iapnhi Hkou] lh-vkbZ-th ekxZ] ubZ fnYyh&110 002Hkkjr ljdkj] Government of India

xq.koÙkk LOkkLF; ns[kHkky dk oknk ,oalkekftd lqj{kk dk vk'oklu

PROMISE OF QUALITY HEALTHCARE &

ASSURANCE OF SOCIAL SECURITY

Employees’ State Insurance Scheme of India – An introduction :

Benefits under ESI Scheme :

Medical Benefits – An Overview :

The promulgation of Employees’ State Insurance Act by the Parliament in 1948

was the first major legislation on comprehensive Social Security for Workers in

Independent India. The Act envisages social protection of workers in the organized

sector in contingencies, such as sickness, maternity, death or disablement due

to employment injury and occupational disease. Based on the principle of “pooling

of risks and resources”, the unique, multidimensional health insurance Scheme

guarantees a fair deal to the covered members by providing full medical facilities to

the beneficiaries, besides, adequate cash compensation to insured persons for loss of

wages or earning capacity in times of physical distress arising out of sickness or

employment injury or unemployment.

The main benefits provided under ESI Scheme are:• Sickness Benefit• Disablement Benefit• Dependants’ Benefit• Maternity Benefit• Medical Benefit

Besides the above, other benefits being provided to the beneficiaries are

Confinement Expenses, Funeral Expenses, Vocational Rehabilitation, Physical

Rehabiliation, Unemployment Allowance (RGSKY) and Skill Upgradation Training

under RGSKY.

In ESIC, comprehensive medical care ranging from OPD, medical attendance,

treatment, drugs, specialist consultation, hospitalization of insured persons (IPs) and

their family members to super-speciality treatment, are provided under the Scheme.

Medical Benefit is available to the Insured Person (IP) and his family members from the

day one enters the insurable employment. What makes this Scheme unique, is that,

medical care is provided to ESI Beneficiaries as per need. There is no ceiling on

expenditure on individual medical care. Besides this, Medical Care as available in ESI

Dispensaries/Hospitals is also provided to retired and permanently disabled insured

persons and their spouses on payment of a token annual premium of ̀ 120/-.

Section 56 (1) of ESI Act, 1948 provides, “an Insured Person or (where such

medical benefit is extended to his family) a member of his family whose

condition requires medical treatment and attendance shall be entitled to

receive medical benefit”.

Hkkjrh; dh deZPkkjh jkT; chek ;kstuk & ifjp; %

bZ,lvkbZ ;kstuk ds rgr fgrykHk %

fpfdRlk fgrykHk & ,d ut+j esa %

laln esa deZpkjh jkT; chek vf/kfu;e] 1948 dk iz[;kiu Lora= Hkkjr esa dkexkjksa ds fy, O;kid

lkekftd lqj{kk ij izFke izeq[k fo/kku FkkA bl vf/kfu;e esa vkdfLedrkvksa ;Fkk chekjh] ekr`Ro] jkstxkj

pksV ds dkj.k e`R;q ;k viaxrk ,oa O;olkf;d jksx dh fLFkfr esa laxfBr {ks= ds dkexkjksa dks lkekftd

lqj{kk iznku djus dh ifjdYiuk dh xbZ gSA *tksf[keksa vkSj lalk/kuksa dk ,d=hdj.k* ds fl)kUr ij

vk/kkfjr ;g vuks[kh] cgqeq[kh LOkkLF; chek ;kstuk] O;kIr lnL;ksa dks vFkkZr~ ykHkkfFkZ;ksa dks lEiw.kZ fpfdRlk

lqfo/kk;sa iznku dj mfpr O;ogkj dh xkjaVh nsrh gSA blds vfrfjDr] chekÑr O;fDr;ksa dks chekjh ;k

jkstxkj pksV ;k csjkstxkjh ls mRiUu 'kkjhfjd d"V ds le; etnwjh ;k vtZu {kerk esa gqbZ gkfu gksus ij

i;kZIr udn {kfriwfrZ iznku dh tkrh gSA

bZ,lvkbZ ;kstuk ds rgr iznku fd, tkus okys eq[; fgrykHk gSa % • chekjh fgrykHk• fu%'kDrrk fgrykHk• vkfJrtu fgrykHk• ekr`Ro fgrykHk• fpfdRlk fgrykHk

mijksDr ds vykok ykHkkfFkZ;ksa dks fn, tkus okys vU; fgrykHk gSa izlwfr O;;] vaR;sf"V O;;]

