Respected Seniors,
Thanks a lot for this forum. As I am very new to the HR field, I have a basic doubt in ESI treatment. I request you to kindly clarify.
One of our workmen got an injury in the left-hand thumb while working. We arranged for first aid at a nearby hospital. They took an x-ray and informed us that there were no issues. The worker then went to another hospital, where they discovered a fracture and performed an operation. Now, the workman states that the treatment charges amount to around Rs. 15,000. He is covered under ESI. Is it possible to receive any assistance from ESI?
From India, Hyderabad
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1Thanks a lot for this forum. As I am very new to the HR field, I have a basic doubt in ESI treatment. I request you to kindly clarify.
One of our workmen got an injury in the left-hand thumb while working. We arranged for first aid at a nearby hospital. They took an x-ray and informed us that there were no issues. The worker then went to another hospital, where they discovered a fracture and performed an operation. Now, the workman states that the treatment charges amount to around Rs. 15,000. He is covered under ESI. Is it possible to receive any assistance from ESI?
From India, Hyderabad
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If one doctor is saying that there is no problem, and another is saying that there was a fracture, how should I proceed? I suggest you contact the ESI dispensary, ask them for a report and X-ray. When did this accident happen, and have you informed the ESI hospital? Please check first.
From India, Pune
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From India, Pune
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Hi,
1. Sir, if the employer has not submitted the accident report to the ESIC Branch Office as well as to the ESI Dispensary concerned, it may be submitted now with an explanation or reasons for such delay.
2. After the Accident Report is received in the ESI dispensary, the Injured Insured Person may get himself examined at the ESI dispensary, obtain medical certification, and submit the same to the ESIC Branch Office. However, since the case is delayed, the insured person will have to produce all papers of his operation and treatment he received from the private hospital.
3. ESIC has its own system or referral policy, and therefore, it is not certain whether they will reimburse any expenses incurred in private hospitals. The Insured Person can discuss the issue with the ESI dispensary doctor/Incharge.
Thank you.
From India, Noida
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1. Sir, if the employer has not submitted the accident report to the ESIC Branch Office as well as to the ESI Dispensary concerned, it may be submitted now with an explanation or reasons for such delay.
2. After the Accident Report is received in the ESI dispensary, the Injured Insured Person may get himself examined at the ESI dispensary, obtain medical certification, and submit the same to the ESIC Branch Office. However, since the case is delayed, the insured person will have to produce all papers of his operation and treatment he received from the private hospital.
3. ESIC has its own system or referral policy, and therefore, it is not certain whether they will reimburse any expenses incurred in private hospitals. The Insured Person can discuss the issue with the ESI dispensary doctor/Incharge.
Thank you.
From India, Noida
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There is always a chance that when a second opinion is taken, only then will we come to know about something wrong in the first medical examination. Therefore, you cannot blame the employee for this. But you should blame yourselves for not sending the injured to ESI hospital and not submitting the accident report online. Now you can submit the accident report online and send the printout to the ESI branch office with an explanation that since the injury was not found fatal, you gave only first aid but when he developed pain subsequently, he consulted another hospital where he was operated. The ESIC will reimburse the cost incurred by the insured person, i.e., Rs 15,000, at a later date. He has to submit the bills in support of his claim in original to the ESI.
There are two alternatives to handle this situation. You can pay it to the worker now and ask him to pay it back to the company when he gets the money from the ESIC. This will take time. Otherwise, ask him to claim it from ESIC and bear the cost by himself for the time being. I would recommend that you should at least do the first thing because it is a matter of a worker whose earnings are very less, say less than Rs 15,000, and the accident happened while on duty.
If you can convince the delay in submitting the accident report, the employee will get at least wages (100% of benefit rate since it is an accident) for the days he may have to be on leave. Again, for an employee like this, a loss of income for a single day is a huge loss.
Moral of the story: Always send an ESI-covered employee to an ESI hospital only for treatment and also advise the employees by putting a notice that if anyone falls sick, never visit any private hospital unless it is an empanelled one. Also note that even direct admission to an empanelled hospital should not be encouraged because this facility has been withdrawn, and in order to get better treatment, you have to get your case referred from ESi dispensary or hospital.
Madhu.T.K
From India, Kannur
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There are two alternatives to handle this situation. You can pay it to the worker now and ask him to pay it back to the company when he gets the money from the ESIC. This will take time. Otherwise, ask him to claim it from ESIC and bear the cost by himself for the time being. I would recommend that you should at least do the first thing because it is a matter of a worker whose earnings are very less, say less than Rs 15,000, and the accident happened while on duty.
If you can convince the delay in submitting the accident report, the employee will get at least wages (100% of benefit rate since it is an accident) for the days he may have to be on leave. Again, for an employee like this, a loss of income for a single day is a huge loss.
