Esi Benefits 3g3p2b

PROJECT REPORT ON AWARENESS AND EFFECTIVE UTILIZATION OF ESI BENEFITS

UNDER THE GUIDANCE OF PROF. Pius Moras

SUBMITTED BY Mr. Ankit Krishna Patkar ROLL NO. 321

MASTER IN HUMAN RESOURCE DEVELOPMENT MANAGEMENT

UNIVERSITY OF MUMBAI (2014-2017)

N.L. DALMIA INSTITUTE OF MANAGEMENT STUDIES AND RESEARCH

Awareness and Effective Utilization of ESI Benefits

1

CERTIFICATE I, Prof. Pius Moras hereby certify that Mr. Ankit Krishna Patkar of N.L. Dalmia Institute of Management Studies and Research, MHRDM, 5th Semester, has completed a project on “Awareness and effective utilization of ESI benefits” in the academic Year of 2014-2017.This information submitted is true and original to the best of my knowledge.

Signature of Director of the

Signature

College/Institution

Project Guide

____________________

___________________

Prof. Dr. Gulab Mohite

Prof. Pius Moras

Director Incharge


2

ACKNOWLEDGEMENT This project on “Awareness and effective utilization of ESI benefits” is the result of co-operation, hard work and good wishes of many people. I, student of N.L. Dalmia Institute of Management Studies and Research, would like to thank my project guide Prof. Pius Moras for his involvement in my project work and timely assessment that provided me inspiration and valued guidance throughout my study.

I owe my debt to Prof. Dr. Gulab Mohite Director Incharge, N. L. Dalmia Institute of Management Studies and Research, for giving me this opportunity to present a creative outcome in the form of a project work. I would also like to thank Mr. Shailendra Dhamdhere HR Director of Human Resource in Johnson and Johnson Private Limited and all Executives working Johnson and Johnson Private Limited for parting with the relevant information for my project work and helping me in the completion of the same.

I would also like to take this opportunity to express my gratitude to the faculty and staff for their friendly guidance and constant encouragement. I also express my heart felt gratitude to my institute friends and family whose efforts and creativity has helped me in giving the final shape and structure to this project work.

I am also thankful to those seen and unseen hands and heads, which has been of direct or indirect help in the completion of this project work.


3

DECLARATION I, Mr. Ankit Krishna Patkar of N. L. Dalmia Institute of Management Studies and Research of MHRDM (SEM V), hereby declare that I have completed this project on Study on “Awareness and effective utilization of ESI benefits” in the academic year 2014-2017. The information submitted is true and original to the best of my knowledge.

Signature of Student

____________________

(Mr. Ankit Krishna Patkar)


4

EXECUTIVE SUMMARY One of the main objectives of a health system is to reduce the monetary cost of accessing health services, thereby enabling individuals with substantial unmet needs to access otherwise unaffordable care.

Health insurance protects households against the financial burden of illness, especially large out-of-pocket (OOP) expenses resulting from catastrophic illnesses, while at the same time raising additional resources for the public sector.

The purpose of this study is to analyze the health service utilization of those enrolled in the Employees’ State Insurance Scheme (ESIS) and its role in protecting against catastrophic health payments in a low-income country setting. The study uses primary data collected through a semi structured questionnaire which sought detailed information on healthcare utilization and spending and on other key individual and household factors.

ESIS is not found to provide financial protection against the risk of catastrophic payments, as the majority of the beneficiaries are seeking care outside the insurance plan from private facilities at a relatively high personal cost. This under use of ESIS services is due to; perceived low quality drugs, long waiting periods, impolite personnel, long delays in reimbursement of money spent on treatment from covered providers, and lack of or low interest of employers and low awareness of Employees’ State Insurance (ESI) procedures.


5

Contents

Certificate ........................................................................................................................ 2 Introduction ..................................................................................................................... 7 Social security ................................................................................................................. 9 Social security laws in india........................................................................................... 13 Employees' state insurance (esi)................................................................................... 14 Employees' state insurance corporation (esic) .............................................................. 16 Employees' state insurance act, 1948 ........................................................................... 17 Coverage – areas, organizations and employees20 ..................................................... 21 ESI scheme at a glance -- maharashtra ........................................................................ 24 Benefits for employees .................................................................................................. 25 Need based benefits ..................................................................................................... 44 New initiatives - awareness ........................................................................................... 49 Esic – 2.0: reform initiatives of esic ............................................................................... 53 Recent news ................................................................................................................. 56 Achievements/initiatives of esic..................................................................................... 64 Fetal medicine unit at esic super specialty hospital ....................................................... 68 Esic grievance redressal ............................................................................................... 71 Medical appeal tribunals................................................................................................ 73 Employees' insurance (ei) courts .................................................................................. 74 Employees and employers, retired and disabled persons ............................................. 75 Frequently asked questions .......................................................................................... 78


6

INTRODUCTION

An equitable health system must ensure that utilization conforms to need (impartiality in delivery) and that payment conforms to the ability to pay (impartiality in financing). A failure to separate utilization from payments will have a negative financial impact on the poor who suffer from ill health. The poor lack financial resources to pay for health services. Ill health, through the loss of productive labour, can also undermine their ability to cope financially; thereby strengthening further the nexus between poverty and poor health. Hence, the purpose of health financing is to use the appropriate funding instruments to set the right financial incentives for providers, and to ensure that all individuals have access to effective public health and affordable personal healthcare.

In recent years, India, like several other low-income countries, has established different types of national health insurance scheme. The ESIS is one such scheme. One of its main objectives is to reduce the monetary cost of accessing health services; thereby enabling individuals with substantial unmet needs to access otherwise unaffordable care. Health insurance also protects households against the financial burden of illness, especially large OOP expenses resulting from catastrophic illnesses, while at the same time raising additional resources for the public sector. This helps reduce or eliminate the possibility that an individual will be unable to pay for such care, or will be impoverished trying to do so. Catastrophic health payments have been found to be significant in both rich and poor countries.

For example, results from a recent study of healthcare payments in India indicate that around 70% of total health expenditure is made of OOP payments and around 30% of households spend more than 10% of their income on health.

In Indonesia also, the rich are found to be at risk of experiencing catastrophic health payments defined as exceeding 10% of income and in the United States certain vulnerable groups are more affected by such payments than other groups. A recent global review of household catastrophic health payments emphasized the role of health


7

insurance as a key instrument in reducing the risk of such payments. Given that one of the key purposes of health insurance is to provide protection against particularly high healthcare costs, this study aims to test this proposition empirically in a low-income country setting. The health insurance is an important policy tool for providing financial health protection is well grounded in both theory and experience.

The highly heterogeneous array of health financing arrangements justifies the systematic analysis of individual cases to provide evidence on the practical effects of health insurance programmes. Furthermore, access to the potential benefits of health insurance may be curtailed if indirect financial and non-financial barriers (such as travel and lodging expenses, lost income, and a lack of knowledge of what provider’s offer) impede the insured from seeking care. Even when care is actually sought, the insured may still face a wide range of hurdles before actually receiving health insurance benefits.

Some of these hurdles include the tedious paperwork, the limited portability of the insurance schemes, or the unwelcoming attitude of health staff towards insured patients. Although much has been written on the barriers to access that prevent individuals from seeking appropriate care, comparatively little is known about the factors influencing the insured person's decision to access their insurance benefits when care is actually sought.

This study was undertaken with the following objectives: 1. To analyze overall trends in utilization and number of beneficiaries of ESIS over a period of time in Maharashtra; 2. To assess the effectiveness of the scheme as perceived by beneficiaries, and from utilization level of ESI facilities, in Maharashtra; and 3. Analyze the development of ESI policy in the state and factors influencing its implementation.


8

SOCIAL SECURITY

India has a very basic social security system catering to a fairly small percentage of the country’s workforce. Traditionally, Indians relied on their extended families for in the event of illness or other misfortunes. However, due to migration, urbanization, and higher social mobility, family bonds are less tight and family units much smaller than they used to be. So far, neither the state nor private insurance companies have quite stepped up to fill this gap. There are two major social security plans in India, the Employees’ Provident Fund Organization (EPFO) and the Employees’ State Insurance Corporation (ESIC). The EPFO runs a provident fund, also known as a pension scheme, and an insurance scheme. All of these are supposed to grant EPFO and their families’ benefits for old age, disability, and in case the primary breadwinner dies.

The ESIC, on the other hand, covers low-earning employees providing them with basic healthcare and social security schemes. Originally aimed at factory workers, the coverage is being gradually extended to include greater parts of the population, e.g. employees in hospitals or educational institutions.

What is Social Security? 

any of the measures established by legislation to maintain individual or family income or to provide income when some or all sources of income are disrupted or terminated or when exceptionally heavy expenditures have to be incurred (e.g., in bringing up children or paying for health care).



social security may provide cash benefits to persons faced with sickness and disability, unemployment, crop failure, loss of the marital partner, maternity, responsibility for the care of young children, or retirement from work.


9



Social security benefits may be provided in cash or kind for medical need, rehabilitation, domestic help during illness at home, legal aid, or funeral expense.



It acts as a facilitator – it helps people to plan their own future through insurance and assistance.

History of Social security 

was the first country to introduce Social security scheme (1883)



each member of a particular trade (blacksmiths, painters, weavers etc) was required to contribute at regular intervals;



Money from this fund was used for food,lodging, hospital and feneral expenses of aged and disabled .



In USA, Social Security Act came into existence in 1935. (years not important, this is only fodder material for Essay.)

Social Security in India 

India has always had a t Family system that took care of the social security needs.



However, with rise of migration, urbanization, nuclear families and demographic changes, t family system has declined. Hence we need a formal system of social security.


10

Difference between Organized and Unorganized Sectors

Organized sector 

includes primarily those establishments which are covered by the Factories Act, 1948, the Shops and Commercial Establishments Acts of State Governments, the Industrial Employment Standing Orders Act, 1946 etc.



This sector already has social security benefits under above laws.



Examples: employees of union and state Government, army, navy, airforce, Multinational companies, Infosys, TCS and so on.

Unorganized sector 

Unorganized sector doesn’t have labour law coverage. These are seasonal and temporary nature of occupations.



Casual nature of work, labour mobility is high hence bargaining power is low.


11

Examples of Unorganized sector Rural Areas

Urban Areas

1. landless agricultural labourers 2. small and marginal farmers 3. share croppers

1. street vendors

4. persons engaged in

2. hawkers

a. animal husbandry

3. head load workers

b. fishing

4. cobblers

c. horticulture

5. tin smiths

d. bee-keeping

6. garment makers

e. toddy tapping

7. Construction workers

5. forest workers 6. rural artisans


12

SOCIAL SECURITY LAWS IN INDIA Employees’ State Insurance Act, 1948 (ESI Act) 

covers factories and establishments with 10 or more employees



Provides medical care to employees and their families.



Provides Cash benefits during sickness and maternity



Monthly pension after death or permanent disability.

Employees’ Provident Funds Act, 1952 

applies to specific scheduled factories and establishments employing 20 or more employees and ensures terminal benefits to provident fund, superannuation pension, and family pension in case of death during service.

Workmen’s Compensation Act, 1923 (WC Act) 

Requires payment of compensation to the workman or his family in cases of employment related injuries resulting in death or disability.

Maternity Benefit Act, 1961 (M.B. Act) 

provides for 12 weeks’ wages during maternity as well as paid leave in certain other related contingencies.

Payment of Gratuity Act, 1972 (P.G. Act) 

provides 15 days’ wages for each year of service to employees who have worked for five years or more in establishments having a minimum of 10 workers.


13

EMPLOYEES' STATE INSURANCE (ESI)

Employees' State Insurance (abbreviated as ESI) is a self-financing social security and health insurance scheme for Indian workers. It is a comprehensive Social Security Scheme designed to accomplish the task of socially protecting the 'employees' in the organized sector against the events of sickness, maternity, disablement and death due to employment injury and to provide medical care to the insured employees and their families. The ESI Scheme is istered by a corporate body called the 'Employees' State Insurance Corporation' (ESIC), according to rules and regulations stipulated there in the ESI Act 1948.

ESIC is an autonomous corporation by a statutory creation under Ministry of Labour and Employment, Government of India. Employees’ State Insurance Scheme of India is an integrated social security scheme tailored to provide social protection to workers in the organized sector and their dependants in contingencies, such as, sickness, maternity or death and disablement due to an employment injury or occupational disease. The scheme tailored to suit health insurance requirements of workers provides full medical facilities to insured persons and their dependants, as well as, cash benefits to compensate for loss of wages or earning capacity in different contingencies.

