Medical Benefits
You are entitled to all the following Medical Benefits
Broad Speciality
- 1 General Medicine
- 2 General Surgery
- 3 Pulmonary Medicine (Tuberculosis and Chest Diseases)
- 4 Obstetrics and Gynaecology
- 5 Pathology, Microbiology & Biochemistry
- 6 Paediatrics
- 7 Ear, Nose and Throat Diseases
- 8 Skin and STD
- 9 Eye
- 10 Radiology
- 11 Orthopaedics Rehabilitation Services (Physiotherapy and Occupational Therapy)
Super Speciality
- 1 Cardiology
- 2 Neurology
- 3 Urology and Nephrology
- 4 Gastro-enterology Oncology
- 5 Endocrinology
- 6 Oncology
- 7 Burns and Plastic Surgery
- 8 Cardio Thoracic Surgery
- 9 Neurosurgery
- 10 Occupational Medicine
- 11 Critical Care Services
- 12 Blood Transfusion Services
- Under the ESI Scheme, you and your family are entitled to hospitalization if you live in areas with full medical care. The ESI Corporation has ensured that hospitals are built to the same standard across the country, with the right equipment and staff based on the hospital’s size. You will receive all the necessary medicines, vaccines, and dressings according to the ESI-approved list.
- You and your family can get free imaging and tests like CT Scans, MRIs, Echocardiograms, and lab tests at state-level specialty hospitals or other centers partnered with the ESI Scheme.
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You and your family are provided with artificial limbs, aids, and appliances,
particularly:
- Artificial limbs
- Hearing Aids
- Spectacles (Frame costing not more than Rs.1200/- and replacement of frames not to be made earlier than 5 years) (To insured persons only)
- Artificial Dentures, teeth (To insured persons only)
- Artificial Eye (To insured persons only)
- Wigs (replacement not earlier than 5 years) to female beneficiaries only
- Cardiac pacemaker
- Wheelchair/tricycle
- Spinal supports (jackets, braces etc.)
- Cervical collars
- Walking calipers, surgical boots etc.
- Crutches
- Hip prosthesis, total hip
- Intraocular lens (IOL)
- Any other aid or appliances prescribed by the specialist as part of treatment.
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Regarding reimbursements:
- You are entitled to free first-aid medical care and transport if you have an accident at work. Your employer is responsible for arranging this until you are seen by a doctor, and they can get reimbursed for the costs.
-
You and your family can claim reimbursement for medical expenses under certain conditions if
you
had to use private treatment or pay for medicines or other medical services. Some of these
situations
include:
- If the mobile dispensary is not available due to technical issues.
- If you needed private treatment outside ESI dispensary hours due to an emergency.
- If medicines prescribed by your doctor or specialist were not available at the ESI dispensary, forcing you to buy them elsewhere.
- If a specialist prescribes special appliances like spinal supports, walking aids, or crutches, which are necessary for your treatment.
- If your doctor did not make a home visit you requested, and you had to arrange private treatment.
- You can also be reimbursed for transport costs if an ambulance or other transport under the scheme was not available in an emergency, or if you had to travel more than 8 km for specialist consultations or treatment.
- If you need an escort due to your medical condition, their transport costs may also be covered.
- All conveyance costs are reimbursed at the rate of a second-class train ticket or a seat in public transport, depending on what’s feasible.
- Special Provisions
- Your benefits are protected: Any benefits you receive cannot be assigned to others or taken away under Section 60.
- No double benefits: You cannot claim benefits under both the ESI Act and any other law at the same time, as per Section 61.
- Wages protected during sickness: Your wages cannot be reduced while you are on sick leave, according to Section 72.
- Job security during sickness: You cannot be dismissed, discharged, or have your employment reduced while you are on sick leave, under Section 73.
- Appeal rights: If you disagree with a decision, you can appeal to the Medical Appeal Tribunal or the Employees' Insurance Court. You have 3 months to file an appeal, but this period can be extended.
- Tribunal members: The tribunal will consist of a judicial member, a doctor from the relevant specialty, and a labor leader.
- False statements: If you make false statements, you may face punishment under Section 84.
- Repayment of wrongly received benefits: If you receive benefits improperly, you will be required to repay them under Section 70.
- Contribution deductions: Your employer can only recover your share of contributions from your wages for the period in which the contribution is due, as outlined in Section 40.
Medical Benefits
Insured persons and their families get full medical care from the first day of their job. There is no limit on the cost of their treatment. Retired and permanently disabled insured persons, along with their spouses, can also receive medical care by paying a small annual fee of ₹120.
- Generally, allopathic (modern medicine) is used to provide medical benefits. However, if a large number of workers prefer treatment through Indian systems of medicine (ISM & H) like Ayurveda, Unani, Siddha, Yoga therapy, or Homeopathy, and if the State Government recognizes the qualifications, treatment can be offered in these systems too.
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You are entitled to necessary medical, surgical, and maternity care at ESI dispensaries,
hospitals,
diagnostic centers, or recognized institutions. The services include:
- Outpatient treatment
- Specialist consultation
- Hospitalization (inpatient treatment)
- Free medicines, dressings, and aids (like artificial limbs)
- Imaging and lab services
- Family welfare, immunization, maternity and child care, and other health programs
- Ambulance service or reimbursement of travel costs for hospital visits
- Medical certificates
- Special provisions for certain cases
- Family members of IPs also receive full medical care, similar to the insured person, including hospitalization. The Corporation ensures that the same medical standards are provided to families across all areas, since the contributions paid by employees and employers are the same throughout the country.
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If you are retired, or specially-abled: By paying ₹10 per month (in a lump sum for one year),
medical benefits can be provided under Section 56 of the Act to:
- An insured person and their spouse who leave their job due to reaching retirement age, taking Voluntary Retirement (VRS), or early retirement after being insured for at least five years. They will receive medical benefits for the period they have paid for.
- An insured person and their spouse who can no longer work due to a permanent injury from their job are also entitled to receive medical benefits.
- You are entitled to a consultation with a specialist: The ESI Scheme offers specialist consultations to insured persons (IP) in all cases, and to their family members in areas with "Expanded" or "Full" medical care. Specialist consultations can be arranged at ESI hospitals, specialist/diagnostic centers, or other institutions by appointing full-time or part-time specialists where proper facilities are available.