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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.
Table of Contents
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:
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:
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:
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:
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:
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:
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:
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
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.