In March 1923, B. P. Adarkar was appointed by Government of India to create a report on health insurance scheme for industrial workers. The report became the basis for the Employment State Insurance (ESI) Act of 1948. The ESI Act was enacted in 1948 and came into effect from 24 February 1952. The act was initially intended for factory workers but later became applicable to all establishments having 10 or more workers. As of 2011-12, the total beneficiaries are 65.5 million.

The scheme was inaugurated in Kanpur on 24th February 1952 (ESIC Day) by then Prime Minister Pandit Jawahar Lal Nehru. The venue was the Brijender Swarup Park, Kanpur and Panditji addressed a 70,000 strong gathering in Hindi in the presence of Pt.Gobind Ballabh Pant, Chief Minister Uttar Pradesh; Babu Jagjivan Ram, Union


14

Labour Minister; Raj Kumari Amrit Kaur, Union Health Minister; Sh.Chandrabhan Gupt, Union Food Minister and Dr.C.L.Katial, the first Director General of ESIC.

The scheme was simultaneously launched at Delhi as well and the initial coverage for both the centre’s was 1,20,000 employees. Our first prime Minister was the first honorary insured person of the Scheme and the declaration form bearing his signature is a prized possession of the Corporation.

It is important to mention here that it blossomed as the first social security scheme in 1944, when the Government was still British. The first document on social insurance was "Report on Health Insurance" submitted to the Tripartite Labour Conference, headed by Prof. B.P.Adarkar, an eminent scholar and visionary.

The Report was acclaimed as a worthy document and forerunner of the social security scheme in India and Prof. Adarkar was acknowledged as "Chhota Beveridge" by none other than Sardar Vallabhbhai Patel. Sir, William Beveridge, as all know, was one of the high priests of social insurance.

The report was accepted and Prof. Adarkar continued to be actively associated with it till 1946. On his disassociation, he strongly advocated management of the Scheme by an expert from ILO. In 1948 Dr. C.L.Katial, an eminent Indian doctor from London took over as the 1st Director General of ESIC and he steered the affairs of the fledgling Scheme till 1953. Since the red-letter day of 24th February in the annals of social security in India, there has been no looking back.


15

EMPLOYEES' STATE INSURANCE CORPORATION (ESIC)

Employees' State Insurance Corporation (ESIC), established by ESI Act, is an autonomous corporation under Ministry of Labour and Employment, Government of India. As it is a legal entity, the corporation can raise loans and take measures for discharging such loans with prior sanction of the central government and it can acquire both movable and immovable property and all incomes from the property shall vest with the corporations. The corporation can set up hospitals either independently or in collaboration with state government or other private entities, but most of the dispensaries and hospitals are run by concerned state governments.

ESIC LOGO A lighted lamp which is the logo of ESIC truly symbolizes the spirit of the Scheme, lighting up lives of innumerable families of workers by replacing despair with hope and providing help in times of distress, both in physical and financial . During the 61 years of its existence, ESIC has grown from strength to strength and the Corporation owes it, most of all, to the commitment, dedication and perseverance of persons like Prof. Adarkar and Dr. Katial.


16

EMPLOYEES' STATE INSURANCE ACT, 1948

The promulgation of Employees' State Insurance Act, 1948 envisaged an integrated need based social insurance scheme that would protect the interest of workers in contingencies such as sickness, maternity, temporary or permanent physical disablement, death due to employment injury resulting in loss of wages or earning capacity. the Act also guarantees reasonably good medical care to workers and their immediate dependants.

Following the promulgation of the ESI Act the Central Govt. set up the ESI Corporation to ister the Scheme. The Scheme, thereafter was first implemented at Kanpur and Delhi on 24th February 1952. The Act further absolved the employers of their obligations under the Maternity Benefit Act, 1961 and Workmen's Compensation Act 1923. The benefit provided to the employees under the Act are also in conformity with ILO conventions.

APPLICABILITY OF THE ESI ACT The ESI Act, (1948) applies to the following categories of factories and establishments in the implemented areas: 

Non-seasonal factories using power and employing ten (10) or more persons



Non-seasonal and non-power using factories and establishments employing twenty (20) or more persons.

The “appropriate Government” State or Central is empowered to extend the provisions of the ESI Act to various classes of establishments, industrial, commercial, agricultural or otherwise in nature. Under Section 1(5) of the Act the Scheme has been extended to certain specific classes of establishments, such as, shops, hotels, restaurants, cinemas, preview theatres, motors transport undertakings and newspaper and advertising establishments etc., employing 20 or more persons.


17

ORGANISATION As provided under the ESI Act, the scheme is istered by a duly constituted corporate body called the Employees’ State Insurance Corporation (ESIC). It comprises representing Central and State Governments. Employers, Employees, Parliament and the medical profession. Union Minister of Labour functions as Chairman of the Corporation whereas Director General as chief executive discharges the duty of running the day-to-day istration.

A Standing Committee representing all stake holders is elected from the body corporate for managing the affairs of the scheme and monitoring the progress of implementation of various decisions and policies etc. from time to time. The Medical Benefit Council, a statutory body advises the Corporation on matters related to istration of medical benefit under the ESI scheme.

INFRASTRUCTURE The central headquarters of the Corporation is located at New Delhi. For purpose of coverage, revenue collection, extension of the scheme to new classes of establishments, implementation of the scheme in new areas, co-ordination with the State Governments and general istration the Corporation has established Regional and sub-Regional Offices across the country mostly located in State capitals. Given the huge number of beneficiaries – about 340 lakhs now – the Corporation has set up a wide spread network of service outlets for prompt delivery of benefits in cash and kind that includes full medical care.

Medical facilities are provided through a network of 1452 ESI Dispensaries, about 3000 Clinics, 307 diagnostic centres besides 140 ESI hospitals and 43 hospital annexes with over 26000 beds. For providing super specialist medical care the


18

Corporation has tie up arrangements with advanced medical institutions in the country, both in public and private sector.

The medical benefit is istered with the active co-operation of State Governments. The payment of cash benefits is made at the grass roots level through as many as 800 Branch Offices and Cash Offices that function under the direct control of the Corporation.

NEW AMENDMENT The Employees’ State Insurance Corporation (ESIC) raised the monthly wage limit to Rs 21,000, from the existing Rs 15,000, for coverage with effect from October, 2016 Labour Minister Bandaru Dattatreya added that the move of raising the threshold will help bring in an additional 50 lakh to ESIC. Labour Minister is the Chairman of the ESIC Board.

At present, ESIC has 2.6 crore insured persons, which covers over 10 crore people, assuming four of a family. The minister also said there is a plan to increase the wage threshold for retirement fund body EPFO subscribers and it may be considered in the next meeting of the Central Board of Trustees (CBT). At present, the wage threshold is Rs 15,000 per month for coverage under its social security scheme.


19

COVERAGE – AREAS, ORGANIZATIONS AND EMPLOYEES

COVERAGE The ESIC Scheme is being implemented in various phases area-wise across India. The Scheme has already been implemented in different areas in various States/Union Territories across India except in states like Arunachal Pradesh, Manipur, Mizoram, Nagaland, Tripura and Sikkim.

UNION TERRITORIES Delhi and Chandigarh

Coverage(As on 31st March, 2015) No. of Insured Person family units

2.03 Crores

No. of Employees

1.79 Crores

Total No. of Beneficiaries

7.89 Crores

No. of Insured women

3.36 Lacs

No. of Employers, etc.

7.23 Lacs

COVERAGE OF FACTORIES The Act is applicable to all non-seasonal factories that utilize power providing employment to 10 or more individuals as well as factories not utilizing power employing 20 or more individuals for wages on any day in areas wherein ESIC Act has been implemented.

There is an amendment to the Act under Section 1(5) to extend the benefits to other classes of establishment – agricultural, commercial, industrial or otherwise. The provisions of this Act have been extended by majority of the State Governments in India to the following class of establishments such as shops, hotels, restaurants, cinemas


20

road-motor transport agencies, newspaper agencies, workshops, establishments employing 20 or more individuals.

In case, at any stage or in due course of time, if the number of employees working with an establishment or factory covered under the ambit of this Act falls short of the stipulated number of 10 or 20 employees as specified, ceases to be a beneficiary of ESIC Act without any aid of power. However, this Act is not applicable to workers engaged in mining operations, railway running sheds and certain seasonal/temporary factories operating for less than 7 months in a calendar year. The employees of establishments or factories run with the aid of Central or State Governments who are in receipt of social security benefits that are substantially similar or superior as compared to those provided under this Act can be exempted from coverage.

COVERAGE OF EMPLOYEES The Central Government of India has issued guidelines pertaining to monthly wage limit that has been prescribed for the purpose of coverage of employees/workers of the factories or establishments covered under this Act.

Under Section 2(9) of this Act, an employee has been defined as any individual employed for wages in connection with the work related to a factory or establishment which is a beneficiary under ESIC Act. The wage ceiling is revised from time to time. The existing wage ceiling effective from 1.10.2006 is Rs. 10,000/- per month.

ISTRATION The comprehensive and multi-pronged social security programme is istered by an apex corporate body called the Employees' State Insurance Corporation. It comprises representing vital interest groups, including, employees, employers, the Central and State Government, representatives of Parliament and medical profession. The Corporation is headed by the Union Minister of Labour, as its Chairman, whereas the Director General, appointed by the Central Government functions as its Chief Executive Officer. The broad based corporate body is, primarily, responsible for


21

coordinated policy planning and decision making for growth, development and efficacy of the scheme.

A Standing Committee, constituted from among the of the Corporation, acts as an Executive Body. The Medical Benefit Council, constituted by the Central Government, is yet another Statutory Body that advises the Corporation on matters related to effective delivery of medical services to the Beneficiary Population.

The Corporation, with its Central Headquarters at New Delhi, operates through a network of 52 Regional, Sub- Regional and Divisional Offices located in various States. The istration of Medical Benefit is taken care of by the respective State Government except in case of Delhi and Noida/Greater Noida area in Uttar Pradesh where the Corporation isters medical facilities directly. The Corporation has taken over the istration of 23 ESI Hospitals in various States for developing them as ESIC Model Hospitals.

FINANCE ESI Scheme, like most of the Social Security Schemes the world over, is a selffinancing health insurance scheme. Contributions are raised from covered employees and their employers as a fixed percentage of wages.

As of now, covered employees contribute 1.75% of the wages, whereas, the employers contribute 4.75% of the wages, payable to their employees. Employees earning upto Rs.100/- a day are exempted from payment of their share of contribution. The State Governments, as per provisions of the Act, contribute 1/8th of the expenditure of medical benefit within a per capita ceiling of Rs. 1500/- per Insured Person per annum. Any additional expenditure incurred by the State Governments, over and above the ceiling and not falling within the shareable pool, is borne by the State Governments concerned.

CONTRIBUTION


22

E.S.I. Scheme being contributory in nature, all the employees in the factories or establishments to which the Act applies shall be insured in a manner provided by the Act. The contribution payable to the Corporation in respect of an employee shall comprise of employer's contribution and employee's contribution at a specified rate. The rates are revised from time to time. Currently, the employee's contribution rate (w.e.f. 1.1.97) is 1.75% of the wages and that of employer's is 4.75% of the wages paid/payable in respect of the employees in every wage period. Employees in receipt of a daily average wage upto Rs.100/- are exempted from payment of contribution. Employers will however contribute their own share in respect of these employees.

Collection of Contribution An employer is liable to pay his contribution in respect of every employee and deduct employee’s contribution from wages bill and shall pay these contributions at the above specified rates to the Corporation within 21 days of the last day of the Calendar month in which the contributions fall due. The Corporation has authorized designated branches of the State Bank of India and some other banks to receive the payments on its behalf.

Contribution Period and Benefit Period There are two contribution periods each of six months’ duration and two corresponding benefit periods also of six months’ duration as under.


23

Contribution period Corresponding Cash Benefit period

Contribution Period

Cash Benefit Period

1st April to 30th Sept.

1st Jan of the following year to 30th June

1st Oct to 31st March of the year 1st July to 31st December. following.

