Rs. 10 lac on expenditure on the treatment of an Insured Person or his family member has been laid down some time back.

(b) Sickness Benefit (SB): Sickness Benefit in the form of Cash Compensation at the rate of 70 per cent of wages is payable to insured workers during the periods of certified sickness for a maximum of 91 days in a year. In order to qualify for sickness benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months.

Extended Sickness Benefit (ESB): SB is extendable up to two years in the case of 34 malignant and long-term diseases at an enhanced rate of 80 per cent of wages.

Enhanced Sickness Benefit: Enhanced Sickness Benefit equal to full wages is payable to insured persons undergoing sterilization for 7 days/14 days for male and female workers respectively.

(c) Maternity Benefit (MB) : Maternity Benefit for confinement/pregnancy is payable for three months which is extendable by further one month on medical advice at the rate of full wages subject to contribution for 70 days in the preceding year.

(d) Disablement Benefit    
Temporary disablement benefit (TDB):  Temporary Disablement Benefit at the rate of 90% of wages is payable so long as disability continues. It is admissible from day one of entering insurable employment and irrespective of having paid any contribution in case of employment injury.

Permanent disablement benefit (PDB): The benefit is paid at the rate of 90% of wages in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a Medical Board.

(e) Dependants' Benefit (DB): DB is paid at the rate of 90% of wages in the form of monthly payment to the dependants of a deceased Insured person in cases where death occurs due to employment injury or occupational hazards.

(f) Other Benefits:
i) Funeral Expenses: An amount of Rs.10, 000/- is payable to the dependents or to the person who performs last rites from day one of entering insurable employment.

ii) Confinement Expenses: A sum of Rs. 5,000/ is payable to an Insured Women or an I.P.in respect of his wife in case confinement occurs at a place where necessary medical facilities under ESI Scheme are not available, however restricted to 2 confinements only.

In addition, the scheme also provides some other need based benefits to insured workers.

Vocational Rehabilitation (VR): To permanently disabled Insured Person for undergoing VR Training at VRS.

Physical Rehabilitation: In case of physical disablement due to employment injury.

Old Age Medical Care : For Insured Person retiring on attaining the age of superannuation or under VRS/ERS and person having to leave service due to permanent disability insured person & spouse on payment of Rs. 120/- per annum.

Rajiv Gandhi Shramik Kalyan Yojana :  An Insured Person  becoming unemployed after being insured for three or more years, due to closure of factory/establishment, retrenchment or permanent invalidity are entitled to Unemployment Allowance equal to 50% of wage for a maximum period of up to one year.

Medical care for self and family from ESI Hospitals/Dispensaries is also available during the period IP receives Unemployment Allowance.

Vocational Training provided for upgrading skills - Expenditure on fee/travelling allowance borne by ESIC.

Incentive to employers in the Private Sector for providing regular employment to the persons with disability:

Minimum wage limit for Physically Disabled Persons for availing ESIC Benefits is 25,000/-.Employers' contribution is paid by the Central Government for 3 years. Cash Benefits are disbursed by the Corporation through its Branch Offices (BOs) / Pay Offices (POs), subject to certain contributory conditions.

Benefits for EMPLOYERS: 
i)    Employers covered under ESI Scheme are exempt from the Maternity Benefit Act and Employees' Compensation Act for employees.

ii)    Employers are freed from responsibility during physical distress of workers such as sickness, employment injury or physical disablement resulting in loss of wages, as the financial support in such contingencies is provided by the ESIC in respect of insured employees.

iii) Any sum contributed under the ESI Act is deductible while computing 'Income' under the Income Tax Act.

The infrastructural network: 
ESI Corporation has set up 151 hospital and 42 hospital annexes for inpatient services. Primary and out-patient medical services are provided through 1418 Dispensaries run by State Govts. and 140 ESI dispensaries and AYUSH units, and 1017 panel clinics.

New Initiatives by ESIC: 
1.    Inspection Scheme: Transparent  Inspection Scheme via computerized system as per risk-based criteria, instead of arbitrary inspections based on discretion, and uploading of Inspection Reports within 72 hours by Inspectors has been introduced.

2.    ESI Corporation has extended the benefits of the ESI Scheme to the workers deployed on the construction sites located in the implemented areas under ESI Scheme w.e.f. 1st August, 2015.

3.    24X7 MEDICAL HELPLINE NO.1800 11 3839 HAS BEEN PROVIDED IN ALL ESIC HOSPITALS

4.    There is a Plan to cover whole of the 393 districts, where clusters of Workers are located. 

5.    Opening Health Scheme for selected group of unorganized workers like rickshaw pullers/auto rickshaw drivers in selected urban/metropolitan areas. 

(6)    Up-grading dispensaries to six bedded hospitals in phases.

(7)    Providing appropriate cancer detection/treatment facilities at different levels of hospitals. 

(8)    Providing appropriate cardiology treatment facilities at different levels of hospitals. 

(9)    Providing dialysis facilities in all ESIC Model Hospitals on PPP Mode. 

(10) Providing all possible pathological facilities in hospital premises by outsourcing or by upgrading. 

(11) Tracking each and every mother and new born child of IP family to achieve 100% immunization as well as safe delivery.

(12) Creating at least one Mother Child care hospital with higher facilities in every State. 

(13) To start setting up State ESI Corporations/Societies in all States as subsidiary of ESI Corporation. 

(14) Electronic Health Record will be made available to the IP family members on-line. The record will also include laboratory record in digital format and there will be no need to visit the hospital for getting this information. 

(15) ESIC Hospitals change BED SHEETS every day and for each day of the week specific colour of bed sheet has been fixed based on VIBGYOR pattern. 

(16) ESIC Hospitals have started to operate Special OPD every day in the afternoon from 3.00 pm to 5.00 pm for senior citizens/differently abled patients. 

Final verdict about any Plan or Scheme can be given by the users. The feedback from the users has been mixed one. As regards Cash Benefits there is no doubt that the beneficiaries have been a satisfied lot. In case of Medical benefit it has been very good in states like Delhi but many States lack in providing Medical Benefit as per the norms. It has been seen that there are insufficient number of beds in many States and the delivery of medicines etc has been reported to be unsatisfactory. The reasons for dissatisfaction are mainly because of Dual Control of the Scheme by Centre as well as States. It has always been a point of consideration why ESIC should not take full responsibility of the Insured Population as it is the Insurer and collects the Contribution. ESI scheme seems to be a necessary evil as it is better to have something than not having anything and the workers have a support mechanism to depend on. The Scheme, of course, is a comprehensive Scheme to fulfil the aspirations of the workers in the hours of distress, need and life threatening contingencies. More efforts in execution can earn it a better name.