ESI – Removal of difficulties in ESIC Pensioners Medical Scheme 2006
ESIC issued circular vide No. D-12/16/1/2017-E-VI-Vol.1 dated: 28.11.2018 regarding ESIC Pensioners Medical Scheme, 2006 — Removal of difficulties and details as follows.
It is informed that Ministry of Health & Family Welfare has issued circular dated 14/5/2018 prescribing time-lines for settlement of medical claims of CGHS pensioner beneficiaries. The circular has been issued in CGHS in compliance of the directions of Honble Supreme Court of India in their Judgement in WP (Civil) No. 694 of 2015 between Shiva Kant ha Vs U01 delivered on 13th April, 2018 and in supercession of earlier guidelines in the matter. The circular was examined in ES1 Corporation and guidelines prescribing similar time-lines are issued for pensioners / family pensioners covered under ESIC Pensioners’ Medical Scheme, 2006 as per the details below :
1) Pensioners/family pensioners enrolled under ESIC-PMS-2006 shall submit the medical claims to the concerned Nodal Officer i.e. Regional Director / Director (I/c) Director(M) Delhi / Director (M) Noida / Med. Supdtt. of ESIC hospitals. The claims shall be issued serial number and are to be processed I examined by the Nodal Officer as per rules. If found reimbursable, the claims shall he sent to the DDO for payment to the beneficiary by ECS. The payment shall be completed within 30 days of submission of the medical claims to the Nodal Officer.
2) Medical claims requiring approval of higher authorities / Medical Committee
(i) Total time within 45 days in Delhi / Noida
(ii) Total time within 60 days in other cities.
3) The Nodal Officer shall thoroughly check the papers initially for completeness of the requisite documents before accepting the claim papers to ensure that the claim papers are not returned subsequently for want of some documents. Care shall be taken not to reject medical claims of pensioners on minor technical objections, if they fall under procedural lapses, which can be condoned.
This issues with the approval of Director General.
The receipt of this letter may please be acknowledged.