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.
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.
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.10000 to perform the final rites of the expired individual.
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.
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.
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.