Moral of the story: Always send an ESI-covered employee to an ESI hospital only for treatment and also advise the employees by putting a notice that if anyone falls sick, never visit any private hospital unless it is an empanelled one. Also note that even direct admission to an empanelled hospital should not be encouraged because this facility has been withdrawn, and in order to get better treatment, you have to get your case referred from ESi dispensary or hospital.
Madhu.T.K
From India, Kannur
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Respected Seniors,
I thank everyone for your kind consideration and suitable reply. I wish to say a special thanks to T.K. Madhu for his detailed reply. The accident took place on 18th July. We registered the accident report online (ESI portal) on 21st July. After that, we forgot about the matter, which was a major blunder on our part. Now, I realize the importance of follow-up activities. I would like to seek one more clarification from seniors: should the accident report be filed immediately or after two days of the occurrence of the accident?
Once again, I thank everyone and all.
From India, Hyderabad
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I thank everyone for your kind consideration and suitable reply. I wish to say a special thanks to T.K. Madhu for his detailed reply. The accident took place on 18th July. We registered the accident report online (ESI portal) on 21st July. After that, we forgot about the matter, which was a major blunder on our part. Now, I realize the importance of follow-up activities. I would like to seek one more clarification from seniors: should the accident report be filed immediately or after two days of the occurrence of the accident?
Once again, I thank everyone and all.
From India, Hyderabad
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1. Sir, in the case of fatal accident cases, the accident report is to be submitted through a special messenger. In serious accident cases that may result in permanent disablement or death, the accident report is required to be submitted immediately. In other types of cases, the accident report is required to be submitted within 48 hours.
2. For more exact details, I hope you will refer to Regulation 68 of ESI (General) Regulations, 1950.
From India, Noida
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2. For more exact details, I hope you will refer to Regulation 68 of ESI (General) Regulations, 1950.
From India, Noida
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To: Mr. Harsh Kumar Mehta
Sir,
Thank you very much for your valuable guidance. While discussing with peers, one said that it is to be filed immediately, and the other person told me that it can be filed after 2 days. Hence, I raised that question. You clearly clarified that both of my peers' statements are correct, but it depends on the severity of the accident.
Once again, thank you, sir.
From India, Hyderabad
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Sir,
Thank you very much for your valuable guidance. While discussing with peers, one said that it is to be filed immediately, and the other person told me that it can be filed after 2 days. Hence, I raised that question. You clearly clarified that both of my peers' statements are correct, but it depends on the severity of the accident.
Once again, thank you, sir.
From India, Hyderabad
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Hi,
Thank you for the appreciation.
I would like to mention that if the injured insured person is declared fit by the ESI dispensary/hospital, but feels that there is permanent disability in the injured hand, please do not forget to have the injured insured person referred to the medical board for an assessment of the loss of earning capacity. If the medical board awards any percentage of loss of earning capacity, the injured person will be entitled to another benefit under the ESI Act, 1948, known as Permanent Disablement Benefit (PDB). Relevant rules and instructions can be found on the ESIC website.
From India, Noida
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Thank you for the appreciation.
I would like to mention that if the injured insured person is declared fit by the ESI dispensary/hospital, but feels that there is permanent disability in the injured hand, please do not forget to have the injured insured person referred to the medical board for an assessment of the loss of earning capacity. If the medical board awards any percentage of loss of earning capacity, the injured person will be entitled to another benefit under the ESI Act, 1948, known as Permanent Disablement Benefit (PDB). Relevant rules and instructions can be found on the ESIC website.
From India, Noida
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Dear Seniors,
One of the employees who is under ESI coverage has slipped from the stairs at his home. In this accident, he has been badly injured in his leg and hand, hence he is unable to perform his duties. Please clarify if he is eligible to receive ESI treatment since the accident occurred at his home. Also, provide information on the amount of wages the employee is entitled to receive from the ESI department since he is on leave.
Thank you,
Aman
From India, Jaipur
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One of the employees who is under ESI coverage has slipped from the stairs at his home. In this accident, he has been badly injured in his leg and hand, hence he is unable to perform his duties. Please clarify if he is eligible to receive ESI treatment since the accident occurred at his home. Also, provide information on the amount of wages the employee is entitled to receive from the ESI department since he is on leave.
Thank you,
Aman
From India, Jaipur
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Since this is not an accident occurring during employment, he will not receive a 100% rate as is typically admissible for accident cases. However, if he is within the benefit period (having joined at least 9 months prior), he will be entitled to sickness benefits, which amount to around 90% (ensuring that the recent hike from 70% to 90% has been implemented) of his average wages. For new employees, they will only receive medical benefits and will not be eligible for any cash benefits meant to compensate for lost earnings during ESI leave days.
Madhu.T.K
From India, Kannur
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Madhu.T.K
From India, Kannur
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