ESI SCHEME AT A GLANCE -- MAHARASHTRA

REGIONAL OFFICE

1

SUB REGIONAL OFFICES

5

NUMBER OF EMPLOYEES

11,67,712

NUMBER OF INSURED PERSONS

13,09,235

NUMBER OF HOSPITALS

14

NUMBER OF DISPENSARIES

72

NUMBER OF INSURANCE MEDICAL PRATICTIONERS

1063


24

BENEFITS FOR EMPLOYEES

Benefits

Under Section 46 of ESIC Act, totally six social security benefits have been conferred on employees working with various organizations across India. These six social security benefits for the welfare of the employees are enlisted as follows: (a) Medical Benefit (b) Sickness Benefit (SB) (c) Maternity Benefit (MB) (d) Disablement Benefit (e) Dependants' Benefit (DB) (f) Retirement Benefit

And some Other Benefits

(a) Medical Benefit:

In ESIC, comprehensive medical care ranging from OPD, medical attendance, treatment, drugs, specialist consultation, hospitalization of insured persons (IPs) and their family to super-speciality treatment, are provided under the Scheme. Medical Benefit is available to the Insured Person (IP) and his family member from the day one he enters the insurable employment. What makes this Scheme unique is that, medical care is provided to ESI Beneficiaries as per need. There is no ceiling on expenditure on individual medical care. Besides this, Medical Care as available in ESI Dispensaries/Hospitals is also provided to retired and permanently disabled insured persons and their spouses on payment of a token annual of `120/-.

Full medical care is provided to an Insured person and his family from the day he enters insurable employment. There is no ceiling on expenditure on the treatment of an Insured Person or his family member. Medical care is also provided to retired and


25

permanently disabled insured persons and their spouses on payment of a token annual of Rs.120/- Section 56 (1) of ESI Act, 1948 provides, “an Insured Person or (where such medical benefit is extended to his family) a member of his family whose condition requires medical treatment and attendance shall be entitled to receive medical benefit”.

Eligibility for Medical Benefit: An insured person (IP) and his/her family member become eligible for primary & secondary medical benefit under the ESI Scheme from day one of entering insurable employment. Section 56 (3) of ESI Act, 1948 provides, “A person shall be entitled to medical benefit during any period for which contributions are payable in respect of him or in which he is qualified to claim sickness benefit or maternity benefit (or is in receipt of such disablement benefit as does not disentitle him to medical benefit under the regulations)”.

Duration and Scale of Medical Benefit: The insured person/family member of an insured person can avail the medical treatment under this Scheme till the insured person is in insurable employment. Full medical care (all facilities including hospitalization) for insured person and their family is provided.

Delivery of Medical Benefit: As per the provisions of ESI Act, 1948, the State Governments are responsible for providing the medical benefits through the network of ESI Dispensaries (for primary medical services) and ESI Hospitals (for secondary medical services). However, the ESI Corporation provides medical care directly, in Delhi and Noida area. Besides these two areas, the Corporation is also running 34 ESIC Hospitals directly which includes ESIC Model Hospitals, at least one in each State. The beneficiaries are provided OPD services, in-patient services, diagnostic facilities, free drugs and dressings etc. in all ESI medical delivery institutions. ESIC has developed its own pharmacopeia for drugs.


26

All drugs and dressing (including vaccine & sera), which is considered necessary and generally in accordance with pharmacopeia, are supplied to all patients free of charge. In the case of critical patients, incidental expenditure on transport, stoppage charges at the centre, traveling expenses for attendants (if required) are also being paid by ESIC.

Medical Infrastructure of ESI Scheme: The ESI Scheme has the largest medical infrastructure under one umbrella, in India. Medical Care is provided through its huge network of 150 ESI Hospitals, 1372/91 ESI Dispensaries/ISM Units, 1380 Clinics and 7340 IMOs. The ESI Scheme is also the largest employer of Medical and Para-Medical personnel of the country. It includes: 1.

System of Treatment

2.

Scale of Medical Benefit

3.

Benefits to Retired IPs

4.

istration of Medical Benefit in a State

5.

Domiciliary treatment

6.

Specialist consultation

7.

In-Patient treatment

8.

Imaging Services

9.

Artificial Limbs & Aids

10. Special Provisions 11. Reimbursement


27

System of Treatment

Generally, the allopathic system of medicine is used for providing Medical Benefit. However, where a substantial number of workers demand treatment by Indian system of medicine and Homoeopathy (ISM & H) other than Allopathy and where the State Government has recognized the qualifications in such system, treatment facilities may be provided under the ISM & H as well. The various ISM &H systems of treatment in vogue are: Ayurveda, Unani, Siddha, Yoga therapy and Homeopathy.

Certificates required for the purpose of Cash Benefits in respect of persons treated by ISM &H should be issued by IMO /IMP having recognized qualifications in such system and duly appointed by the State Government. The issue of certificates under ISM &H is possible only where dispensaries in systems other than allopathic medicine are functioning independently with IPs and their family units attached to them and not functioning merely as referral units. In places where ISM &H units function only as referral centres, certificates will have to be issued by the Allopathic dispensary to which the IP is attached.

Scale of Medical Benefit

The scale of Medical Benefit under section 57 of Act to be provided to the IPs and of their families is to be prescribed by State Government in consultation with the Corporation under Section 58(1 & 3) of Act under State Medical Benefit Rules. An IP and/or a member of his family does not have the right to claim Medical Services over and above those which have been so prescribed. The beneficiaries are entitled to reasonable medical, surgical and obstetric treatment.


28

a. To

Insured

Persons:

-

IPs

are

entitled

to

avail

treatment

in

ESI

Dispensary/Hospital/Diagnostic Centre and recognized institutions, to which he is attached such as: 

Outpatient treatment



Domiciliary treatment by visits at their residences.



Specialists Consultation.



In-patient treatment(Hospitalisation)



Free supply of drugs dressings and artificial limbs, aids and appliances.



Making and laboratory services.



Integrated family welfare, immunisation and MCH Programme and other national health programme etc.



Ambulance service or re-imbursement of conveyance charges for going to hospitals, diagnostic centre’s etc.



Medical Certification and



Special provisions.

b. To Family of Insured Persons:- While in all implemented areas, IPs are entitled to medical care as detailed above, of a family of an IP are entitled to one or other of the following scales of Medical Benefits:

"FULL" Medical Care i.e., all facilities as for IPs including hospitalization.



"EXPANDED" Medical Care i.e., all facilities as for IPs except hospitalization. A small number of IPs in the States of Gujarat and Bihar fall under this category.

The Corporation aims at providing uniform scale of Medical Care to the Family in all implemented areas as the rates of the contribution paid by the employees and the employers are the same throughout the country.


29

Benefits to Retired Insured Persons (IPs)

Medical Benefit to Retired Insured Persons and Permanent Disabled Insured Persons:-

On payment of Rs.10/- P.M. in lump sum for one year in advance, Medical Benefit can be provided (under Section 56 of the Act) to: i.

An Insured Person and his or her spouse who leaves insurable employment on attaining the age of superannuation after being insured for not less than five years, till the period for which contribution is paid.

ii.

An Insured Person and his/her spouse who ceases to be in insurable employment on of permanent disablement due to employment injury shall be entitled to medical benefit.

istration of Medical Benefit in a State

The istration of Medical Benefit under the ESI Scheme is the statutory responsibility of the State Government except in the Union Territory of Delhi where the ESIC has taken over direct responsibility to ister the same with effect from 1.4.1962. The Corporation has also taken the responsibility of directly istering the existing Occupational Disease Centre’s at Delhi. Mumbai, Calcutta, Chennai and Nagda as well as the Scheme in the Industrial pocket of Uttar Pradesh i.e., Noida and Greater Noida.

Domiciliary Treatment

An Insured Person and his family are entitled to free medical attendance by IMO/IMP at their residence when the condition of the patient is such that he/she cannot reasonably

be

expected

to

attend

the

dispensary/clinic.


30

Conveyance allowance for Domiciliary visit i.

For the domiciliary visit, the IMO's are paid conveyance allowance. The quantum of this allowance is decided by the State Government in consultation with the Corporation.

ii.

The IMPs are not paid any domiciliary conveyance allowance. In their case, it is included in the capitation fee upto a distance of 5 km. between the Clinic of IMP and IP's residence. The IMOs/IMPs are required to maintain record of domiciliary visits in a monthwise. The columns in this are given under the Chapter "Sickness Absenteeism and Recording".

Specialists Consultation

The standard of Medical Care under the E.S.I. Scheme provides for specialist consultation to IP in all cases and to of their families in areas with "Expanded" and "Full" Medical Care. Arrangements for specialist consultation may be provided at Specialist/Diagnostic Centre’s, E.S.I. Hospitals or at such other institutions by appointing Specialists/Super Specialists on full time/part-time basis where suitable arrangements exist. Such consultation is provided in the following specialities: -

1

General Medicine

15 Cardiology

2

General Surgery

16 Neurology

3

Pulmonary Medicine (Tuberculosis and 17 Urology and Nephrology Chest Diseases)

4

Obstetrics and Gynaecology

5

Pathology

18 Gastro-enterology 19 Endocrinology 20 Oncology


31

6

Paediatrics

21 Burns and Plastic Surgery

7

Eye

22 Cardio Thoracic Surgery

8

Ear, Nose and Throat Diseases

23 Neurosurgery

9

Skin and STD

24 Occupational Medicine

10 Radiology

25 Laboratory Services

11 Orthopaedics Rehabilitation Services 26 Blood Transfusion Services (Physiotherapy

and

Occupational

28 Haematological Services

Therapy) 29 Anaesthesiology 12 Dental 13 Psychiatry 14 Critical Care Services

It may not be necessary to appoint specialists in all specialities at all centre’s. However, specialists in the first 13 specialities mentioned above may be made available in each diagnostic Centre and emergency centre’s as far as possible. The other specialities may be provided as per disease profile of the area/as per requirement.

In-Patient Treatment

Under the E.S.I. Scheme, IPs in all areas and their family in areas with "Full" medical care facility are entitled to hospitalization. In-patient treatment is provided at hospitals constructed by E.S.I.C or by reservation of beds in the hospitals owned by the State Government, local Fund Organization or Private Bodies or by constructing annexes to such institutions. The E.S.I. Scheme pays for these beds on the basis of occupied bed days. The Corporation has framed standard plans for construction of different sizes of hospitals/annexes mainly with a view to achieving uniformity and standardization all


32

over the country. The Corporation has also laid down norms for equipment and staff for hospitals of different bed strengths.

Drugs and Dressing All drugs and dressings (including vaccines and sera) that may be considered necessary and generally in accordance with the E.S.I.C drug formulary are supplied free of charge. There are two parts in E.S.I.C Drug Formulary, 1998 as follows:-

Part-I: - List of medicines for emergency kit for a. dispensary b. hospital

Part II: -List of medicines to be supplied by dispensaries in Service Areas or by approved chemists or depots on prescription in areas.

Imaging Services Imaging Services and Laboratory Investigations Imaging and investigations including CT Scan, MRI, Echocardiography and laboratory facilities are provided free of cost to IPs and their families at state level speciality hospitals or other institutions having tie up with E.S.I. Scheme.

Artificial Limbs & Aids Artificial Limbs, Aids and Appliances Insured Persons and their family are provided following artificial limbs, aids and appliances as part of medical care under the E.S.I. Scheme.:

Artificial limbs



Hearing Aids



Spectacles (Frame costing not more than Rs.100/- and replacement of frames not to be made earlier than 5 years) (To insured persons only)



Artificial Dentures, teeth (To insured persons only)


33



Artificial Eye (To insured persons only)



Wigs (replacement not earlier than 5 years) to female beneficiaries only



Cardiac pacemaker



Wheel Chair/tricycle



Spinal s (jackets, braces etc.)



Cervical collars



Walking callipers, surgical boots etc.



Crutches



Hip prosthesis, total hip



Intra ocular lens (IOL)



Any other aid or appliances prescribed by the specialist as part of

treatment.

The expenditure on artificial limbs, aids and appliances is met from the shareable pool of expenditure on medical care.

Special Provisions

Benefits received by Insured Person- Not assigned or attachable

Sec 60

Bar on benefits under other enactments

Sec 61

No reduction of wages during sickness

Sec 72

No termination/Dismissal/Discharge/ Reduction during sickness

Sec 73

Medical Board- Medical appeal tribunal employees' Insurance Court

Sec 54-A

Appeal

can

be

filed

within

3

months but

this

period

can

be

extended.

of medical appeal tribunal 

Judicial member



Doctor of concerned speciality



Labour Leader



Medical Board- Medical appeal tribunal employees' Insurance Court


34

Other Provisions of ESI Act Punishment for false statement by Insured Person

Sec 84

Establishment of E.I. Court

Sec 74

Submission of Return of Contribution

Sec 44

Provision for Prosecution for Non-submission

Sec 85

RETURN OF CONTRIBUTION IS REQUIRED TO BE SUBMITTED BY THE EMPLOYER EVERY 6 MONTHS.

