panchdeep insurance benefits 2.0
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ESIC
Pragati (Insurance)
Benefits
October 30, 2013 1
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Introduction
Benefits : The insured persons, besides full medical care for self and
family, are also entitled to a variety of cash benefits in times of physical
distress due to sickness, maternity (in respect of insured women),
temporary or permanent disablement etc. resulting in loss of wages or
earning capacity.
The section 46 of the ESI Act, 1948 envisages following five benefits
1. Medical Benefit
2. Sickness Benefit (SB)
a. Extended Sickness benefit (ESB)
b. Enhanced Sickness Benefit
3. Maternity Benefit (MB)
4. Disablement Benefit (TDB, PDB)a. Temporary Disablement Benefit
b. Permanent disablement benefit
5. Dependants Benefit (DB)
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Benefit Bouquet
Panchdeep
SicknessBenefit
Medical
Benefit
MaternityBenefit
DisablementBenefit
DependentBenefit
Extended SicknessBenefit
Enhanced Sickness
Benefit
Super-SpecialtySickness benefit
Temporary DisablementBenefit
Permanent
Disablement benefit
Medical
Cash Benefits
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Other Benefit
Other Cash Benefits
Conveyance Expenses
Unemployment Allowance
(Under Rajiv GandhiShramik Kalyan Yojana)
Vocational Rehabilitation
Funeral Expenses
Confinement Expenses
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Benefit at glance
Benefit Contributory conditions Duration Rate
Sickness benefit
Payment of contribution forat least 78 days in therelevant contributionperiod
91 days in any twoconsecutive benefitperiods
Standard benefit rate (not lessthan 50% of daily wages)
Extended Sicknessbenefit (ESB)
Continuous employment fora period of 2 years
and payment ofcontribution for atleast 156 days in4 contributionperiods.
up to 2 years in deservingcases
150% of the standard benefitrate (not less than 70%of daily wages.
Enhanced SicknessBenefit
Payment for at least 78days in the relevantcontribution period
7 days for vasectomy and 14days for tubectomyextendable in case ofpost operativecomplication etc.
200% of the standard benefitrate.
Temporary DisablementBenefit
No condition.Till the temporary disablement
lasts
140% of the Standard SicknessBenefit rate(not less than70% of daily wages)
Permanent disablementbenefit
No condition for lifeUpto 140% of the Standard
Sickness Benefit rate.
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Benefit at glance
Benefit Contributory conditions Duration Rate
Dependant's benefit No condition
To widow/widows for life oruntil remarriage.
Upto 140% of the StandardSickness Benefit rate (not
less than70% of
dailywages to be divided
among the dependants inthe prescribed ratio.
To legitimate or adopted son/unmarried daughter till
age of 18 years.
To legitimate infirm son.
To legitimate adoptedson/unmarried infirmdaughter till infirmity
lasts.
To widowed mother
Maternity benefit
Payment of contributionfor 70 days inimmediatelypreceding twoconsecutive periods.
12 weeks of which not more
than six can precede theexpected date ofconfinement;
Double the Standard Benefitrate (Not less than full
wages)
6 weeks for miscarriage andadditional one month forsickness arising out of
confinement, prematurebirth of child or
miscarriage
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Benefit Contributory conditions Duration Rate
Funeral Expenses
No condition. DeceasedIP should be an IP
on the date ofdeath.
One time paymentActual expenditure on funeral
not exceeding Rs. 5000/-(wef 01.12.07)
Confinement expenses
No condition other thaninsurable
employment ofself/spouse.
payable for two confinementsonly
Rs. 2500 is paid as a lump sumgrant towards
confinement expenses toan insured woman, wife of
insured person.
Conveyance Expenses
No condition other thaninsurable
employment and aincapacity referencehas been made bythe Branch office or
Regional office
No duration
Payable based on the travelmode recommended bythe Medical referee orMedical board or the
Actuals
Rehabilitation allowance No condition
For each day on which insured
person remains admittedin Artificial limb centrefor fixation / repair or
replacement of artificiallimb.
200% the standard sicknessbenefit rate but not less
than full wages
VocationalRehabilitation
Insurable employmentupto 40%permanent
disablement and
below 45 years age.
Till such training lasts at arecognized centre /
institute
As per the daily expense at thecentre or Rs. 45 /-whichever is more
Benefit at glance
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Benefit Claim Entry Trigger
Insured Person submits the claim form to the branch office.