O;kolkf;d iquokZl] 'kkjhfjd iquokZl] csjkstxkjh HkÙkk ¼jk-xk-J-d-;ks½ vkSj jk-xk-J-d-;ks ds

rgr dkS'ky mUu;u izf'k{k.kA

bZ,lvkbZLkh esa O;kid fpfdRlk ns[kHkky vksihMh] fpfdRlk ifjp;kZ] bykt] nokvksa] fo'ks"k ijke'kZ] chfer

O;fDr;ksa ¼vkbZIkh½ dks vkSj muds ifjokj ds lnL;ksa dks vLirky esa HkrhZ djuk rFkk lqij Lisf'k;fyVh ds

mipkj] ;kstuk ds rgr fn, tkrs gSaA fpfdRlk fgrykHk chfer O;fDr;ksa ¼vkbZIkh½ vkSj muds ifjokj ds

lnL;ksa dks mlh fnu ls miyC/k gksrs gSa tc os chek ;ksX; jkstxkj esa izos'k djrs gSaA bl ;kstuk dh vuks[kh

fo'ks"krk ;g gS fd blesa bZ,lvkbZ ykHkkfFkZ;ksa dks t:jr ds vuqlkj fpfdRlk ns[kHkky iznku dh tkrh gSA

blesa oS;fDrd fpfdRlk ns[kHkky ij O;; dh dksbZ lhek ugha gSA blds vykok bZ,lvkbZ

fMLisalfj;ksa@vLirkyksa esa lsokfuo`Ùk vkSj LFkk;h :Ik ls fu%'kDr chfer O;fDr;ksa vkSj muds thou lkfFk;ksa

dk ̀ 120 ds ukeek= okf"kZd izhfe;e ij ns[kHkky iznku dh tkrh gSA

bZ,lvkbZ vf/kfu;e]1948 dh /kkjk 56 ¼1½ ds vuqlkj ^^dksbZ chfer O;fDr ;k ¼tgka mDr fpfdRlk

fgrykHk mlds ifjokj dks fn;k tk jgk gS½ mlds ifjokj dk lnL;] ftldh fLFkfr ds fy, fpfdRlk

mipkj ,oa ifjp;kZ dh vko';drk gS mls fpfdRlk fgrykHk ikus dh gdnkjh gksxh**

fpfdRlk fgrykHk ds fy, ik=rk %

fpfdRlk fgrykHk dh vof/k vkSj Lrj %

fpfdRlk fgrykHk dk forj.k %

dksbZ chfer O;fDr ¼vkbZih½ vkSj mlds ifjokj ds lnL; bZ,lvkbZ ;kstuk ds rgr izkFkfed vkSj f}Rkh;d

fpfdRlk fgrykHk ds ik= mlh fnu cu tkrs gSa tc os chek ;ksX; jkstxkj esa izos'k djrs gSaA bZ,lvkbZ

vf/kfu;e]1948 dh /kkjk 56 ¼3½ ds vuqlkj ̂ ^,d O;fDr dks ml vof/k ds nkSjku fpfdRlk fgrykHk ikus dh

gdnkjh gksxh] ftlds nkSjku mlds lca/k esa va'knku ns; gSa ;k og chekjh fgrykHk ;k ekr`Ro fgrykHk ikus

ds nkos gsrq vgZd gS ¼;k og mDr fu%'kDrrk fgrykHk ikrk gS] tSls fd mls fofu;eksa ds rgr fpfdRlk

fgrykHk ikus dh vi;kZirk ugha gS**½A

,d chfer O;fDr@,d chfer O;fDr ds ifjokj ds lnL; bl ;kstuk ds rgr fpfdRlk mipkj dk rc

