What is Employees State Insurance Corporation (ESI Scheme)?

Due to the hectic pace of today's society, healthcare expenses incurred to the people can be a major issue. This is where an insurance plan becomes very important. To this effect, the Indian government launched the ESI scheme. ESI full form is Employees State Insurance.

This scheme is managed by Employee State Insurance Corporation (ESIC) and offers financial and medical assistance to the employees, thus relieving them from the burden of health care costs in case of emergencies. Continue reading to know more about how the ESI scheme can benefit you.

Team Digit

What is the ESI Scheme?
Features & Benefits
What is Not Covered?
Who is Eligible for ESI Scheme?
List of Diseases Covered
How to Register for ESIC Online?
Documents Required
How to Find List of Hospital?
What is an ESI Card?
How to Download an ESI Card?
Hospitalisation Process Under ESI
Frequently Asked Questions

What is the Employee State Insurance Scheme (ESI)?

A multidimensional social security scheme, the Employee State Insurance scheme aims to offer socio-economic protection to the population employed in the organised sector and their dependent members. Under this insurance scheme, individuals can avail of financial assistance during medical emergencies due to occupational hazards, sickness, and maternity.

The corporate body responsible for administering this integrated program is called the Employee State Insurance Corporation (ESIC).

This scheme is enforced under the Employees State Insurance Act, whereby every employer must ensure a new employee’s enrolment under this programme.

Overview of the Employee State Insurance Act

The Parliament of India introduced the Employees State Insurance Act in 1948 and first launched it in 1952 in Delhi and Kanpur, covering approximately 1.20 lakh employees. After this initial implementation, the state governments took up this initiative to include more parts of the country in several phases.

This act defines several terms and conditions related to the scheme’s validity, including insured employees’ eligibility and duties and responsibilities of the Employees’ State Insurance Corporation (ESIC).

It also specifies certain requirements for a family member to become a dependent of the insured individual under the ESI scheme. According to this Act, eligible dependents include:

Any parent, including a widowed mother.
Sons and daughters, including any adopted or illegitimate offspring.
A widowed or unmarried sister.
A minor brother
A paternal grandparent in case his/her parents are dead.
A widowed daughter-in-law.
A minor offspring of a predeceased son or a predeceased daughter provided no child parent is alive in the latter case.

The Employees State Insurance Act 1948 also specifies 2 contribution periods and 2 cash benefit periods, which are marked as follows:

Period	Months
Contribution periods	1st April-30th September, 1st October-31st March
Cash benefit periods	1st January-31st June, 1st July-31st December

Depending on an employee’s contributory days during a contribution period, they can avail of compensation in the succeeding cash benefit period accordingly.

What are the Features of The ESI Scheme?

If you are curious to get down to the nitty-gritty of this government-sponsored insurance scheme, here are some key characteristics of the same:

Feature	Description
Coverage	The Employee State Insurance Scheme aims at providing coverage to all workers with a monthly payment of less than or equal to Rs.21000. This scheme ensures financial support for eligible employees in various contingencies.
Healthcare Benefits	Healthcare benefits against specific illnesses can be availed by the insurer as well as their dependent members. This coverage extends to a range of medical conditions for both the insured and their dependents.
Contribution Rates	The current rate of contribution for employers is 3.25%, and for employees, it is 0.75% of the wages payable. The government reduced the total contribution from 6.5% to 4% in 2019. Note that workers with daily average wage of upto Rs. 176 are exempted from paying their share.
Contribution Deadline	Employers must clear any due contribution within 21 days of the month. Timely payment is crucial to maintain compliance with the scheme’s regulations and ensure that workers receive their entitled benefits without delays.
State Government Contribution	State governments must pay 1/8th of the total medical expenses up to Rs.1500 per head under the ESI scheme. This contribution helps cover part of the medical costs and ensures that they receive necessary healthcare services.
Benefits After Retirement	The scheme will continue offering benefits to insured individuals even after opting for premature retirement or those under the VHS scheme. Even an unemployed individual can continue benefiting from the scheme for up to 3 years. However, they need to provide their retrenchment letter and all details regarding their last workplace.
Medical College Development	The scheme encourages opening of more medical colleges to help enhance individuals' quality of healthcare. The initiative aims to improve training and healthcare services by increasing the number of medical institutions.
Accident Coverage	This scheme includes accidents encountered while commuting under occupational hazards. It ensures protection for workers against risks, especially workplace-related incidents.
Maternity Benefits	Women employees can avail of special benefits in case of pregnancy-related problems. They can extend their maternity leave of 26 weeks by up to 1 month without affecting their wage slab.

