ESI Revision in the eligibility conditions for super specialty treatment to the Insured Persons and members of their family
ESIC issued Office Memorandum vide No. -V-14/11/5/2018-Med.1 (SST) Dated:-29/10/2018 regarding Revision in the eligibility conditions for super specialty treatment to the Insured Persons and members of their family and details as follows.
In supersession of the instruction on the above cited subject dated 07/11/2016, the ESI Corporation, in its 175th meeting held on 18.9,2018, have approved a revised eligibility condition to mitigate the hardship faced by the Insured Person. The new eligibility conditions are being made a part of the Regulation and is under process of notification/calling objections etc. Till it takes a final shape, it may be executed with this administrative instruction.
- The Insured Person who has contributed for 78 days in a contribution period be allowed to avail super specialty treatment provided he/she has completed minimum of six months of insurable employment i.e. from the date of registration on IP Portal.
- The members of the family of the Insured Person be allowed super specialty treatment if the Insured Person has contributed 156 days (78 days in each contribution period) and have completed minimum one year of insurable employment from the date of registration.
- In both the above cases, the employer should have filed the monthly contribution as per section 44 read with regulation 26(a) failing which Regulation 31 of the ESI (General) Regulation, 1950.
- This shall be available only in the corresponding benefit period.
- Insured Persons and their family members shall continue to avail the super specialty if the Insured Persons is in receipt of extended sickness benefit.
- The Insured Women shall be eligible for super specialty treatment in case it arises due to or out of maternity if she is in receipt of maternity benefit.
- The cases of employment injury shall not attract the aforesaid conditions.
The aforesaid conditions shall apply only in those cases where expenditure of the treatment for reference is made outside the ESI set-up and is to be paid by the ESIC without share from the State Govt. In cases, the Insured Person or their family member requires a treatment which is not available in ESI Hospital or ESI Medical Education Institutions and aforesaid eligibility conditions are not met by the Insured Person, such cases be referred to the Hospitals/Medical Colleges of the State Govt. who are duty bound to render services to a citizen.