FOR HALF YEAR ENDING 31ST MARCH

12 MAY

FOR HALF YEAR ENDING 30TH SEPTEMBER

11 NOV

Liability of Transferee - t & Severally

Sec 93-A

Restricted to the value of Assets Repayment of Benefits improperly received

Sec 70

Recovery of Employees' share of contribution by Reduction from his Sec 40 wage and not otherwise- Shall relate to the period or part of the period in respect of which contribution is payable - AND Shall not be in excess of the sum representing the Employees' Contribution for the period Power of Central Govt. to give directions

Sec 92

Provision for Prosecution

Sec 85, 85-A &

For

non/delayed

payment

of

contribution,

non-submission

of 86

returns/records No contribution by employee if wages less than Rs. 50/- per day


35

Reimbursement

Under Regulation 69, every employer has to arrange for First-aid Medical care and transport of accident cases till the injured IP is seen by the IMO/IMP and such employer is entitled to reimbursement of expenses incurred in this regard upto the maximum of scale prescribed from time to time. However, reimbursement is not permissible, if the employer is required to provide such medical aid free of charge under any other enactment.

The cost of provision of such emergency treatment would be reimbursed to the employer by the Director/AMO (ESI Scheme) of the respective State and, therefore, all claims duly ed by relevant receipts and vouchers should be sent to him for verification and payment.

Reimbursement of expenses incurred in respect of medical treatment under regulation-96 A.

Regulation-96 A reads as follows: - Claims for reimbursement of expenses incurred in respect of medical treatment of IP and his family may be accepted in circumstances and subject to such conditions as the Corporation may by general or special order specify.

The following conditions have been laid down under this Regulation: -

1. Full authority is vested with the State Government concerned to reimburse expenditure in respect of medical treatment of IP and his family.

2. It may be left to the discretion of the State Government to decide the Authority within their machinery who will approve the expenditure in question; and

3. Time limit for submission of the claims for reimbursement is one year


36

The State Government has to keep in view the following points while considering the cases of reimbursement of expenditure on Medical Care:-

1. Whether such facilities for which reimbursement is recommended are not available with the State.

2. Whether the hospital where the IP was sent or proposed to be sent was/is the nearest hospital having required facilities/services.

A List of Types of cases for which reimbursement is permitted is given below: -

1. Reimbursement is permissible in case of failure of the mobile dispensary van due to technical defects or otherwise to adhere to its schedule timings or where IP attached to such a dispensary sustained serious injuries or suffered from serious illness during off hours of the dispensary.

2. IPs and their family had to resort to private treatment during the off hours of ESI dispensary/Emergency Centre due to unavoidable circumstances.

3. Medicines

prescribed

by

IMO/Specialist

were

out

of

stock

in

the

ESI

Dispensary/Approved Chemist thereby compelling the IPs to make purchases from the market.

4. Medicines prescribed by Specialist and not provided by the IMO/IMP and where specialist considered such special Medicines absolutely necessary for the treatment of the beneficiaries as no substitute medicine was considered equally efficacious whether as an outpatient or in patient.

5. Special appliances prescribed by Specialist such as Spinal s, Cervical Collars, Walking Callipers, and Crutches, etc. if considered necessary as part of the treatment.


37

6. Where an IMO/IMP failed to make domiciliary visit requested by an IP thereby compelling the IP to make private arrangement for treatment. Under the system such cost is recoverable from the IMP if recommended after investigation by the Medical Service Committee.

7. Serious cases of accident or illness itted directly into recognized hospitals where owing to the clinical condition of the patient, being unconscious or otherwise, it was not possible to reveal his identity as an ESI patient and the hospital authorities recovered hospital expenses directly from the patient or the employer.

8. Serious cases of accident/illness where a beneficiaries was itted directly at a private hospital or in a non-recognized hospital where ission in a hospital recognized under the scheme would have seriously jeopardized his health like sudden heart attacks, fracture of the spine, cerebral haemorrhage, etc.

9. Expenditure incurred on investigation for blood transfusion.

10. Mental cases that may have incurred expenditure either as an outpatient on specialized Therapy such as ECT etc.

11. Serious cases of accident and illness itted to recognized hospitals where all the reserved ESI beds were occupied.


38



Reimbursement of conveyance charges incurred by IP where ambulance or any other transport under the scheme is not available owing to some reason or the other and where in the opinion of the IMO/IMP such a patient was non-ambulatory.



In respect of Specialized examination, laboratory test, X-ray, other imaging services etc., recommended by specialist, but where the IP either due to the break down in the machinery or where the nature of the examination of the Laboratory Tests was such that it was beyond the scope of the facilities available in the recognized laboratory/hospital.



In addition to above types of cases, reimbursement may also be allowed in other cases depending upon the merits of each case and the circumstances under which expenditure was incurred.

Reimbursement of Conveyance Charges

In the absence of availability of an ambulance and where needed in an emergency, any other quick form of transport may be used and amount so spent subject to the maximum rate prescribed by the Government/Transport authority (both ways) is reimbursed to IPs. To avoid hardship to IP and his family who have to go to any hospital or medical institution for ission, specialist consultation or investigation, but whose condition is not such as to need an ambulance, provision has been made for the payment of conveyance charges, if hospital/medical institution to which the case is referred to, is at an out-station or is at a distance of more than 8 kms from the ESI Dispensary or the clinic of the doctor. The charges are restricted to actual IInd class railway fare or cost of a single seat in public conveyance both ways whichever is feasible.

If the beneficiary is not in a fit condition to travel without escort for reasons to be recorded and so certified by IMO/IMP, the conveyance charges are also allowed for an


39

escort. The IMO/IMP should keep a separate of such payments in the prescribed and send a quarterly statement of this expenditure to the Director/AMO by the 15th of the month following the quarter ending in March, June, Sept. and December. The returns received from different areas in the State may be consolidated area-wise by the Director/ AMO and quarterly statement sent to the Corporation. The expenditure on conveyance charges forms part of the Medical Care under the E.S.I. Scheme and hence shareable between the Corporation and the State Government in the usual ratio within ceiling prescribed.

(b) Sickness Benefit (SB) :

Sickness Benefit in the form of cash compensation at the rate of 70 per cent of wages is payable to insured workers during the periods of certified sickness for a maximum of 91 days in a year. In order to qualify for sickness, benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months.

1. Extended Sickness Benefit(ESB) : SB extendable upto two years in the case of 34 malignant and long-term diseases at an enhanced rate of 80 per cent of wages.

2. Enhanced Sickness Benefit : Enhanced Sickness Benefit equal to full wage is payable to insured persons undergoing sterilization for 7 days/14 days for male and female workers respectively.

(c) Maternity Benefit (MB) :

Maternity Benefit for confinement/pregnancy is payable for three months, which is extendable by further one month on medical advice at the rate of full wage subject to contribution for 70 days in the preceding year. The Maternity Benefit is paid at the rate of 100% of the average daily wages up to 12 weeks in case of confinement, up to 6 weeks in case of miscarriage.


40

This can be extended by one month on medical advice in case of sickness arising out of pregnancy, confinement and miscarriage. The total Expenditure incurred during 201314 on cash benefit payments is Rs.598.69 crores from which one can assess the huge extended by ESIC to its IPs at the time of distress, which otherwise should have put extra burden on the low-income bracket of the workforce of the country

Maternity Benefit is payable to an Insured Woman in the following cases subject to contributory conditions: 

Confinement-payable for a period of 12 weeks (84 days) on production of Form 21 and 23.



Miscarriage or Medical Termination of Pregnancy (MTP)-payable for 6 weeks (42 days) from the date following miscarriage-on the basis of Form 20 and 23.



Sickness arising out of Pregnancy, Confinement, Premature birth-payable for a period not exceeding one month-on the basis of Forms 8, 10 and 9.



In the event of the death of the Insured Woman during confinement leaving behind a child, Maternity Benefit is payable to her nominee on production of Form 24 (B).

(d) Disablement Benefit

1.

Temporary disablement benefit (TDB) : From day one of entering insurable

employment & irrespective of having paid any contribution in case of employment injury. Temporary Disablement Benefit at the rate of 90% of wage is payable so long as disability continues.


41

2.

Permanent disablement benefit (PDB) : The benefit is paid at the rate of 90% of

wage in the form of monthly payment depending upon the extent of loss of earning capacity as certified by a Medical Board.

(e) Dependants' Benefit(DB) :

DB paid at the rate of 90% of wage in the form of monthly payment to the dependants of a deceased Insured person in cases where death occurs due to employment injury or occupational hazards. This is payable to the widow for life or until her re-marriage and also to the dependent children till the age of 25 years and also to the dependent parents, subject to conditions. In an endeavour to reach out to the beneficiaries and make the system more customer friendly, long-term benefits such as Permanent Disablement and Dependants Benefits are being credited to the bank of the beneficiaries through ECS System.

(f) Retirement Benefit

When an insured person who leaves the insurable employment on attainment of the age of superannuation or retires under a voluntary Retirement Scheme or takes premature retirement, after being an insured person for not less than 5 years, shall be eligible to receive medical benefit for himself and his spouse subject to production of proof thereof, and payment of a nominal contribution of Rs.120/- (rupees one hundred and twenty only) for one year.

In case, the insured person expires, his spouse is entitled to the medical benefit for the remaining period for which the contribution was made, and she can continue to receive the medical benefit on payment of the contribution of Rs.120/- (rupees one hundred and twenty only) per annum for further period. This medical benefit is also issible to an insured person who ceases to be in employment on of permanent disablement caused due to employment injury for himself and his spouse on payment of similar


42

contribution till the date on which he would have vacated the employment on attaining the age of superannuation, had not sustained such permanent disablement

(g) Other Benefits:

Funeral Expenses: An amount of Rs. 10,000/- is payable to the dependents or to the person who performs last

rites

from

day

one

of

entering

insurable

employment.

Confinement Expenses: An Insured Women or an I.P.in respect of his wife in case confinement occurs at a place where

necessary

medical

facilities

under

ESI

Scheme

are

not

available.


43

NEED BASED BENEFITS

In addition, the scheme also provides some other need based benefits to insured workers.

Vocational Rehabilitation: Vocational Training in case of physical disablement due to employment injury for which the actual fee charged or Rs.123/- per day, whichever is higher is paid as long as the vocational training lasts.

Physical Rehabilitation: In case of physical disablement due to employment injury.

Old Age Medical Care: For Insured Person retiring on attaining the age of superannuation or under VRS/ERS and person having to leave service due to permanent disability insured person & spouse on payment of Rs. 120/- per annum.

Rajiv Gandhi Shramik Kalyan Yojana: This scheme of Unemployment allowance was introduced w.e.f. 01-04-2005. An Insured Person who become unemployed after being insured three or more years, due to closure of factory/establishment, retrenchment or permanent invalidity are entitled to: 

Unemployment Allowance equal to 50% of wage for a maximum period of upto one year.



Medical care for self and family from ESI Hospitals/Dispensaries during the period IP receives unemployment allowance.



Vocational Training provided for upgrading skills - Expenditure on fee/travelling allowance borne by ESIC.


44

Un-employment Allowance under RGSKY is payable in case of involuntary loss of employment due to closure of factory, retrenchment or permanent invalidity due to nonemployment injury and contribution for three years prior to the loss of employment, 50 % the average daily wages is payable for a maximum period of twelve months during life time. Under RGSKY, in case of involuntary loss of employment, skill up gradation training is provided for duration of maximum 6 months, so that the IP can enhance his skill and opt for other jobs.

Incentive to employers in the Private Sector for providing regular employment to the persons with disability: 

Minimum wage limit for Physically Disabled Persons for availing ESIC Benefits is 25,000/-.



Employers' contribution is paid by the Central Government for 3 years.

Benefits & Contributory Conditions:

An interesting feature of the ESI Scheme is that the contributions are related to the paying capacity as a fixed percentage of the workers’ wages, whereas, they are provided social security benefits according to individual needs without distinction. Cash Benefits are disbursed by the Corporation through its Branch Offices (BOs) / Pay Offices (POs), subject to certain contributory conditions.


45


46

THE EMPLOYEES’ STATE INSURANCE SCHEME AS A MECHANISM TO POOL RISK

The ESIS was introduced in India in 1955 with the intention of providing financial protection to those in the lowest income groups in the industrial/manufacturing sector. Although it has grown in both size and scope, many have been critical of the scheme. One criticism is that most beneficiaries, or , of the scheme do not utilize the services for a variety of reasons, the primary one being a perception of the poor quality of care. Description of the Employees’ State Insurance Scheme The promulgation of the ESI Act by the Parliament in 1948 was the first major legislation on social security for workers in India.