All these features of this health insurance scheme allow you to avail a number of benefits.

Benefits of the ESI Scheme

The Employee State Insurance (ESI) Scheme offers comprehensive coverage for workers, including medical benefits, disability support, and financial aid. It ensures protection and assistance in various contingencies, enhancing worker welfare and security.

You can avail of the following benefits at an ESI hospital/dispensary if you are enrolled under the ESI scheme.

1. Sickness Benefits

Insured employees can enjoy cash compensation worth 70% of their wages for periods of certified illness, valid up to 91 days per year. To claim such benefits, individuals need to contribute for at least 78 days during a contribution period.

Individuals with long-term illnesses can avail of greater compensation rates of 80% for up to 2 years under extended sickness benefits of the Employees State Insurance Act 1948.

2. Medical Benefits

The insured and his/her dependent family members can avail of complete medical and surgical care under this scheme, including doctor consultation, medication, and ambulance services.

There is provision of immunisation and vaccination service at all the ESI centres implemented in the state. The scheme does not specify any maximum limit for such expenses.

3. Disablement (Temporary and Permanent) Benefits

Insured workers can avail 90% of their wages as compensation if they face temporary disability from an employment injury.

This benefit is admissible from day 1 of employment, notwithstanding the fact if you have paid any contribution or not.

Compensation is provided for the entire period of loss of earning capacity, provided the disability lasts for more than 3 days after the date of the accident.

4. Maternity Benefits

Women employees can claim cash benefits in case of any health complications arising out of pregnancy, miscarriage, medical termination of pregnancy, premature birth, or confinement.

The maximum period for compensation varies between 6-12 months, depending on the type of medical requirement, and can be extended by another 1 month.

Note that you can only benefit if you have made contributions for at least 70 days in the 2 successive contribution periods prior to your cash benefit period.

Know about: Health Insurance Plans with Maternity Coverage

5. Death Benefits

In case an insured employee expires from an occupational hazard, his dependent family members can avail of monthly compensation worth 90% of the deceased individual’s salary.

While dependent spouses and parents can enjoy these benefits until death, dependent offspring can benefit from 25 years of age.

6. Funeral Expenses

If you are a dependent family member, you can claim up to Rs. 15,000 to perform the final rites of the expired individual.

The money is paid in cash to the family of the deceased. This benefit helps to alleviate the financial burden on the family of the deceased by covering part of the funeral costs.

7. Post-retirement Benefits

If you have been covered under employee state insurance for at least 5 years, you and your spouse can continue enjoying medical benefits even after your retirement.

Note that you will need to pay a nominal fee of Rs.120 every year to avail of scheme benefits. Additionally, it's important to ensure that your coverage remains active by renewing the nominal fee annually to avoid any lapse in benefits.

8. Provision for Unemployed Individuals

If you become unemployed due to retrenchment, shutting down the workplace, or permanent disability, after having been an insured employee for at least 3 years, you can still enjoy specific benefits under the Rajiv Gandhi Shramik Kalyan Yojana.

These benefits include medical care and an unemployment allowance worth 50% of your pay for up to 1 year.

Unemployed beneficiaries can also claim cash compensation under the Atal Beemit Vyakti Kalyan Yojana. Policyholders will receive 25% of their monthly wages for three months under Section 2(9) of the ESI Act.

Besides the above benefits of the ESI scheme, individuals can also avail compensation of up to Rs.5000 if confined in any place other than ESI hospitals/dispensaries. However, such claims are only admissible up to 2 times.

9. The Extent of Coverage Under the Employee State Insurance Scheme

This scheme applies to all business institutions across India with more than or equal to 10 employees under the Shops and Establishment Act or the Factory Act.

If you wish to understand in detail what the ESIC coverage includes, refer to the following list.

