Explore essential ESIC topics: claim timelines, private treatment claims, direct fund transfers, time limitations, medical coverage limits, and penalties for late filings.
The Employees State Insurance Act, of 1948 was enacted by the Government of India through the Parliament to strengthen the social security for workers in independent India. In order to speed up manufacturing processes, manufacturing sectors started hiring many workers during the industrial revolution of the 1950s. The purpose of the legislation was to give these numerous employees a security mechanism, particularly in the event of health-related emergencies. Continue reading to learn about the advantages, coverage, and eligibility for the Employees State Insurance Scheme.
ESI provides medical care to eligible employees and their families as well as protection from illness, maternity, disability, and death due to a work-related accident.
But what does it actually stand for and how can you claim ESI after treatment?
Keep reading to learn everything about ESI.
What is ESI?
ESI stands for Employees’ State Insurance Scheme. Employees’ State Insurance Scheme of India is a multi-faceted social security program created to protect “workers” in the organized sector from events such as sickness, pregnancy, disability, and death due to workplace damage as well as to give healthcare services to the registered workers and their families.
The program offers the employee covered by the ESI Registration comprehensive medical care throughout the term of his illness, restoring his health and ability to work. It offers financial support to make up for the income lost while they were unable to work due to illness, pregnancy, or an occupational injury. The program also covers the medical expenses of the patient’s family members.
Who is in Charge of the ESI Scheme?
“The Employees’ State Insurance Corporation (ESIC), a statutory corporate entity that contains members representing employers, employees, the central government, state governments, the medical profession, and honorable members of parliament, is responsible for managing the ESI Scheme.”
The director general serves as both the corporation’s CEO and a former member of the board.
For whom is Medical Reimbursement Available?
Medical reimbursement is available in the following circumstances–
- The money should have gone toward the employee’s medical care.
- The money should have gone toward his or his family’s medical care.
- The employer needs to pay back that sum.
- The employer will not refund more than INR 15,000 in a given fiscal year.
What Is Covered by the State Insurance Program for Employees?
In 1952, Kanpur and Delhi, the two main industrial hubs at the time, introduced the ESI Scheme (ESIS) for the first time. However, as the industrial revolution gathered steam, the plan began to spread across the nation. The ESIS has been adopted in more than 34 states and Union Territories as of March 31, 2019, as a result of the rise in industrialization over time.
Over 3 crore employees or family units are now benefiting from the ESI Act, which presently includes approximately 12 lakh industrial and commercial buildings. More than 13 crore individuals presently receive benefits from the program.
What Does the Employees’ State Insurance Plan Not Cover?
Currently, the ESIC program does not include workers or employees making more than Rs. 21,000 per month, and for disabled individuals, the monthly maximum salary is Rs. 25,000. The current criterion for coverage in Maharashtra and Chandigarh is still 20 employees, not 10, as it is in other states or UTs.
What Is the Procedure for Submission of Medical Reimbursement?
- To file a compensation claim bill/bills, an IP must write an application to the Administrative Medical Officer, ESI Scheme, Assam via the appropriate Insurance Medical Officer i/c, ESI Scheme Dispensary, including the claim statement form, which is accessible at the Dispensary.
- The employee must state the source of the sickness.
- Along with the bill(s), the employee must submit a clear Photocopy of the insured person’s card, and bank information, including the name of the bank, branch, IFSC code: https://www.rbi.org.in/Scripts/IFSCMICRDetails.aspx, account number, and insured person’s phone number.
- The deadline for submitting reimbursement claims is only one (one) year.
What Situations Require ESI Registration?
A corporation, organization, or business institution must register for ESI if it employs ten or more workers or twenty or more in Chandigarh and Maharashtra. The business needs to register with the ESIC.
When workers or employees make less than Rs. 21,000 per month or Rs. 25,000 in the case of a disabled individual, they are eligible for coverage under the ESI. The employee contributes 1.75 percent of their wage, and the company matches that amount with a 4.75 percent contribution to the ESI program. Please be aware that these prices may occasionally change. Employees with a daily average pay of up to Rs. 50 are excluded from making contributions to the ESI returns, but employers will still make contributions on their behalf.
Paperwork Required For ESI Online Registration
- The list of documents needed for ESI online registration is as follows:
- The Registration Certificate obtained under the Factories Act or the Shops and Establishments Act
- Certificate of Registration for a firm or partnership.
- The company’s articles of association and memorandum of association.
- A list of every employee at the business.
- Information on each employee’s pay.
- Information about the business entity’s and each employee’s PAN cards.
- Canceled check from the company’s bank account.
- A list of the Company’s Directors and shareholders.
- A register with information about employees’ attendance.
- Employer’s Registration Form (Form No. 1), which needs to be downloaded, completed, and uploaded on the ESIC website together with the aforementioned files.
The IRS permits you to write off as eligible medical expenses online registration any unreimbursed costs for procedures, treatments, operations, and dental and eye care. Additionally, unreimbursed costs for appointments with psychologists and psychiatrists are deductible. If you need any more help in this regard, you can get in touch with Vakilsearch in-house legal experts. We will keep you updated regarding the ESI claim and will help you with the whole process.
What is the duration for ESIC reimbursement claims?
ESIC reimbursement claims should be submitted within 3 months from the date of treatment to facilitate timely processing and approval.
How Can I claim ESI if I take treatment in private?
To claim ESI for private treatment, submit the bill along with a referral from an ESIC dispensary, ensuring adherence to ESI guidelines.
Can we get ESI money back in the account?
Yes, ESI reimbursement is directly credited to the insured person's bank account, providing convenient and direct access to the entitled funds.
What is the limitation period of ESI?
The limitation period for filing ESI reimbursement claims is typically 6 months from the date of treatment. Claims submitted beyond this period may not be considered.
What is the limit of ESI medical treatment?
There is no limit on the spending for the treatment of an Insured Person or their family. Additionally, medical care is extended to retired and permanently disabled insured individuals and their spouses by paying a nominal annual premium of 120/-.
What is the amount of penalty for filing ESI late?
The penalty for late filing of ESI contributions is 12% per annum, calculated monthly until the contribution is paid. Timely submissions are crucial to avoid financial penalties.