The Act envisages protection to workers in the organized sector in the case of sickness, maternity and death or disability due to injury at work. Based on the principle of pooling of risks and resources, this health insurance scheme provides medical facilities to beneficiaries and cash compensation for loss of wages or earning capacity while in service.

The ESI Act applies to non-seasonal factories or manufacturing units employing ten or more people in a power using factory and twenty or more people in a non-power using factory. Employees drawing wages of up to Rs. 10,000 per month (as on Jan 2009) are currently entitled to a health insurance scheme. However, the wage ceiling for the purpose of coverage is revised from time to time. To increase the coverage the ESI Act has also been extended gradually to other establishments such as shops, hotels and restaurants, road and motor transport undertakings, newspaper establishments and cinema halls.


47

The ESI Act however, is not applicable to factories or establishments run by the State Governments/Central Government whose employees receive other social security benefits. Under the ESI scheme, employees contribute 1.75% of their wages and the employers contribute 4.75% of the wages of eligible beneficiaries/employees towards payments. Employees earning less than Rs. 50 per day are exempted from contribution towards payments. The contributions made by the employees and the employers are deposited in a common pool known as the ESI Fund, which is used for meeting istrative expenses as well as cash and medical benefits to Insured Persons (IP) and their dependents. The state governments, as per the ESI Act, contribute 12.5% of the total expenditure (within the per capita ceiling of Rs.1000 per annum) incurred by the ESIC on medical care in respective states.


48

NEW INITIATIVES – AWARENESS

24x7 medical helpline no.1800 11 3839 in all esic hospitals:The ESI Corporation has launched a 24x7 Helpline No.1800 11 3839 for attending the calls of Insured Persons and their family who wish to seek advice and guidance from casualty/emergency of ESIC Hospitals. In case an Insured Persons calls on 24x7 helpline functioning at ESIC Headquarter Office and desires to have some medical advice in emergency from a doctor, this call will be connected through conference from 24x7 helpline to the emergency of ESIC Hospital of the concerned state and the doctor available in the casualty/emergency will attend the call for needful.

Redressal of public grievances: The ESI Corporation has set up the Public Grievances Redressal System at all levels i.e. Hqrs. Office/Regional/Sub-Regional/Divisional/Branch Offices/ESI Dispensaries/ESI Hospitals. To ensure expeditious disposal and speedy redressal of public grievances under the ESI Scheme, various measures have been taken by the Corporation. It includes a Toll-Free Helpline No. 1800-11-2526 activated at Hqrs. office. Besides the above, the following help lines have also been installed in ESIC RO/SRO to cater to local stakeholders

Suvidha Samagam:-

In order to deal with oral, written complaints/suggestions and grievances, Suvidha Samagam is being held regularly in various field offices i.e. at RO/SRO/ESIC Hospitals on 2nd Wednesday of every month and at ESIC BO on 2nd Friday of every month.


49

Enhancement of exemption limit: -

The ESI Corporation has also decided to enhance the exemption limit from payment of employees’ contribution for employees drawing wages upto Rs. 137/- per day from existing Rs. 100/- per day.

ENHANCEMENT OF PERMANENT DISABLEMENT BENEFIT & DEPENDANT BENEFIT RATES: -

The ESI Corporation has approved for enhancement of the Permanent Disablement Benefit and Dependants’ Benefit Rates for its Insured Persons vide its notification dated 12.05.2015 in order to address the erosion in its real value due to inflation.

HAPPY EMPLOYEES, HAPPY EMPLOYER: -

1. Employers are freed of all liabilities of providing medical facilities to employees and their dependants in kind or in the form of fixed cash allowance, reimbursement or actual expenses, lump sum grant or any other medical insurance policy of limited scope, unless it is a contractual obligation.

2. Employers are also exempted from the applicability of the Maternity Benefit Act and Employees’ Compensation Act for employees covered under the ESI Scheme.

3. Employers are freed of any responsibility in time of physical distress of workers such as sickness, employment injury or physical disablement resulting in loss of wages, as the responsibility of paying cash benefits shifts to the Corporation in respect of insured employees.

4. Any sum paid by way of contribution under the ESI Act is deducted in computing ‘Income’ under the Income Tax Act.


50

5. Besides this, a New Inspection Policy has also been launched and integrated with Shram Suvidha Portal of the Ministry of Labour & Employment wherein 13 Central Labour Acts, DGMS and EPF Act are aligned. It aims to achieve the objective of simplifying business regulations and bringing transparency and ability in labour inspection.

Fast and efficient Services: 

Project ‘Panchdeep’: To digitize internal and external processes and to ensure efficiency in operations, especially services to Employers and Insured Persons, ESIC has launched its IT Project ‘Panchdeep’.



Employer Portal under ‘Panchdeep’: The Employer Portal permits various transactions online without visiting any ESIC Office, saving time and avoiding the drudgery of routine paperwork. Employer and Employee Registrations are done online. The portal enables employers to file monthly contributions, generate Temporary Identity Cards and create monthly contribution challans online.



IP Portal under 'Panchdeep': Insured Persons (IPs) can check contributions paid/payable by employers, family details, entitlement to various benefits and status of claims.



Pehchan Card for IP: The photograph of the Insured Persons (IPs) and their family are clicked during registration. Their fingerprints are also scanned for Pehchan Card. Two sets of Pehchan Card (one for the IP, another for his/her family ) are provided for swift and convenient delivery of services.


51



e-Biz Platform: ESIC is the first entity to integrate its services (Registration of Employers via e-Biz portal of Department of Industrial Policy and Promotion of DIPP) to promote ease of business and curb transaction costs.



Online payment of ESI Contribution by the Employer made easier via the payment gateway of State Bank of India and 58 other banks was launched on 01st April, 2015.


52

ESIC – 2.0: REFORM INITIATIVES OF ESIC

With a view to accelerating expansion of coverage of ESIC, ESIC has launched the 2nd Generation Reforms Agenda named “ESIC-2.0” during the inaugural session of 46th Indian Labour Conference by Shri Narendra Modi, Hon’ble Prime Minister of India on 20th August, 2015 at Vigyan Bhawan, New Delhi. Some of the salient features of ESIC 2.0 are: -

(i) Starting ESIC Scheme in Arunachal Pradesh, Mizoram, Manipur, Andaman & Nicobar Island.

(ii) At present, ESIC Scheme is being implemented in industrial/commercial clusters. Now, the target is to cover whole of the 393 districts, where these clusters are located.

(iii) Covering all the construction workers under ESI Scheme.

(iv) Opening Health Scheme for selected group of unorganized workers like rickshaw pullers/auto rickshaw drivers in selected urban/metropolitan areas.

(v) Up-grading dispensaries to six bedded hospitals in phases.

(vi) Providing appropriate cancer detection/treatment facilities at different levels of hospitals.

(vii) Providing appropriate cardiology treatment facilities at different levels of hospitals.

(viii) Providing dialysis facilities in all ESIC Model Hospitals on PPP Mode.

(ix) Providing all possible pathological facilities in hospital premises by outsourcing or by upgrading.


53

(x)

Tracking each and every mother and new born child of IP family to achieve 100%

immunization as well as safe delivery.

(xi) Creating at least one Mother Child care hospital with higher facilities in every State.

(xii) To start setting up State ESI Corporations/Societies in all States as subsidiary of ESI Corporation.

(xiii) Electronic Health Record will be made available to the IP family on-line. The record will also include laboratory record in digital format and there will be no need to visit the hospital for getting this information.

(xiv) In another initiative, 24x7 medical helpline No. 1800 11 3839 have been made operational through which IP can directly talk to Doctor, in case of emergency. This helpline will be toll free and will also be available in regional languages. (xv) In an unique initiative under Swachh Bharat – Swachh Bharat Campaign of Hon’ble Prime Minister, besides the on-going cleanliness drive being taken up in all the ESIC hospitals, ESIC has decided that under ‘Abhiyan Indradhanush’ bedsheets in Hospitals will be changed every day and for each day of the week specific colour of bed sheet has been fixed based on VIBGYOR pattern, as given below:-

Day

Colour of Bedsheet

Sunday

Violet

Monday

Indigo

Tuesday

Blue

Wednesday

Green

Thursday

Yellow

Friday

Orange

Saturday

Red


54

(xvi) From 20th July, 2015, every hospital of ESIC have started to operate Special OPD every day in the afternoon from 3.00 pm to 5.00 pm for senior citizens/differently abled patients.

(xvii) Appropriate Queue Management System in every Hospital for helping in registration and pharmacy.

(xviii) To provide behavioural training to Para-medical and other staff of the hospitals guiding them to provide due courtesy in dealing with the patients/attendants. (xix) To provide facility for Reception and ‘May I Help You’ in each hospital to guide the patients/attendants.

(xx) To provide for a system for all indoor patients. (xxi) To put in place proper and attractive signage’s at the required places in all ESIC Hospitals for guidance and proper communications to the patients and beneficiaries.

(xxii) To provide yoga facilities in all ESIC Hospitals.

(xxiii) AYUSH facilities to be extended up to the dispensary level in phases.

(xxiv) To create tele-medicine facilities for the beneficiaries in phases. Further, ESIC has set up 8 new ESI Hospitals, 7 Postgraduate Medical Institutes & Medical Colleges, 1 Dental College, 1 Nursing College and 1 Paramedical Institute during the period.


55

RECENT NEWS

ESIC is going to promote Khadi by introducing Khadi Products in ESIC Hospitals & Dispensaries

ESI Corporation has been providing health care and other social security benefits to the workers of specified wage group over the past 65 years as a labour welfare measure. As a part of Swach Bharat initiative launched by the Hon’ble Prime Minister, ESIC has introduced many new initiatives like change of bedsheets every day on VIBGYOR pattern in all ESIC Hospitals & Dispensaries.

In order to promote Khadi, a meeting was held under the chairmanship of Shri Giriraj Singh, Hon’ble Minister of State for MSME, Govt. of India with Shri Deepak Kumar, IAS, Director General, Employees’ State Insurance Corporation. During the meeting, Shri Deepak Kumar, Director General, ESIC informed that ESIC is having network of 151 Hospitals and 1500 Dispensaries across the country and suggested that as part of the 70th year of Independence Day Celebrations, in line with the Hon’ble Prime Minister’s clarion call for promoting Khadi, Memorandum of Understanding (MoU) may be signed between KVIC and ESIC for supply of bedsheets and pillow covers in ESI Hospitals and Dispensaries.

He also suggested that as far as possible the supplies should be made from the locally available Khadi institutions so that there is no additional burden on transportation. It was also suggested by Shri Deepak Kumar that ESIC has recently introduced a system of laying disposable paper rolls on the examination beds while examining the patients and asked KVIC to manufacture these paper rolls and supply to ESIC. Apart from this, he also mentioned that Coir Board could supply mattresses, medical examination beds and door mats etc. to the Hospitals.


56

Smt. Hema Malini associates with ESIC in its awareness programme through TVC/Film on ESIC - 2.0

ESI Corporation has produced a TV Commercial/Film on Health Reforms Agenda- ESIC 2.0, launched by Hon’ble Prime Minster in the month July, 2015 for awareness amongst ESI beneficiaries covered under ESI Scheme. The main character of this TVC/Film has been played by Smt. Hema Malini, Hon’ble Member of Parliament and famous film personality. This TVC/Film has been done by Smt. Hema Malini free of cost, on complimentary basis for ESIC being a social security organisation for working class in the lower wage bracket.

In this film, she gives words to the significance and role of ESIC in the sphere of social security: “ESIC is the country’s singular organization in the sphere of social security that thinks of the millions of workers and their families all the time. Besides taking care of their health & s in the case of maternity, disability, sickness, unemployment, old age and death, I am happy that I am associated with ESIC”.

It is worth noting that her father was also associated with ESI Corporation, who served as an officer in ESIC Regional Office, Delhi. Smt. Hema Malini ji has become a part of ESIC’s new initiatives under Health Reforms Agenda-ESIC 2.0, launched by Hon’ble Prime Minister, Shri Narendra Modi Ji. This TVC/Film was launched by Shri Bandaru Dattatreya, Hon’ble Minister of State for Labour & Employment (Independent Charge), Govt. of India in the 168th Meeting of ESI Corporation held on 12.02.2016 at Hyderabad, Telangana. It is hoped that this TVC/Film on ESIC will enthuse and bring awareness about the benefits of the ESI Scheme and educate to the millions of workers in the country.