Section 2(12) under the Employees State Insurance Act 1948 covers all non-seasonal factories.
Section 1(5) makes this scheme applicable to all restaurants, cinemas, shops, newspaper establishments, road-motor transport undertakings, and hotels. Subsequent extensions have been made to include private educational and medical institutions under the ESI scheme.

As already mentioned, workers with up to Rs.21000 gross salary can subscribe to this insurance scheme, while the salary limit for those with disabilities is up to Rs.25000.

What is Not Covered Under the Employee State Insurance Scheme?

Employee State Insurance (ESI) provides comprehensive coverage, but there are specific exclusions and limitations within the scheme. Here’s what is generally not covered under the ESI:

Exclusion	Description
Pre-existing Conditions	Medical conditions that existed before joining the ESIS may not be covered immediately. There may be waiting periods for coverage.
Cosmetic and Elective Procedures	Cosmetic surgeries or elective procedures that are not medically necessary are not covered.
Non-Medical Expenses	Expenses for non-medical services, such as private room charges or luxury amenities during hospitalisation, are not covered.
Certain Chronic Conditions	Some long-term or chronic conditions may have specific exclusions or limited coverage under the scheme.
Out-of-Network Facilities	Treatments received at hospitals or clinics not part of the ESIC network may not be covered, affecting cashless treatment options.
Non-Occupational Injuries	Injuries or illnesses not related to occupational hazards or commuting may not be covered under the scheme.
Self-Inflicted Injuries	Injuries that are self-inflicted or result from self-harm are typically excluded from coverage.
Treatment Abroad	Medical treatments and services received outside India are generally not covered under the ESIC scheme.
Certain Diseases and Treatments	Some specific diseases or treatments may have exclusions or limitations based on the policy terms.
Optional and Additional Services	Services that are optional or considered additional beyond the standard medical coverage may not be included.

Who is Eligible for the ESI Scheme?

The Employee State Insurance (ESI) Act provides social security and health insurance benefits to employees working in various sectors. Here’s an overview of the eligibility criteria:

Eligibility Criteria	Details
Employees in Covered Establishments	Workers in factories, shops, hotels, cinemas, and other establishments with 10-20 or more employees.
Income Criteria	Employees earning up to ₹21,000 per month (or ₹25,000 for persons with disabilities) are eligible.
Employer's Contribution	Employees contribute 0.75% of their wages, and employers contribute 3.25%.
Workers in Government-Supported Sectors	Certain government-supported sectors are covered under ESIC.
Voluntary Coverage	Self-employed people and workers in specific sectors may opt for voluntary coverage if they meet the criteria.
Dependents	Family members, including spouses, children, and dependent parents of insured employees, are eligible.

List of Long-term Diseases Covered by Employee State Insurance Scheme

Employees facing long-term illnesses struggled when regular sickness benefits ended after 91 days. To help, the Extended Sickness Benefit allows them to receive payments for up to 2 years within a 3-year period if they remain unwell.

The ESI Covers the following long-term diseases:

Category	Conditions
Infectious Diseases	Tuberculosis Leprosy Chronic Empyema AIDS
Neoplasms	Malignant Diseases
Endocrine, Nutritional and Metabolic Disorders	Diabetes Mellitus with proliferative retinopathy/diabetic foot/nephropathy
Disorders of the Nervous System	Monoplegia Hemiplegia Paraplegia Hemiparesis Intracranial Space Occupying Lesion Spinal Cord Compression Parkinson's disease Myasthenia Gravis/Neuromuscular Dystrophies
Diseases of Eye	Immature Cataract with vision 6/60 or less Detachment of Retina Glaucoma
Diseases of the Cardiovascular System	Coronary Artery Disease: (a) Unstable Angina (b) Myocardial Infarction with ejection fraction less than 45% Congestive Heart Failure: Left, Right, Cardiac Valvular Diseases with failure/complications Cardiomyopathies Heart disease with surgical intervention, along with complications
Chest Diseases	Bronchiectasis Interstitial Lung Disease Chronic Obstructive Lung Disease (COPD) with congestive heart failure (Cor Pulmonale)
Diseases of the Digestive System	Cirrhosis of the liver with ascites/chronic active hepatitis
Orthopaedic Diseases	Dislocation of vertebra/prolapse of intervertebral disc Non-union or delayed union of fracture Post-Traumatic Surgical Amputation of lower extremity Compound fracture with chronic osteomyelitis
Psychoses	Schizophrenia Endogenous Depression Manic Depressive Psychosis (MDP) Dementia
Others	More than 20% burns with infection/complication Chronic Renal Failure Reynaud's disease/Buerger's disease

How to Register for ESIC Online?

