State the various benefits available to the insured persons under the Employees State Insurance Act 1948.

Benefits Under ESI Act: The Act provides for six types of benefits to which the insured persons, their dependents or certain other persons are entitled. These benefits are as follows:

Sickness benefit: As per Section 46, an insured person shall be entitled to sickness benefit only if his sickness is certified by a duly certified medical practitioner or by any other person possessing such qualifications and experience as the corporation may specify in this behalf. The qualification of a person to claim sickness benefit, the conditions subject to which such benefit may be given, the rates and period thereof shall be such as may be prescribed by the Central Government. This benefit is not available for the first two days of sickness. But if spell of sickness recurs within 15 days he shall be entitled to recover the benefit even for the first 2 days in the second or subsequent spell.

Maximum sickness benefit can be for 91 days in any two consecutive benefit periods. In order to qualify for sickness benefit the insured worker is required to contribute for 78 days in a contribution period of 6 months. Sickness benefit will be available at the standard benefit rate specified in Rule 54.

Maternity benefit: A woman employee is entitled to periodical payments in case of confinement or miscarriage or sickness arising out of pregnancy, confinement, premature death of a child or miscarriage. Before an insured woman is entitled to maternity benefit, she must be eligible for Such payment by an authority specified in this behalf. [Section 46(1)b]. The qualification of an insured woman to claim maternity benefit, the conditions subject to which such benefit may be given, the rates and period thereof shall be ,such as may be prescribed by the Central Government. [Section 50] Maternity benefit for confinement/pregnancy is payable for three months, which is expendable by further one month on medical advice at the rate of full wage subject to contribution for 70 days in the preceding year.

Disablement benefit: Disablement benefit shall be payable to an insured person suffering from disablement as a result of an employment injury
sustained as an employee if he is certified for such payment by an authority specified in this behalf [Section 46(1)(c)].

As per Section 51 of this Act as regards disablement benefit :

  • A Person who sustains temporary disablement for not less than three days (excluding the day of the accident) shall be entitled to periodical payment at such rates and for such period and subject to such conditions as may be prescribed by the Central Government.
  • A person who sustains permanent disablement, whether total or partial, shall be entitled to periodical payment at such rates and for such period and subject to such. conditions as may be prescribed by the Central Government. For the purpose of this Act, an accident arising in the course of insured’ person’s employment shall be presumed, in the absence of evidence to the contrary, to have arisen out of that employment.

De-pendants benefit: If an insured person dies as a result of an employment injury sustained as an employee under this Act, (whether or not he was in receipt of any periodical payment for temporary disablement in respect of the injury) dependents benefit shall be payable at such rates and for such period and subject to such conditions as may be prescribe by the Central Government to his dependents specified below:

  • A widow,
  • Widowed mother,
  • Each legitimate or adopted son until he attains 18 years of age.
  • Minor unmarried daughters of the deceased employee.

If insured person dies without leaving behind him the dependents as aforesaid, the dependents benefit shall be paid to the other dependents
of the deceased at such rates and for such period and subject to such conditions as may be prescribed by the Central Government.

Medical benefit: Section 56 of the ESI Act, 1948 provides that 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. Such medical benefit may take the form of

  • Out -patient treatment and attendance in a hospital, dispensary, clinic or other institution or
  • Visits to the home of the insured person or
  • Treatment as in patent in a hospital or other institution.

An insured 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 dis-entitle him to medical benefit under the regulations.

A person in respect of whom contribution ceases to be’payable under this Act may be allowed medical benefit for such period and of such nature
as may be provided under the regulations. Scale of medical benefit: An insured person and (where such benefit is extended to his family) his family is entitled to receive medical benefit only of such kind and on such scale as may be provided by the State Government or by the ESI Corporation. An insured person and his family may claim medical treatment of such kind is is provided by the dispensary, hospital, clinic or other institution which has been allotted to them or as may be provided by the regulations.

No claim for reimbursement from the ESI Corporation of any expenses incurred in respect of any medical treatment is allowed except as may
be provided by the regulations. [Section 57].

Other Benefits ESI Act

Funeral Expenses: If an insured employee dies, an amount of 10,000 is payable to the eldest surviving member of the family or the person who incurs the expenditure on funeral of the deceased employee. The claim for such payment has to be submitted within 3 months of the death of the insured person. The formalities to be observed for claiming the funeral expenses are the immediate reporting of the death of the insured person, production of a death certificate from the Employees State Insurance Medical Officer, and the documents showing the actual expenditure incurred.

Confinement Expenses : An insured woman or an insured person in respect of his wife is entitled to confinement expenses in case confinement occurs at a place where necessary medical facilities under ESI scheme are not available.

General Provisions Relating to ‘Benefits’

  • The right to receive benefit under this Act is neither transferable nor assignable.
  • The cash benefit payable under this Act cannot be attached or sold in execution of any decree or order of any Court.
  • When a person is entitled to any of the benefits provided by this Act, he is not entitled to receive any similar benefit admissible under the
    provisions of any other enactment.
  • An insured person shall not be entitled to receive for the same period

    — Both sickness and maternity benefit; or

    — Both sickness and temporary disablement benefit; or

    —Both maternity benefit and temporary disablement benefit.

    Where a person is entitled to more than one benefit,he is entitled to choose the benefit which he would like to receive.

  • No insured person shall be entitled to sickness benefit or disablement benefit for temporary disablement in respect of any day on which he
    works or remains on leave or on a holiday for which he receives wages or remains on strike.
  • If a person receives any benefit or payment under this; Act which he is not lawfully entitled to, he shall be liable to pay back to the ESI Corporation the value of the benefit or the amount of such payment received. In case of his death, this payment will have to be made by
    his legal representative from the assets of the deceased, if any, in , his hands.
  • No employer shall dismiss, discharge, or reduce the wages or, otherwise punish an employee during the period the employee is in receipt of sickness or temporary disablement benefit, or is under medical treatment or is absent from work as a result of illness (duly certified) arising from pregnancy or confinement rendering the employee unfit for work.

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