57

ESI Scheme in India The Employees’ State Insurance Corporation is a pioneer Social Security organization providing comprehensive social security benefits like reasonable Medical Care and a range of Cash Benefits in times of need such as employment injury, sickness, death etc. The ESI Act applies to premises/precincts where 10 or more persons are employed. The employees drawing wages up to Rs. 15,000/- a month are entitled to health insurance cover and other benefits, under the ESI Act.

The Act now applies to over 7.23 lakh factories and establishments across the country, benefiting about 2.03 crores family units of workers. As of now, the total beneficiary population of ESI Scheme stands over 7.89 crores. Ever since its inception in 1952, the ESI Corporation has, so far, set up 151 Hospitals, 1459/188 Dispensaries / ISM Units, 812 Branch/Pay Offices and 61 Regional & Sub-Regional/Divisional Offices. ESIC’s latest initiatives – ESIC 2.0 A.

A. Extending coverage of ESI Scheme for extending its social security net to the whole country

1. Extending the social security benefits of ESI Scheme in the remaining North-East States Arunachal Pradesh, Mizoram, Manipur and Andaman & Nicobar Island. It has been implemented in Mizoram w.e.f. 1.12.2015 and in Port Blair w.e.f. 01.01.2016.

2. At present, ESI Scheme is being implemented in industrial/commercial clusters within districts. Now, the target is to cover whole of the 393 districts of the States by 31.03.2016, where these clusters are located.

3. Opening Health Scheme for selected group of unorganized workers like rickshaw pullers/auto rickshaw drivers in selected urban/metropolitan areas, on pilot basis.


58

4. ESI Coverage has been extended to Construction workers in the implemented area. Construction site Workers has been covered to avail benefits under the ESI Scheme w.e.f. 1st August, 2015.

B. New Initiatives under Health Reforms Agenda of ESIC 2.0, for improving the medical care Aimed at providing better health services, Hon’ble Prime Minister of India had launched a series of Health Reforms Agenda of ESIC on 20.07.2015 which includes• Online availability of Electronic Health Record of ESI Beneficiaries (Insured Persons and their family ). • Abhiyan Indradhanush : Ensuring the change of bedsheet according to VIBGYOR pattern during the week i.e. to be changed everyday • Medical Helpline No. 1800 11 3839 for emergency and seeking guidance from casualty/emergency of ESIC Hospitals. • Special OPD for Sr. Citizens and differently-abled persons in ESIC hospitals.

Other initiatives for Improving Patients/Attendant Care

(i) ESIC has now resolved to adopt two Model Hospitals, in each State.

(ii) Providing appropriate cancer detection/treatment facilities, cardiology treatment facilities, dialysis facilities on PPP Model at different levels of hospitals.

(iii) For facilitating the practice of telemedicine, the RFP for pilot run has already been floated and the project is expected to go live in the next three months.


59

(iv) Special focus has been paid for upgradation of Dispensaries, 24 Dispensaries in ESIC buildings have been identified for upgradation to 30 bedded set up to provide 24x7 services.

(v) Pathological & X-ray facilities will be provided on PPP model in all the dispensaries in phases. Pathological services in all dispensaries of Delhi has been started from 30th November, 2015. Laboratory and ECG Services has been started in ESI Dispensary of Delhi/Noida area.

(vi) Tracking of every pregnant mother & new born: With a view to ensure 100% immunization as well as safe delivery, every mother and new born child of Insured Person, a pilot project for tracking every pregnant mother and new born is to be started in Delhi, for which coordination will be done with the State Programme Officer under Ministry of Health and Family Welfare.

(vii) Mother and Child Care Hospital in every State: ESIC has constituted a committee to prepare the norms for setting up a Mother and Child Care Hospital in every State.

(viii) AYUSH: Besides Allopathic treatment, ESIC hospitals also provide treatment under AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy). Facilities of AYUSH are to be extended to all dispensaries in phases by December, 2015 and Yoga in all ESIC Hospitals by 30th November, 2015. C. Digital India – e-initiatives of ESIC • e-Biz Platform: ESIC is the first organization of Central Government, to integrate its services (Registration of Employers via e-Biz portal of Department of Industrial Policy and Promotion of DIPP) to promote ease of business and curb transaction costs.


60

• Under its flagship digital project ‘Panchdeep’ ESIC has facilitated Online payment of ESI Contribution by the Employer, via the payment gateway of State Bank of India and 58 other banks with launch on 01st April, 2015. • ESIC has launched independent Public Grievance Module 2.0 from 15.08.2015 for lodging ESIC related Grievance online through ESIC website ‘www.esic.in’ or ‘www.esic.nic.in’. • Launch of dedicated website www.esichospitals.gov.in for ESIC Hospitals and Dispensaries in December, 2015.


61

HEALTH REFORMS AGENDA TO EASE THE HARDSHIPS FACED BY ESIC BENEFICIARIES

Dialysis facilities, Cath Lab, CT Scan and MRI facilities now going to be available in ESIC, shortly. The Dialysis facilities are now going to be there, in most of the ESIC Hospitals on PPP Model for which MoU and the process of installation of equipments are underway at present in the 11 ESIC Hospitals in the first phase. Likewise, seven ESIC Hospitals are now being selected for establishment of Cathlab in its first phase and the treatment may commence shortly.

It is also heartening to note that almost all the ESIC Hospitals are now going to be equipped with MRI (1.5 Tesla) and CT Scan facilities on PPP Model. The MRI facilities in 08 ESIC Hospitals are now open and have started functioning. Earlier, for these medical services, the beneficiaries of ESIC were referred to other outside service providers or medical establishments.

Against the backdrop of Health Reforms, ESIC has undertaken major Health Reforms initiatives on PPP (Public-Private-Partnership) Model to provide specialized medical treatment and diagnostic services to the beneficiaries covered under ESI Scheme. Emphasis has been given to introduce appropriate Cardiology treatment, Dialysis and Pathological facilities, Dental services, Physiotherapy services, X-ray facilities and establishment

of

ICUs

in

all

the

ESIC

Hospitals. The

appropriate

cancer

detection/treatment facilities at different levels are also going to be provided in the ESIC Hospitals.

Aimed at providing better and improved facilities to the ESIC beneficiaries, ESIC had launched a series of Health Reforms Agenda named ESIC-2.0 last year which included availability of Electronic Health Records of ESI Beneficiaries, Abhiyan Indradhanush, 24 X 7 Medical Helpline Number in all ESIC Hospitals, Special OPD for Sr. Citizens and differently-abled persons in all ESIC Hospitals.


62

For providing specialized treatment in the field of Physiotherapy and Dental and also for providing ECG and X-ray facilities, the necessary infrastructure and formalities are being completed and the ESIC beneficiaries will now be getting all such treatment and facilities under one roof. Not only this, Pathological facilities in the hospital premises have been created either by outsourcing or by upgrading the existing facilities.

Besides the above, some of the basic infrastructure facilities like Queue Management System in the registration area and pharmacy have also been introduced. Also reception area and ‘May I help you’ desk of such Hospitals have been further strengthened to guide the patients/attendants. The system for all the indoor patients has been upgraded and appropriate/attractive signages to communicate and guide the visitors have been put in place. Further, AYUSH facilities are being further introduced in all the ESIC Hospitals.

ESIC is now geared up for meeting all the requirements and aspirations of all covered under ESI Scheme. The establishment of most modern medical facilities in the ESIC Hospitals has made it a better health service provider and improved the hardships being faced by the patients.


63

ACHIEVEMENTS/INITIATIVES OF ESIC DURING PAST TWO YEARS

ESIC has been providing health care and other social security benefits to the workers of specified wage group over the past 65 years as a labour welfare measure.

During the last two years, under the guidance and leadership of Shri Bandaru Dattatreya, Hon’ble Minister of State (Independent Charge) for Labour & Employment, Govt. of India, ESIC has taken a number of new initiatives in order to extend the social security coverage of ESI Scheme and to improve the medical care being provided under the ESI Scheme as under: -

(1) Extending coverage of ESI Scheme for extending its social security net to the whole country • Extending the social security benefits of ESI Scheme in the remaining North-East States Arunachal Pradesh, Mizoram, Manipur and Andaman & Nicobar Island. It has been implemented in Mizoram w.e.f. 1.12.2015 and in Port Blair w.e.f. 01.01.2016. • At present, ESI Scheme is being implemented in industrial/commercial clusters within districts. The target was to cover all 393 districts, where these clusters are located. In this regard, Now, the further target is to cover all 681 districts of the country by end of this year i.e December 2016. • Opening Health Scheme for selected group of unorganized workers like rickshaw pullers/auto rickshaw drivers in selected urban/metropolitan areas, on pilot basis. • ESI Coverage has been extended to Construction workers in the implemented area. Construction site Workers has been covered to avail benefits under the ESI Scheme w.e.f. 1st August, 2015.


64

• Facilities for Cancer, Cardiology, Dialysis, Dental, CT Scan, MRI and ICU facilities introduced on PPP model in ESIC Hospitals and also Pathology and X-Ray facilities in ESIC Dispensaries. • AYUSH and Yoga introduced in ESIC Hospitals and introduced facility for telemedicine. • Resolved to set up two Model Hospitals and one Super Speciality Hospital in each state • Launched ESIC-2.0 Reform Agenda with facilities for changing bed sheets every day in ESIC Hospitals, Online Electronic Health Records, 24x7 Medical Helpline, special OPD for sr. citizens and differently-abled persons and grading of Hospitals based on performance. • As a part of Digital Initiative, launched Aadhar linked e- Pehchan Card, integrated ESIC services with e-Biz Portal, Launched Public Grievance Module 2.0 for lodging grievances online and launched a dedicated website www.esichospitals.gov.in


65

(2) New Initiatives under Health Reforms Agenda of ESIC 2.0, for improving the medical care Aimed at providing better health services, Hon’ble Prime Minister of India had launched a series of Health Reforms Agenda of ESIC on 20.07.2015 which includes• Online availability of Electronic Health Record of ESI Beneficiaries (Insured Persons and their family ). • Abhiyan Indradhanush : Ensuring the change of bedsheet according to VIBGYOR pattern during the week i.e. to be changed everyday • Medical Helpline No. 1800 11 3839 for emergency and seeking guidance from casualty/emergency of ESIC Hospitals. • Special OPD for Sr. Citizens and differently-abled persons in ESIC hospitals.

(3) Other initiatives for Improving Patients/Attendant Care

(i) The ESI Corporation has launched a pilot project of Tele-medicine Services at 11 ESI locations in co-ordination with Health Informatics and Electronics Division (HIED), CDAC, Mohali under ‘Digital India’ programme of Government of India.

(ii) In order to improve the health care facilities for the beneficiaries, ESI Corporation has decided to open 6 bedded Day Care Centre’s in various ESI Dispensaries, all over the country. To begin with, 1st Day Care Centre at ESIC Dispensary at Factory Road, Sarojini Nagar, New Delhi has been started from 10.06.2016.

(iii) ESIC has introduced a landmark health initiative to keep Insured Persons (IPs) healthy and aware about their health by starting of Annual Preventive Health Check-up for Insured Persons (IPs) of age 40 years and above in all ESIC/ESIS Hospital and equipped ESI Dispensary.


66

(iv) Providing appropriate cancer detection/treatment facilities, cardiology treatment facilities, dialysis facilities on PPP Model at different levels of hospitals.

(v) Pathological & X-ray facilities will be provided on PPP model in all the dispensaries in phases. Pathological services and ECG Services in all dispensaries of Delhi have been started.

(vi) Quality Control on Medicine & Drugs: - ESIC has made testing of drugs more stringent. Now, all batches of Drugs/Medicines supplied are subjected to quality testing through Govt. approved laboratories at the time of supply or at any time during the shelf life.

(vii) Queue Management System in hospitals.

(viii) Behavioural training to doctors, paramedics and other staffs is being given in most of the hospitals.

(ix) May I Help Your Desk facility is available in all hospitals.

(x) Pilot project for tracking of pregnant mothers and new-borns.

(xi) Special mother and child care hospital.

(xii) AYUSH facilities to be extended to all dispensaries in phases.

(xiii) Yoga facilities in all the ESIC hospitals.

(xiv) In order to promote Khadi, ESIC proposes to sign a Memorandum of Understanding (MoU) between KVIC and ESIC for supply of bedsheets and pillow covers in ESI Hospitals and Dispensaries.