If you own a company and want to register the same under ESIC, here is a step-by-step guide:

Step 1: Visit the official ESIC portal and click on “Sign Up.”

Step 2: Fill in the form on the next screen with accurate details and submit.

Step 3: Next, you will receive a confirmation mail containing your username and password details on your registered e-mail ID.

Step 4: Using your received username and password, log in on the ESIC portal and click on “New Employer Registration.” Choose a “Type of Unit” from the drop-down menu and select “Submit.”

Step 5: Now duly fill in the “Employer Registration Form 1” and submit it along with all mandatory documents.

Step 6: You will be redirected to a page titled “Payment of Advance Contribution,” where you need to enter the amount for 6 months’ advance contribution and choose the payment mode.

Post completion of payment, you will receive a Registration Letter (C-11) containing a 17-digit ESIC registration number.

What are the Documents Required for ESIC Registration?

Before proceeding with online registration under ESIC, make sure to keep the following documents handy.

Registration certificate or licence under the Shops and Establishment Act or Factory Act.
Partnership deed for partnership firms and Certificate of Registration for Private Limited Companies.
List of all workers with their monthly compensation details.
Address proof and PAN card of all employees as well as the business entity.
List of shareholders, partners, and directors of the establishment.
Employee attendance registers.

Once business owners successfully register themselves under this scheme, they can enrol new employees as and when they join the institution. After successful enrolment, every worker will receive an ESIC or Pehchan card, which they need to produce every time they want to avail of this scheme’s benefits against medical treatments.

How to Find a Hospital List Under Employees' State Insurance Corporation (ESIC)?

To find the list of hospitals empanelled under the Employees' State Insurance Corporation (ESIC), you can follow these detailed steps:

Step 1: Visit the Official ESIC Website: Open your browser and go to the ESIC hospitals page by navigating to https://www.esic.gov.in/ssts.

Step 2: Select Your State: On the ESIC hospitals page, you will find a drop-down menu or search field. Enter the name of your state or select it from the list provided.

Step 3: Initiate the Search: After selecting your state, click on the ‘Search’ button. This will prompt the system to display a list of hospitals that are empanelled in your region.

Step 4: Browse the Hospital List: Once the results are displayed, you can browse through the list of hospitals. Each hospital will have details about its specialisation, services offered, and coverage under the ESIC scheme.

By following these steps, you can easily access a comprehensive list of ESIC hospitals in your area, ensuring that you and your dependents receive the appropriate medical care covered by the ESIC scheme.

Know about: Digit's Cashless Network Hospitals

What is an Employee State Insurance Card or Pehchan Card?

If you are wondering what your proof of ESIS registration is, the ESI or Pehchan card is that document. It helps the hospital authorities identify the insured, trace his/her medical history, and display the following details.

Name of the insured individual
His/her insurance number
Address details
Insured individual’s date of birth
Family photograph

As an employee, you will receive a temporary ID card valid for up to 90 days till the actual ESI card is issued. The latter is a permanent card that will remain the same throughout the rest of your life. However, note that you must get yourself registered in your new employer’s portal every time you switch jobs.

Haven’t you received your Pehchan card yet?

How to Download an ESI Card Online?

Ensure that your employer has registered your details correctly in the ESIC database before attempting to download the card. Here are the steps to download the card:

Visit the ESIC Portal: Go to the official ESIC website and click on employee/beneficiary.

Login: Use your credentials (user ID and password) to log in to the portal.
Access Employee Details: Navigate to the 'Employee' section and select 'Employee Details'.
Download ESI Card: Find the option to download the 'e-Pehchan Card' and click on it.
Print the Card: Once downloaded, you can print the ESI card for use.