Employer submits Accident report at Branch office online or via post
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Benefit Claim Workflow
HIS
ESIC official creates the
Claim form in thesystem through intranet
Claim is processedonline
EligibilityCriteria/Contributorycriteria is ascertained
Certificates will bereviewed
Benefit days, Amount tobe paid will be
calculated
F&A
IncapacityReferences(MR/MB)
IP submits the
claims at BO, ESIC
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Claim approval reject/
recommendation
Branch manager recommends the claim for reference to
MR/MB.
Branch Manager may also refer the claims to RO/
Headquarters for approval of time barred claims or for
special approval of ESB/TDB/PDB cases.
On approval of the claim from the manager, the
payment slip will be generated and forwarded to cashier
(F& A) for making the payment.
Branch ManagerApproves/Rejects/Recommends
Benefits claim
Submit Benefit Claim
Insured Person submits the claim to
the Branch office
Manual Claim
Submission
Generation of claim online and
Processing of the claim
The claim form format is available on the screens for the
LDC to input the claim form received from the IP online into
the application.
The Claim form will be checked and processed by the UDC.
Certificates from HIS is reviewed and checked by UDC
The benefit days and amount to be paid will calculated by the
system and displayed to UDC.
UDC submits the claim for managers approval
Claim entry by LDC
Lower Divisional clerk
Branch manager
Insured Person
Verification by UDC
Upper Divisional clerk
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Exceptions to normal Process
Time barred Claims : Those claims which are submitted beyond the periodof 12 months from the date of certificates are referred to the Regional
Director or at the Headquarters (IC/DG) for approvals during the
processing of benefit claims. It applies for all cash benefit claims.
Incapacity References : References made to Medical Referee/Medical
Board to know his opinion on the incapacity of the insured person toresume his work. While processing the claim, based on the certificates or
the spell of the sickness, the branch office can recommend an IP for a
medical examination by an MR/MB. The reference can be made through
the screens available in the application.
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Benefit Claims Exit Triggers
Payment of the Claims (The processing of the claim may be held in case of anyreferences to Medical Referee/Medical board for medical examination or to
RO/Headquarters for approvals)
Payment Slip is generated for the benefit claims, on the approval from the
branch manager and forwarded to F&A for payment.
The benefits paid per day are recorded and will be sent to F&A . F&A
Interface will be populated and the F&A will update finance records
If insured person failed to satisfy the eligibility criteria, the claim will not
be processed and rejection slip is generated
Claim Rejection
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Process related Reports
Reports from BO Monthly progress report
Statement to P.L.B Data
Statement of P.D.B Cases
Statement of E.S.B Cases
Statement of Excess Payment
Statement of Waiver or Recovery of Excess Payment
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Process related Reports
Reports from RO Return on Disposal of Long term Benefit
Return on waiver of recovery from Insured Persons, beyond the power
of RD
Return on waiver of excess payments made to Insured Persons by the
Regional Director
Half Yearly Report of ESI Beneficiaries with Disability for Whom
Employers Contribution is to be Paid by Ministry of SocialJustice(Region Wise Statement)
Half Yearly Report of ESI Beneficiaries with Disability for WhomEmployers Contribution is to be Paid by Ministry ofSocial Justice
(Disability Wise Statement)
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Claim Verification & Recovery
Abstention verification :
Enquiries regarding IPs abstention from work are filled and submitted by the employer through the
ESIC employer portal.
Excess or wrong payments:
An excess or wrong payment may be paid to the IP/Beneficiary due to false declaration by insuredperson. Such excess or wrong payments made may come to the notice on receipt of reply to
abstention enquiry. These excess payments are recorded and further steps to recover the amount
is taken.
The System generates an alert and prompt when future claims by the IP is received when the
excess paid amount is recovered.
The application provides the option to generate B19 and refer to recovery branch to initiate
recovery procedure if no further claim from the IP is received.
The application also provides the option to refer the non-recoverable excess payments to Regional
office/ Headquarters for waiver of recovery
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Screens
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Screens
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Screensclaim form
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Screens
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Screens
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Screens IP details & Certificates
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Screens Contribution details & Benefit Days calculated
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ScreensIncapacity reference (RM1)
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Thank You