67

FETAL MEDICINE UNIT AT ESIC SUPER SPECIALTY HOSPITAL By Shri Bandaru Dattatreya, Hon’ble Minister of Labour & Employment, Govt. of India (Independent Charge) on the occasion of ‘World Birth Defects Day’ on 3rd March, 2016. About 5 – 10 % of the babies are born with Birth Defects. Infant Mortality Rate is high in India. Birth defects are one of the leading causes of infant deaths in India.

Every year, third day of this month is designated as World Birth Defects day. The cost of the treatment of this group of malformations is high as the birth defects are common and most of the major defects need super specialty treatment.

Children who are successfully treated are at an increased risk for long-term medical and surgical issues. Hence the role of prevention of Birth Defects and education about the Birth Defects is very important. In this direction, as a Chairperson of the ESI corporation with around 8 Crore ESI beneficiaries in India, he propose to start the Fetal Medicine unit at ESIC Super Specialty Hospital associated with the proposed ESIC Medical College at Sanath nagar , Hyderabad.

This unit is contemplated to start a unique national program - ESIC CARES program. CARES : Congenital Anomalies Registration and Education Service. Our Insured Persons would be educated and counselled for the Birth Defects through this initiative. Once well established at Hyderabad, this would be extended to the rest of the country through the ESIC Hospitals. Surgical intervention for the Birth Defects carries significant mortality in India.

He proposes to start the Neonatal Surgery Services unit at ESIC Super Specialty Hospital associated with proposed ESIC Medical College at Sanath nagar, Hyderabad. This unit is envisaged to start International Collaborative ESIC NSS [Neonatal Surgery Service] and ESIC Bids Birth Defects Surgery units.


68

OTHER INITIATIVES

(i) ESIC has decided to enhance period of unemployment allowance under RGSKY from 12 months to 24 months along with the medical benefit to Insured Person/Insured woman and his/her family. The eligibility of contribution condition has also been reduced from three years to two years for getting the benefits under RGSKY.

(ii) ESI Corporation has also decided to enhance wage ceiling for coverage of employees under the ESI Act from Rs. 15,000/- to Rs. 21,000/-

(iii) The duration of Maternity Benefit in confinement has been increased from 12 weeks to 24 weeks.

As of now, the total beneficiary population of ESI Scheme stands over 7.89 crores. Ever since its inception in 1952, the ESI Corporation has, so far, set up 151 Hospitals, 1459/188 Dispensaries / ISM Units, 812 Branch/Pay Offices and 61 Regional & SubRegional/Divisional Offices.


69

LAUNCHES OF TELE-MEDICINE SERVICES OF ESIC

In order to improve the health care facilities for the beneficiaries, Shri Bandaru Dattatreya, Hon’ble Minister of State (Independent Charge) for Labour & Employment, Govt. of India launched the first phase of the Tele-medicine services on 06.09.2016 at Constitution Club of India, New Delhi whereby ESIC Model Hospital, Basaidarapur, New Delhi connected with three ESI Dispensaries at Rudrapur (Uttrakhand), Unnao (Uttar Pradesh) and Kathiyar (Bihar).

ESI Corporation has been providing health care and other social security benefits to the workers of specified wage group since the last 65 years as a labour welfare measure. Under this new initiative, the ESI Corporation has launched a pilot project of TeleMedicine Services at 11 ESI locations in co-ordination with Health Informatics and Electronics Division (HIED), C-DAC, Mohali under ‘Digital India’ programme of Government of India. The chosen HUBs are ESIC’s Post Graduate Medical Institutes in which Super Specialists & Specialists may be able to provide door-step consultative services to the ESI beneficiaries. The ESI Dispensary is chosen as Spokes from those States where there is no secondary care medical services are available. The launch of telemedicine services of ESIC are going to provide the specialized ESI Health care services to the ESI beneficiaries residing/working at different geographical locations with limited medical specialist services.


70

ESIC GRIEVANCE REDRESSAL

This ESIC scheme, being a multi-disciplinary, service intensive, social security programme for workers, an estimated 3.5 lakhs of beneficiaries visit the service outlets at the grassroots level daily either for treatment purposes or for availing cash benefits. In such a highly interactive and dynamic system, there is ample scope for any unlawful, inadvertent or willful harassment being caused to the beneficiaries of this scheme.

Hence, to overcome such incidents, ESIC Corporation has set up an elaborate system for speedy redressal of public grievances and complaints at various levels as follows: -

a) Branch Office Level Manager, In charge of Branch Office

b) Dispensary Level IMO In charge.

c) Hospital Level Medical Superintendent/Deputy Medical Superintendent

d) Regional Level Public Grievance Officer Regional Director ESIC

e) Director Public Grievances, ESI Corporation, Kotla Road, New Delhi-110002. Tel No.: (011) 23239424/23234092

The ESIC has taken various remedial measures for ensuring timely redressal of grievances to the beneficiaries of this scheme. In accordance with Regulation 10 and 10A of ESI (General) Regulations 1950, Local Committees and Regional Board representing employers, employees and Scheme s have been constituted under ESIC Scheme.


71

All the units/offices of the ESI Corporation dealing with the public grievances have been given specific instructions to complaints from varied sources viz. Insured Persons/Employers/VIPs/Associations of Employees and Employers/News items and Complaint-Boxes that are provided at the Branch Offices/Regional Offices. Based on the classification of the nature of complaints received, a registration number should be allotted to each case.

On conducting proper enquiries of such grievances, the cases are settled promptly. In case of rejection of any complaint/grievances, the complainant is informed regarding the reasons of rejection of such petitions.

Subsequently, the ESI Corporation has taken the policy decision to set up an independent cell to deal with the public grievances exclusively at Regional levels across India with effect from April 1999.

Accordingly, special cells to deal with the public grievances as well as to promote the public relations have been set up at Regional Offices across India. This is done with for the purpose of monitoring the redressal of grievances of the beneficiaries and dependants attached to this ESIC Scheme.

The complaints of the beneficiaries including the Employers and representatives of Associations/Labour leaders are given due attention and weightage so as to settle claims and other grievances on priority basis. Besides, 'SHIKAYAT ADALAT' has specially been constituted to deal with the public grievances.

A facilitation centre has been opened at Sub Regional Offices across India allowing insured person, employers etc. to lodge their complaints/grievances freely without any fear and interact with the ESIC. The Complaints are duly attended to and wherever essential, detailed investigations are conducted so that such Complaints are redressed in a prompt and judicious manner and recurrence of such grievances are nipped in the bud.


72

MEDICAL APPEAL TRIBUNALS

The State Government constitutes Medical Appeal Tribunal for the purpose of Section 54 A of ESI Act and Rule 20 A of ESIC (Central) Rules 1950 and regulation 76 of the ESI (General) regulations, 1950. The Medical Appeal Tribunal consists of a Judicial Officer appointed by the State Government of status not higher than judge of the Employee Insurance Courts. He/She will be assisted by one or more senior State Medical Service Experts drawn from the from the respective branch of medicine to which the case pertains. This Tribunal also includes officials nominated by the State Government of recognized trade unions for this purpose.

Procedure of Medical Appeal Tribunal

An insured person or ESI Corporation, whosoever, is dissatisfied with the decision of the Medical Board may appeal to the Medical Appeal Tribunal on Form B.I.5 within 3 months of being informed of the decision., If it is satisfied that the Appellant had sufficient and valid reasons for not submitting the application with the prescribed time as specified by ESIC, then the Tribunal even after the stipulated period of three months may entertain an application. The Tribunal has the powers to confirm, reverse or vary with the decision of the Medical Board in part or in whole.


73

EMPLOYEES' INSURANCE (EI) COURTS

Under Section 74 of the ESIC Act, the State Government shall constitute an EI (Employees’ Insurance) Court for local areas by notification in the Official Gazette. Any person who is or has been a judicial officer or is a legal practitioner of five years’ standing shall be qualified to be a Judge of the Employees’ Insurance Court. Under Section 54A(2) of the Act, the Employees’ Insurance (EI) Court can decide to appeal against the decision of Medical Board/Medical Appeal Tribunal, in case of any shortfalls.

The insured person or the Corporation can file an Appeal under Section 54A of the Act and Rule 20B of ESI (Central) Rules, 1950 to the Employees’ Insurance (EI) Court by presenting an application within three months of the date of communication of the decision of the Medical Board/Special Medical Board or to the Medical Appeal Tribunal to the insured person or the ESI Corporation as the case may be.

The Employees’ Insurance (EI) Court may entertain application after the stipulated period of three months, if it is satisfied that the applicant had sufficient and valid reasons for not presenting the application within the said period. The Rules made by the State government in respect of form and procedures to be followed in presenting an application to Employees’ Insurance (EI) Court shall be applicable to the applications presented for the above purpose.

An appeal can be made against the decision of an Employees’ Insurance (EI) Court can be transferred to the High Court, if a substantial question of interpretation of law is involved under Section 82 of the Act and period of limitation for an appeal shall be sixty days.


74

ISTRATIVE & OPERATIONAL BENEFITS OF ESIC ACT – EMPLOYEES AND EMPLOYERS, RETIRED AND DISABLED PERSONS

Role of ESIC in Delivery of Benefits for Employees/Workers



The ESIC is instrumental in delivery of benefits for wage-earners/employees of factories and commercial organizations across India by ensuring that.



The quality and quantity of benefits is based on the norms and standards as laid down by the ESI Corporation for the purpose.



The benefits are made readily available within the given time frame to insured persons and beneficiaries under this scheme.



No harassment is caused to the beneficiaries of this scheme across the counter at the grass root level by way of word or deed.



All requisite information, procedural norms and guidance etc. are made available to the beneficiaries for availing benefits.



All types of forms etc. are made available to the beneficiaries of ESIC scheme which is free of cost as such forms may be required by such individuals for filing their medical claims



No beneficiary is exploited at any level in the process of delivery of benefits.



As notified for ESIC/ESIS establishments, office hours are strictly adhered to by the staff. This is indeed essential in order to avoid any inconvenience being caused to the beneficiaries of ESIC scheme for the purpose of smooth flow of benefit process.


75

Role of ESIC in Servicing Employers: -

ESIC plays an important role in servicing the employers of factories, commercial establishments, shops etc. This is done with a view to reduce the employer’s responsibility pertaining to the healthcare issues concerning their organizational employees and in turn the issues regarding employees’ welfare is assumed by ESIC. 

To develop a purposive, responsive and productive relationship with the employers.



Seek their active involvement in the improvement of the scheme as a confidence building measure.



Provide the employers necessary guidance in fulfilling their lawful obligations under the ESIC Act.



Make available to them all the requisite Forms and proformae free from all hassles as may be required by them from time to time.



To ensure that any lax medical certification on part of ESIC does not bring down the productivity of a factory or commercial establishment.



To ensure that in case of any doubt, difficulty or misunderstanding the employer is given an opportunity to be heard at an appropriate level.



To ensure that all the correspondences emanating from the employer is responded to in a timely manner and objectively.



To ensure that an employer is not being unnecessarily harassed by any official of the ESIC who have been authorized to inspect the commercial premises or the records.


76

MEDICAL BENEFITS – FOR RETIRED & DISABLED PERSONS (Rules 60 & 61 of ESI Central Rules, 1950)

Insured Persons who cease to be in insurable employment on of permanent physical disablement due to employment injury or those who leave the insurable employment on attaining the age of superannuation are eligible to receive medical benefits for themselves and their spouses (or dependants). The benefit is provided on payment of contribution in lump sum for one year at the rate of Rs. 10/- monthly in advance.

Scale of Medical Benefits Superannuated or disabled insured workers are entitled to the same scale of Medical Benefits and to the same package of medical/healthcare facilities that are issible to an insured person and spouse.


77

FREQUENTLY ASKED QUESTIONS

What is the benefit issible to the family ?

(i) Family are also entitled to full medical care as and when needed

(ii) The family are also entitled to artificial limbs, artificial appliances etc. as a part of medical treatment.

(iii) The medical benefit is also issible to the family during the period the insured person is in receipt of unemployment allowance. In case he dies during the period, his family continues to receive the medical benefit till the end of those twelve months.

(iv) Reimbursement of expenditure incurred on the funeral of the deceased employee.

(v) In case of the death of the insured employee due to employment injury, the widow, widowed mother and children are entitled to Dependants' benefit.

(vi) Any benefit due to the insured employee at the time of death is paid to the nominee.

What is Rajiv Gandhi Sharmik Kalyan Yojana?

In the event of closure of factory/establishment or non-employment injury related unemployment, the insured Person would be entitled to un-employment allowance subject to three years of insurable employment. The un-employment allowance is payable for twelve months in life time.


78

Benefit after Retirement to the Insured Person (IPS)/Widow

What is the benefit issible after retirement of an employee?