Medical Packages Under ESIC

The medical packages under the ESI scheme offer comprehensive coverage for scheme beneficiaries. Check the table below for the detailed package list:

Procedure	Number of Packages
Dental	4
Ear	20
Nose	25
Throat	23
General Surgery	205
Gynaecology	31
Endoscopic Procedures	24
Hysteroscopic	4
Neurosurgery	49
Ophthalmology	40
Orthopaedic	130
Paediatric	30
Endocrine	12
Urology	108
Oncology	10
Medical (General Ward)	52

Hospitalisation Process Under the Employee State Insurance Scheme

The Employees' State Insurance Scheme (ESIC) provides inpatient treatment (hospitalisation) to insured persons (IPs) and their family members in areas with "Full" medical care facilities.

The hospitalisation process under the Employee State Insurance (ESI) Scheme starts with visiting an ESI dispensary for an initial consultation. If hospitalisation is necessary, the dispensary doctor will provide a referral slip to an ESI hospital or an empanelled private hospital.

During emergencies, patients can directly visit an empanelled hospital without a referral but must notify ESI authorities within 24 hours. Once admitted, the ESI scheme covers most hospitalisation expenses, including treatments, surgeries, and medications.

After being discharged, patients should visit their ESI dispensary for any follow-up care, which is also covered under the scheme.

Know about: Pre-Post Hospitalization Expenses in Health Insurance

ESI Toll-Free Number and Address

For any assistance related to the Employees' State Insurance (ESI) scheme, knowing the toll-free number and address is crucial. This information helps you quickly connect with ESI representatives for queries or support.

Toll-Free Number: 1800-11-2526
Medical Helpline: 1800-11-3839
Address: Employees' State Insurance Corporation (ESIC) Panchdeep Bhawan CIG Marg New Delhi - 110002 India

Regular Health Insurance Plan vs Employee State Insurance Scheme

Understanding the differences between regular health insurance plans and the ESI Scheme helps you choose the best option for your healthcare needs. Here's a comparison table between a Regular Health Insurance Plan and the Employee State Insurance Scheme:

Point of Difference	Regular Health Insurance Plan	Employees' State Insurance Scheme (ESI)
Eligibility	Anyone can purchase, subject to the insurer’s criteria	Only for employees earning up to Rs. 21,000 per month
Target Audience	The general public, individuals, families	Low-income employees and their dependents
Premium Payment	Paid by the policyholder	Shared by employee (0.75% of salary) and employer (3.25% of salary)
Coverage	Varies by plan; includes hospitalisation, surgeries, etc.	Comprehensive medical care for insured employees and their dependents
Scope	Can be customised, including health, critical illness, etc.	Standardised benefits across all ESIC members
Coverage Limit	Depending on the chosen plan and sum insured	No fixed limit; coverage as per ESIC regulations
Provider Network	Network hospitals of the insurance company	ESIC network hospitals and dispensaries
Network Hospitals	Extensive list depending on the insurer	Limited to ESIC-empanelled hospitals and dispensaries
Cashless Treatment	Available at network hospitals	Available at ESIC network hospitals
Beneficiary Identification	Policyholder ID card	Pehchan Card
Benefits and Services	Depends on the plan; it can include wellness programs	Includes medical, disability, maternity, and dependents’ benefits
Portability	Available as per IRDAI guidelines	Not applicable
Government Involvement	Regulated by IRDAI, private and public sector involvement	Fully managed and funded by the government
Administration	Managed by private insurers	Managed by ESIC under the Ministry of Labour and Employment
Claim Process	Policyholder needs to file claims	Direct settlement with ESIC hospitals; no need for individual claims
Out-of-Pocket Expenses	Deductibles, co-payments, and exclusions apply	Minimal out-of-pocket expenses for covered services

Even the most basic of medical insurance policies seem to be unaffordable for most of our country’s population - a country with 33% of its population earning less than Rs.143 per day, the international daily wage benchmark.

Well, you can apply for one after you switch jobs and cast off all your worries regarding rising healthcare costs by being a part of the ESI scheme!

FAQs about the ESI Scheme

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What will happen if my monthly salary exceeds Rs.21000 during an ESI contribution period?