rd fgrykHk mBk ldrk gS tc rd chfer O;fDr chek ;ksX; jkstxkj esa dk;Zjr gSA chfer O;fDr vkSj

mlds ifjokj ds lnL;ksa ds fy, iwjh fpfdRlk ns[kHkky ¼vLirky esa HkrhZ djus lfgr lHkh lqfo/kk,a½ nh

tkrh gSaA

bZ,lvkbZ vf/kfu;e]1948 ds micU/kksa ds vuqlkj jkT; ljdkjsa bZ,lvkbZ fMLisalfj;ksa ¼izkFkfed fpfdRlk

lsokvksa ds fy,½ vkSj bZ,lvkbZ vLirkyksa ¼f}rh;d fpfdRlk lsokvksa ds fy,½ ds usVodZ ds ek/;e ls

fpfdRlk fgrykHk iznku djus ds fy, ftEesnkj gSaA tcfd d-jk-ch- fuxe fnYyh vkSj uks,Mk {ks= esa izR;{k

fpfdRlk ns[kHkky iznku djrk gSA bu nks {ks=ksa ds vykok fuxe }kjk 34 bZ,lvkbZLkh vLirky izR;{k :Ik ls

pyk, tkrs gSa ftlesa izR;sd jkT; esa de ls de ,d bZ,lvkbZlh ekWMy vLirky 'kkfey gSaA ykHkkfFkZ;ksa dks

lHkh bZ,lvkbZ fpfdRlk iznk;xh laLFkkuksa esa vksihMh lsok,a] vkarfjd jksxh lsok,a] uSnkfud lqfo/kk,a] eq¶r

nok,a vkSj Mªsflax vkfn nh tkrh gSA

Eligibility for Medical Benefit :

Duration and Scale of Medical Benefit :

Delivery of Medical Benefit :

An insured person (IP) and his/her family member become eligible for primary &

secondary medical benefit under the ESI Scheme from day one of entering insurable

employment. Section 56 (3) of ESI Act, 1948 provides, “A person shall be entitled to

medical benefit during any period for which contributions are payable in respect of

him or in which he is qualified to claim sickness benefit or maternity benefit (or is in

receipt of such disablement benefit as does not disentitle him to medical benefit under

the regulations)”.

The insured person/family member of an insured person can avail the medical

treatment under this Scheme till the insured person is in insurable employment. Full

medical care (all facilities including hospitalization) for insured person and their

family members is provided.

As per the provisions of ESI Act, 1948, the State Governments are responsible for

providing the medical benefits through the network of ESI Dispensaries (for primary

medical services) and ESI Hospitals (for secondary medical services). However, the ESI

Corporation provides medical care directly, in Delhi and Noida area. Besides these

two area, the Corporation is also running 34 ESIC Hospitals directly which includes

ESIC Model Hospitals, at least one in each State. The beneficiaries are provided OPD

services, in-patient services, diagnostic facilities, free drugs and dressings etc. in all

ESI medical delivery institutions.

bZ,lvkbZLkh us nokvksa ds fy, viuh QkekZdksfi;k dk fodkl fd;k gSA lHkh nok,a vkSj Mªsflax ¼Vhdk vkSj

fljk lfgr½ ftUgsa QkekZdksfi;k ds vuqlkj vke rkSj ij vfuok;Z ekuk tkrk gS] budh vkiwfrZ lHkh jksfx;ksa

dks eq¶r nh tkrh gSA xaHkhj jksfx;ksa ds ekeys esa ifjogu ds vuq"kaxh O;;] Bgjus ds izHkkj] ifjpkjdksa ds fy,

