All about Employee State Insurance (ESI Scheme)

Given the busy schedules and sedentary lifestyles, the average human being cannot deny resorting to some form of daily medication for healthy existence.

However, with rising healthcare costs comes the worry of sustaining such costs regularly, where an insurance plan comes into play. 

Keeping the requirements of these workers, the Indian government introduced the ESI scheme to support them during medical emergencies.

Read on!

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.

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.

• The Employee State Insurance Scheme aims at providing coverage to all workers with a monthly payment of less than or equal to Rs.21000. 
• Healthcare benefits against specific illnesses can be availed by the insurer as well as their dependent members. 
• 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 less than Rs.137 worth of daily wages are exempted from paying their share.
• Employers must clear any due contribution within 21 days of the month.
• State governments must pay 1/8th of the total medical expenses up to Rs.1500 per head under the ESI scheme.
• 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.
• The scheme encourages opening more medical colleges to help enhance the quality of healthcare individuals.
• This scheme includes accidents encountered while commuting under occupational hazards.
• 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.

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.

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.

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.

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

• Registration certificate or license 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 enroll 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.

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 and trace his/her medical history and displays 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?

Even the most basic of medical insurance policies seem to be unaffordable for most of our country’s population - a country with 22% of its population earning less than Rs.143 per day, the international daily wage benchmark (1). 

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!