Even if your gross salary crosses the Rs.21000 mark in the middle of a contribution period, you will continue receiving coverage under the employee state insurance scheme till said contribution period ends. The employer will pay 3.25%, and the employee will contribute 0.75% towards this insurance scheme.

Does the ESI scheme allow withdrawal of any amount?

Think of the ESI scheme as any other insurance policy available and your monthly contribution as a premium. Just like you cannot redeem a premium in monetary form, the ESI scheme does not allow you to withdraw any amount of money either. Instead, this scheme allows you and your dependent family members to raise a claim to avail of free medical treatments at ESIC-authorised hospitals and dispensaries.

What is the process to file a claim against ESIS?

Follow the given steps to initiate a claim against ESIS:

Visit the official ESIC portal.
Download Form 15 and fill it in with accurate details.
Submit this filled-in form at Employees’ State Insurance Corporation.
What happens if an employer delays or fails to make payment of deducted employee contribution?
Section 40(4) of the Employee State Insurance Act 1948 mandates every employer to pay any amount deducted from wages as a contribution towards its actual cause. Delay or failure of payment within the prescribed limit under Regulation 31 will cost the employer a 12% per annum simple interest payment for the total number of days of delay or default. The same is regarded as a “Breach of trust” and is also a punishable offence under Section 85 (A) of the Act.

How do I check my ESI details?

To check your ESI details, visit the official ESIC portal and log in with your credentials through the ‘Employee Portal.’ You can review your contributions, eligibility, and claim status online.

What is the monthly payment of the ESI Scheme?

The monthly payment for ESI includes contributions from both the employer and the employee. Employers contribute 3.25% of the employee’s wages, while employees contribute 0.75%. For a monthly wage of Rs. 21,000, the total contribution amounts to Rs. 693.

How to calculate ESI?

ESI contributions are calculated based on the employee's gross monthly wage. The employer contributes 3.25%, and the employee contributes 0.75% of the wage. For example, for a monthly wage of Rs. 21,000, the total ESI contribution is Rs. 693.

Can I withdraw the ESI amount?

ESI contributions cannot be directly withdrawn as they are intended to provide health and social security benefits. However, if you leave your job or retire, you may be eligible for certain benefits or refunds, subject to the scheme’s terms and conditions.

Can ESI be used in private hospitals?

ESI coverage typically applies to hospitals and medical facilities within the ESI network. Private hospitals may be included if they are empanelled with ESI; otherwise, you may need to seek treatment at ESIC-approved institutions for cashless services.

What happens to ESI after leaving a job?

After leaving a job, you may continue to benefit from the ESI scheme for up to 6 months if you provide your retrenchment letter and details of your previous workplace. However, you will not be able to make further contributions or claims until you are employed again.

Who has to pay ESI?

ESI contributions are paid by both the employer and the employee. Employers contribute 3.25% of the employee’s wages, while employees contribute 0.75%. Both contributions are deducted from the employee’s salary and paid to the ESIC.

Does ESI cover pregnancy?

Yes, ESI covers maternity benefits, including expenses related to pregnancy, childbirth, and postnatal care. Women employees can also extend their maternity leave of 26 weeks by up to 1 month without affecting their wage slab.

How to check eligibility for ESI?

Eligibility for the ESI Scheme can be checked based on your monthly wages and employment status. Employees earning up to Rs. 21,000 per month are generally covered. You can also check eligibility details by logging into the ESIC portal or contacting the nearest ESI office.

Can ESI benefits be transferred if I change jobs?

Yes, ESI benefits and coverage can be transferred if you change jobs. Ensure that you provide your new employer with your ESI details so they can update your records. Continuity of coverage is maintained as long as your new employer registers you under the ESI scheme.

What documents are required for ESI claims?

For ESI claims, you typically need to provide documents such as your ESI card, medical treatment bills, discharge summary, and claim forms. Specific requirements may vary depending on the type of claim, so check with the ESI office or portal for precise documentation needed.

How can I appeal if my ESI claim is rejected?

If your ESI claim is rejected, you can appeal the decision by submitting a written appeal along with supporting documents to the ESI office where your claim was processed. Ensure that you provide detailed reasons for the appeal and any additional information that may support your case.