;k=k O;; ¼;fn vko';d gks½ dk Hkqxrku bZ,lvkbZLkh }kjk fd;k tk jgk gSA

d-jk-ch- ;kstuk ds ikl Hkkjr esa ,d N= ds rys lcls cM+h fpfdRlk volajpuk gSA 150 bZ,lvkbZ

vLirkyksa] 1372@91 bZ,lvkbZ fMLisaljh@vkbZ,l,e bdkb;ksa] 1380 iSuy fDyfudksa vkSj 7340 vkbZ,evks

ds fo'kky usVodZ ds ek/;e ls fpfdRlk ns[kHkky iznku dh tkrh gSA bZ,lvkbZ ;kstuk ns'k esa fpfdRlk vkSj

iSjk esfMdy dkfeZdksa dh Hkh lcls cM+h fu;ksDrk gSA

d-jk-ch- ;kstuk dh fpfdRlk volajpuk %

ESIC has developed its own pharmacopeia for drugs. All drugs and dressing

(including vaccine & sera), which is considered necessary and generally in accordance

with pharmacopeia, are supplied to all patients free of charge. In the case of critical

patients, incidental expenditure on transport, stoppage charges at the centre,

traveling expenses for attendants (if required) are also being paid by ESIC.

The ESI Scheme has the largest medical infrastructure under one umbrella, in India.

Medical Care is provided through its huge network of 150 ESI Hospitals, 1372/91 ESI

Dispensaries/ISM Units, 1380 Panel Clinics and 7340 IMOs. The ESI Scheme is also

the largest employer of Medical and Para-Medical personnel of the country.

Medical Infrastructure of ESI Scheme :

Super-Speciality Treatment :

Expenditure on Medical Care :

Medical Benefit for Old Age and for

Permanent Disabled Beneficiaries :

Provision of Artificial Limbs and Appliances :

The eligibility for super-specialty treatment is 3 months

(with contribution paid for at least 39 days) of insurable

employment for insured person (for self) and 6 months

(with contribution paid for at least 78 days) of insurable

employment by Insured Person for their family

members. Such tertiary care (super-speciality treatment)

is provided through in-house super speciality facilities

available in some of ESI Hospitals or ESI-PGIMSRs or

through large no. of advanced empanelled medical

institutions on referral basis through tie-up

arrangements. About 750 private hospitals in all India

are now empanelled as tie-up Hospitals for ESIC.

The ESI Corporation incurred about ` 268962.11

lakhs on the delivery of medical care in the last year.

The expenditure is shared between the ESI

Corporation and State Govt. in the ratio of 7:1.

Medical Care expenditure is reimbursed to State Govt.

based on ceiling which at present is ` 1500/- per IP

unit/per annum.

The Medical Benefit has further been extended to the

insured persons who go out of employment on

account of attaining the age of superannuation (Old

Age) or on account of permanent disability (arising out

of employment injury). The Medical care is provided

in ESI institutions only, to such insured persons and

their spouse on payment of a lump sum amount for

one year at the rate of ̀ 10/- per month.

Artificial limbs, artificial dentures, spectacles, hearing

aids, cardiac pacemaker, walking caliper, surgical

boots, spinal support, cerebral collar, intraoccular

lens etc. are provided free of cost to those patient

beneficiaries, who requires such appliances.

vfr&fo'ks"kKrk mipkj %

fpfdRlk ns[kHkky ij O;; %

o`) vkSj LFkk;h fu%'kDr ykHkkfFkZ;ksa ds fy, fpfdRlk

fgrykHk %

Ñf=e vaxksa vkSj midj.kksa dh O;oLFkk %

chek ;ksX; fu;kstu esa jgus ij chekÑe O;fDr dks ¼Lo;a ds fy,½

vfr fo'ks"kKrk mipkj dh ik=rk 3 ekg ¼de ls de 39 fnu ds

fy, va'knku dk Hkqxrku fd;k x;k gks½ gS rFkk muds ifjokj ds

lnL;ksa ds fy, bl mipkj dh ik=rk 6 ekg ¼de ls de 78 fnu ds

fy, va'knku dk Hkqxrku fd;k x;k gks½ gSA ,slh r`rh;d ns[k&js[k

¼vfr&fo'ks"kKrk mipkj½ dqN d-jk-ch- vLirky ;k d-jk-ch-

LukrdksÙkj vk;qfoZKku ,oa vuqla/kku laLFkkuksa esa miyC/k laLFkkfud

vfr&fo'ks"kKrk lqfo/kkvksa ;k Vkb&vi izca/k ds ek/;e ls jSQjy

vk/kkj ij cM+h la[;k esa mUur ukfedkf;r (empanelled)

