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Medical
Benefits |
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Eligibility:
An Insured Person and his family members become
entitled to medical care from the date he enters
the insurable employment and the entitlement continues
so long as the insured person is in insurable employment
or is qualified to claim sickness, maternity or
disablement benefit.
The entitlement to medical care is extended upto
two years to persons suffering from 34 specified
chronic or long term diseases. Medical
treatment to persons, who go out of coverage during
the period of treatment, is not discontinued till
the spell of sickness ends.
The scheme provides for a comprehensive
medical cover to the retired and disabled insured
persons and their spouses on payment of a nominal
sum of Rs. 120/- per annum per couple.
The scheme, thus, offers total medical cover to
the retired and disabled without any upper ceiling
of expenditure at the lowest premium when compared
with medical cover schemes introduced by some other
insurance agencies.
Benefit:
All Insured Persons and members of their families
are entitled to full and comprehensive medical care
package consisting of:
- Outpatient treatment
- Domiciliary Treatment (treatment by visits
at their residences)
- Specialist consultation;
- In patient treatment;
- Free supply of drugs, dressings, artificial
limbs, aids and appliances;
- X-ray and laboratory investigations;
- Vaccination and preventive inoculations;
- Ante-natal care, confinement and post-natal
care;
- Ambulance service or conveyance charges for
going to hospitals, diagnostic centers, etc.
wherever admissible;
- Family welfare services and other national
health programme services;
- Medical certification
- Special provisions including super-specialist
facilities.
With a view to ensuring that the medical facilities
are of the required standard, the ESI Corporation
has appointed medical experts such as Medical Referees
and the Senior State Medical Commissioners who conduct
periodic inspections of dispensaries, hospitals
and panel clinics. There is also a high powered
committee known as General Purposes Medical
Sub-Committee of the E.S.I. Corporation
comprising representatives of parliament, employers,
employees, medical profession, State Governments.
and the E.S.I. Corporation, that visits E.S.I. institutions
periodically and holds meetings with the representatives
of employers, employees and the State Govt., to
advise and suggest measures for improving the medical
services under the Scheme.
Claim procedure:
For availing the medical facility for self or any
of the declared dependants an insured person has
to produce the temporary identification certificate
issued by the ESIC Branch Office
on taking insurable employment. This temporary identity
certificate is thereafter replaced with a family
photo identity card that carries the photographs
and other particulars of the family member and the
insured person. Failure to obtain the permanent
card or its non production at dispensary/hospital
can result in deprivation of medical care.
It is also to be borne in mind that dispensary is
the base point for availing medical facilities.
The reference for specialist treatment of diagnostic
investigations is made by the ESI dispensary itself
to the concerned hospital. It is only in extreme
emergency or at odd hours when the dispensary is
closed that the insured person/dependant can report
at the Emergency Deptt. of an ESI hospital
directly but should not fail to produce
his/her photo identity card.
All medicines are issued free of cost by the dispensary
to which an IP is attached. However,
in case of non-availability of prescribed drugs
at the hospital/dispensary an insured person can
purchase the medicines from local market if so advised
and submit such claim to the dispensary for reimbursement.
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