An insured person who leaves the insurable employment on attainment of the age of superannuation or retires under a voluntary Retirement Scheme or takes premature retirement, after being an insured person for not less than 5 years, shall be eligible to receive medical benefit for himself and his spouse subject to production of proof thereof, and payment of a nominal contribution of rupees one hundred and twenty for one year.

In case the insured person expires, his spouse is entitled to the medical benefit for the remaining period for which the contribution was made, and she can continue to receive the medical benefit on payment of the contribution @ 120/- p.a. for further period. This medical benefit is also issible to an insured person who ceases to be in employment on of permanent disablement caused due to employment injury for himself and his spouse on payment of similar contribution till the date on which he would have vacated the employment on attaining the age of superannuation, had not sustained such permanent disablement.

Further, this medical benefit is also available to widows of insured persons who are in receipt of dependant benefit on payment of contribution as prescribed under rule 60 However, the medical benefit extended under this rule does not include Super Specialty Treatment (SST).


79

Introduction about Johnson & Johnson

Johnson & Johnson, through its family of companies, is engaged in the research and development, manufacture and sale of a broad range of products in the health care field in virtually all countries of the world. Johnson & Johnson's primary interest, both historically and currently, has been in products related to human health and well-being. Johnson & Johnson was incorporated in the State of New Jersey in 1887.

Johnson & Johnson is organized on the principle of decentralized management. The Executive Committee of Johnson & Johnson is the principal management group responsible for the strategic operations and allocation of resources of the Johnson & Johnson Family of Companies. Johnson & Johnson's operating companies are organized into three business segments: Consumer, Pharmaceutical and Medical Devices. A Group Operating Committee, composed of managers who represent key operations within the segment, as well as management in specialized functional departments, oversees and coordinates the activities of domestic and international companies related to each of the business segments.

However, in line with the principle of decentralized management, senior management groups at U.S. and international operating companies are each responsible for their own strategic plans, as well as the day-to-day operations of those companies, and each international company is, with some exceptions, managed by citizens of the country where it is located. The company's business is divided into three major segments, Pharmaceuticals, Medical Devices and Diagnostics, and Consumer Products. In 2013, these segments contributed 39%, 40%, and 21% of the company's total revenues


80

Products J & J is the world’s most inclusive and broadly-based manufacturer of health care products as well as a provider of related services for the consumer the world over. A wide variety of products across adverse range of categories are continuously innovated, manufactured and marketed to help people across the globe to lead healthy and happy lives.

Consumer Products The company meticulously offers products and information about babycare, skin and hair care, oral care, nutritionals, pain relief, topical careand the like.

Medical Devices & Diagnostics Their medical devices & diagnostics businesses provide help to doctors, nurses and hospitals with enabling technologies to cure patients who suffer from some of the world’s most pervasive and chronic conditions.

Pharmaceuticals The Pharmaceutical segment’s broad portfolio focuses on unmet medical needs across several therapeutic areas: oncology; infectious disease; immunology; neuroscience; cardiovascular and metabolism. It includes products in the anti-infective, antipsychotic, cardiovascular, contraceptive, dermatology, gastrointestinal, haematology immunology, neurology, oncology, pain management, urology and virology fields.

To find out the exact details on how the ESIC works in Johnson and Johnson I did ask some question to the concerned person Mr. Shailendra Dhamdhere who is the HR Director in JNJ who takes care of all such benefits for the employees. There were some questions which I asked him. They are as follows: -


81

1. Are all the persons employed who are not coverable under the Act are also counted for 10/20 employees to determine eligibility?

Yes. All the persons employed in the premises including the boundaries thereof irrespective of their wages including casual, trainees, contract employees are counted for the purpose of coverage of the Factory. Even the Directors employed are to be counted.

2. How are the employees ed under the Scheme?

At the time of ing the insurable employment, an employee is required to fill in a Declaration Form (form1) and submit a family photo in duplicate to the employer, which is to be submitted to the ESI Branch Office/entered in the online system by his employer. The employee is then allotted an insurance number for the purpose of his identification under the scheme and issued a temporary identity card for availing medical benefit for self and family for a period of three months. Thereafter, he is provided with a permanent photo identity card. A person once ed need not again in case of change of employment. The same registration can be transferred from one place to the other.

3. What is difference between Temporary Insurance Card and Permanent Insurance Card?

Temporary Insurance Card (TIC) is generated online from ESI website of the organization ed under ESI mentioning all the demographic, wages, contribution details of the employee. The said TIC is valid for 13 weeks only and employee is supposed to for permanent card within the period. Permanent Insurance Card (PIC) is issued by ESI department after TIC and biometric fingerprints of the employee and family are recorded by the nearest ESI local office.


82

4. Did employees are covered under ESIC after retirement? 

After retirement if the person works with principal employer then PF & ESI deduction is depends on & conditions of the employment



PF - After 58 years - No upper limit of age prescribed by the act.



All amounts go to PF only & no EPS contribution



EPS - Upper age limit is 58 years



ESI - This act has not prescribed any upper limit of age so you can deduct the ESI in mutually agreed between the parties.



After retirement if the person works with principal employer then PF & ESI deduction is depends on & conditions of the employment.

5. Whether the Act provides for voluntary coverage by employees and employer?

No. the ESI Act does not provide for voluntary coverage at the request of employees and employer.

6. What is a Code number?

It is a 17-digit unique identification number allotted to each of the factory/establishment ed under the provisions of the Act. Such a number is generated through ESIC portal on submission of the pertinent information by the employer or generated on receipt of Survey report from the Social Security Officer.


83

7. Is there any interest to be paid by Employer for delayed payments? Did Johnson & Johnson ever have paid such?

Yes they had. If an employer who fails to pay the contribution within the limit prescribed under Regulation 31, shall be liable to pay simple interest at the rate of 12% per annum in respect of each day of default or delay in payment of contribution.

8. Which records are being maintained for ESI purpose at Johnson & Johnson?

In JNJ we maintained the Muster roll, wage record and books of maintained under other laws, the employer is required to maintain the following s for ESI:  Accident in new Form-11 and  An inspection book. The immediate employer is also required to maintain the Employee's for the employees deployed to the principal employer.

9. What is Standard Benefit Rate of Johnson and Johnson?

Means average daily wages obtained by dividing the total wages paid during the contribution period by the number of day for which these wages were paid. The standard benefit rates are specified in Rule 54, lowest rate being Rs. 14.00 and the highest being Rs. 145.00.


84

10. What is Contribution period and Benefit period?

Contribution period and Benefit period are periods fixed for the purpose of paying contributions and deriving benefits under the Act. In respect of the contribution period from 1st April to 30thSeptember, the corresponding benefit period shall be from 1st January of the year following, to 30thJune; and in respect of the contribution period from 1st October to 31st March of the year following, the corresponding benefit period shall be from 1st July to 31st December of the year following.

11. For Newly employed persons, how contribution and benefit period is calculated?

In the case of a newly employed person, the first contribution period shall commence from the date of employment, and the corresponding first benefit period shall commence on the expiry of 9 months from the said date. {Rule 2 & Regulation 4} 12. What is meant by “Sickness Benefit”?

When an insured employee is sick, he is entitled to receive for the period of his sickness, benefit at the daily “Standard Benefit Rate”. This benefit is available to the insured employee for sickness occurring during any benefit period if he has paid contributions for not less than seventy-eight days of the corresponding contribution period. Sickness benefit is not available for the first 2 days of sickness.

13. Payroll Software used at Johnson & Johnson?

There is no such specific payroll been used in Johnson and Johnson. We used the same software (Workday) for this payment as well.


85

Status of Permanent Disablement Benefit (PDB) and Dependant Benefit (DB)

Cases and Payments

Amount

Year

No. of IPs No. of IW

No.of Beneficiaries

No. of

paid in

fresh

PDB in

PDB

Million (INR)

2011-12

Amount

No. of

paid in

fresh

DB in

cases

Million

in DB

(INR)

17,100,958 2,407,302 66,351,717

14,059 1143.95

705

1123.90

2012-13

18,582,000 2,721,789 72,098,160

14,441 1334.39

1841

906.50

2013-14

19,547,620 2,922,345 75,844,766

12,747 1662.65

1984

1164.50

2014-15

20,344,530 3,360,697 78,933,944

11,386 1853.97

2020

1244.30

2015-16

21,320,339 3,517,856 82,722,915

12,331 2135.70

1890

1550.10


86

FINDINGS OF THE STUDY

1. All the workers are aware of sickness benefits; dependant’s benefits and leave benefits of ESI scheme.

2. Majority of workers are aware of the payment funeral expense provided by ESI Corporation.

3. Interpersonal communication is the main source of information about ESI scheme of workers. Some of the workers are getting information from ESI the employer as well as the ESI office.

4. Media is the least sought source of information for getting the ESI.

5. Majority of workers are utilizing the sickness benefits, maternity benefits and dependant’s benefits provided by the ESI dispensary.

6. All the workers are utilizing the leave benefits provided by ESI Corporation. l Majority of workers are utilizing the ESI dispensary. 7. Large majority of workers are utilizing the ESI dispensary for treatment of minor diseases and majority of them are for occupational hazard.

8. Very few are visiting to the ESI dispensary for treatment of major diseases and all the diseases.

9. A large majority of workers feels that bottlenecks in procedure and lack of medical facility as the main barrier in getting services from ESI dispensary.


87

The findings show that the overall utilization level is very low due to; perceived low quality drugs, long waiting periods, insolence of personnel, long waiting spells to unusual delays in reimbursement of money spent on treatment outside, lack of or low interest of employers and low awareness of ESI procedures.

These findings may reflect the existing problems with the operation of the ESI scheme, the reimbursement and the referral systems adopted by the scheme. More specifically if the ESI enrolees are less likely to access their insurance 24 benefits when seeking care, then one might wonder why do the organisations will voluntarily purchase insurance coverage for their workers? Like any other study based on a primary survey, some caveats are in order for this study.


88

RECOMMENDATIONS

Not only is the utilization pattern of the ESI facilities relatively very low but the cost of treatment in the private sector is quite high. On an average the in-patients in the private facilities spent around Rs.6327 (including indirect expenses) and Rs.1104 for outpatient care. This clearly shows that the scheme is failing to provide the financial protection that it should. Based on the responses from policy makers on how to improve the overall effectiveness of the scheme, we offer below some suggestions for improvements.

The government could improve access by constructing more ESI facilities or adding more private facilities to the of recognized hospitals where the insured patients can get treatment. The latter is particularly important as the current perception of quality of care among beneficiaries is poor. Private providers are spread throughout rural and urban areas and are available wherever there is a demand for services. They are also more easily accessible to people than public facilities and have flexible opening hours and short waiting times. Other documented reasons for their popularity are their greater sensitivity to needs and the assurance of confidentiality. Between 75% and 80% of households in India prefer to use the private sector for treatment of major and minor illnesses respectively (National Council of Applied Economic Research, 1995).

The basic infrastructure of the existing facilities could be improved to provide higher quality of service to the beneficiaries; this includes making basic diagnostic equipment available, providing nursing personnel, laboratory services and making conditions more sanitary. A multiple card system could be introduced so that the beneficiaries can use a convenient facility whenever required; this will particularly help those employees whose family or dependents do not live with them. It would mean that employees and their families could hold a card each so that even if they lived apart each could use the most convenient health facility. Finally, our discussion with policy makers suggest that there has been little continuity in the highest policy making system, thereby considerably


89

CONCLUSION ESIC has played a significant role in providing social security millions of workers in the organized sector. It is only social security organization in the country which provides insurance coverage for exigencies related to health, maternity, disablement, death and employment. The corporation thus extends complete social security cover to the workers and their family . However, the working of ESI is not up to the expected level of the insured person from three sectors.


90

WEBLIOGRAPHY 

www.esic.nic.in



www.esicmaharashtra.gov.in



www.en.wikipedia.org



www.medindia.net


91

Esi Benefits 3g3p2b

Overview 4q3b3c

More details 26j3b

Related Documents 171j1w

Esi Benefits 3g3p2b

Esi Benefits 3g3p2b

Esi 3b2q2y

Esi 3b2q2y

Esi Hospitals 1r121

Esi 2 3s5w65

More Documents from "Amey Vartak" 50wt

Hr In Ngo 654w2u

A Study On Effectiveness Of Performance Appraisal In Managerial Employees Of Bank 6g415j

Esi Benefits 3g3p2b

The Mckinsey 7s Model 24431j

Askep Kanker Serviks 45543o

Chapter 1.ppt 5g3h2c