fpfdRlk laLFkkuksa ds tfj;s iznku dh tk jgh gSA vHkh iwjs Hkkjr esa

yxHkx 750 futh vLirky d-jk-ch- fuxe ds fy, Vkb&vi

vLirky ds :i esa ukfedkf;r gSaA

d-jk-ch- fuxe }kjk fiNys o"kZ fpfdRlk ns[kHkky dh iznk;xh ij

` 268962-11 yk[k dh jkf'k O;; dh xbZ gSA bl O;; dks bZ,lvkbZ

fuxe vkSj jkT; ljdkj ds chp 7%1 ds vuqikr esa ckaVk x;k gSA

fpfdRlk ns[kHkky O;; dh izfriwfrZ jkT; ljdkj dks ,d lhek ds

vk/kkj ij dh tkrh gS] tks orZeku esa ̀ 1500 izfr vkbZih ;wfuV@izfr

o"kZ gSA

fpfdRlk fgrykHk iqu% mu chfer O;fDr;ksa dks foLrkfjr fd, x, gSa

tks vk;q c<+us ds dkj.k lsokfuo`fÙk ls ;k LFkk;h fu%'kDrrk ¼jkstxkj

laca/kh pksV ls mRiUUk½ ls jkstxkj ls ckgj gks x, gSaA bUgsa dsoy

bZ,lvkbZ laLFkkuksa }kjk mDr chfer O;fDr;ksa vkSj muds thoulkFkh

dks ̀ 10 izfr ekg dh nj ij ,d o"kZ dh ,d eq'r jkf'k ds Hkqxrku

ij fpfdRlk ns[kHkky nh tkrh gSaA

Ñf=e vax] d`f=e narkoyh] p'ek] Jo.k lgk;d ;a=] dkfMZ;d

islesdj] pyus ds dSfyilZ] lftZdy cwV] jh<+ dh gM~Mh dk lgkjk]

lsjsczy dkWyj] baVjkvksdqyj ysal vkfn mu jksxh ykHkkfFkZ;ksa dks eq¶r

iznku fd, tkrs gSa ftUgsa bu midj.kksa dh vko';drk gksrh gSaA

O;kolkf;d jksx dsUnz %

ifjokj dY;k.k lsok,a vkSj ,M~l fu;a=.k %

Hkkjrh; fpfdRlk i)fr ¼vkbZ,l,e½ %

v{kerk lanHkZu %

deZpkjh jkT; chek fuxe esa fpfdRlk f'k{kk %

ubZ fnYyh] psUubZ] dksydkrk] eqEcbZ vkSj bankSj esa d-jk-ch- fuxe }kjk ikap tksuy O;kolkf;d jksx dsUnz cuk, x, gSa tks O;kolkf;d jksxksa dk tYnh irk yxkus vkSj funku dh lqfo/kk,a nsrs gSa rFkk laacaf/kr {ks=ksa ds vkl ikl ds jkT;ksa ds bZ,lvkbZ ykHkkfFkZ;ksa dh t:jrsa iwjh djrs gSaA bZ,lvkbZ vf/kfu;e] 1948 dh rhljh vuqlwph esa O;kolkf;d jksxksa dks ifjHkkf"kr fd;k x;k gS vkSj bUgsa fu%'kDrrk fgrykHk] vkfJrtu fgrykHk vkfn tSLks udn fgrykHk iznku djus ds fy, jkstxkj laca/kh pksV ds led{k ekuk tkrk gSA

lHkh bZ,lvkbZ vLirky@fMLisalfj;ka ifjokj dY;k.k ls lacaf/kr lsok,a iznku djrs gSaA fuxe }kjk ns'k ds dkedkth oxZ ds chp ,M~l ds fu;a=.k ds mik; Hkh fd, x, gSaA ,d iw.kZ lfTtr funs'kky;] [kkl rkSj ij ifjokj dY;k.k lsokvksa vkSj ,M~l fu;a=.k ds fy, ubZ fnYyh esa dk;Zjr gSA ;g funs'kky; ukdks (NACO) vkSj LOkkLF; ,oa ifjokj dY;k.k ea=ky;] Hkkjr ljdkj ds leUo; ls dk;Z djrk gSA

fpfdRlk dh ,yksiSfFkd i)fr ds lkFk d-jk-ch- fuxe }kjk Hkkjrh; fpfdRlk i)fr ¼vkbZ,l,e½ ds vUrxZr vk;qosZn] ;ksx] ;wukuh] fl) vkSj gksfe;ksiSFkh ¼vk;q"k½ dh fpfdRlk ns[kHkky Hkh iznku dh tkrh gSA bZ,lvkbZ vLirkyksa@fMLisalfj;ksa esa iwjs ns'k esa yxHkx 95 vkbZ,l,e bdkb;ka dk;Zjr gSaA

fu%'kDrrk fgrykHk ¼udn esa½ iznku djus ds iz;kstu ls v{kerk ekiu dss lanHkZ fn, tkrs gSaA mDr v{kerk ekiu lanHkksZa dks vafre :Ik nsus ds fy, iwjs ns'k esa yxHkx 70 fpfdRlk funsZf'k;ksa dk usVodZ gSA

fuxe us i;kZIr fpfdRlk@iSjkesfMdy dkfeZdksa dh miyC/krk lqfuf'pr djus] bZ,lvkbZ ykHkkfFkZ;ksa dks LokLF; ns[kHkky iznku djus ds fy, vkSj fpfdRlk lqfo/kkvksa@Kku esa lq/kkj ykus ds fy, fpfdRLkk f'k{kk esa dne j[kk gSA orZeku esa 06 LukrdksÙkj vk;qfoZKku vkSj vuqla/kku laLFkku ¼cSaxyksj] psUubZ] dksydkrk] eqEcbZ vkSj fnYyh½ ,oa ,d nar egkfo|ky; ¼fnYyh½ vkSj ,d fpfdRlk egkfo|ky; ¼cSaxyksj½ vkjaHk gks pqds gSaA

Occupational Diseases Centre :

Family Welfare Services and AIDS Control :

Indian System of Medicine (ISM) :

In - Capacity References :

Medical Education in ESIC :

The ESI Corporation has set up five zonal occupational Diseases Centre at New Delhi, Chennai, Kolkata, Mumbai and Indore for providing facilities for early detection and diagnosis of Occupational Diseases, and to cater to the needs of ESI Beneficiaries of the neighbouring State in the respective zones. The occupational diseases as defined in the third schedule of ESI Act, 1948 are considered to be arising out of/in the course of employment and are taken as equivalent to employment injury for providing Cash Benefits like Disablement Benefit, Dependants Benefit etc.

All ESI Hospitals/Dispensaries provide services related to family welfare. The Corporation has also taken measures for control of AIDS among the working class of the country. A full fledged Directorate is working specially for family welfare services and AIDS Control at New Delhi. This Directorate works in co-ordination with NACO and also with Ministry of Health & Family Welfare, Govt. of India.

Alongwith the Allopathic system of medicine, the ESI Corporation is also providing medical care through Indian System of Medicine (ISM) including Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH). About 95 ISM units are working in ESI Hospitals/Dispensaries throughout the country.

For the purpose of providing of Disablement Benefit (in cash), references are made for measuring incapacity. There is a network of about 70 Medical Refrees throughout the country for finalizing such incapacity references.

ESIC has ventured into medical education to ensure availability of sufficient Medical/Para-medical personnel and to improve the medical facilities/knowledge for providing health care to the ESI Beneficiaries. Presently, 06 Post-graduate Institutes of Medical Sciences and Research (Bangalore, Chennai, Kolkata, Mumbai and Delhi), One Dental College (Delhi) and one Medical College (Bangalore) are already running.