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Procedure of Making an Employee’s State Insurance (ESI) Claim:-
 

Claim for benefits

 

Every claim for a benefit payable under the Act shall be made
 1.      In writing, in accordance with these regulations,
 2.      To the appropriate Branch Office of ESI 

3.      On the form, appropriate for the purpose of the benefit for which the claim is made

4.       In case of insured persons who cannot do so themselves, assistance for filling the form of claim shall be provided at the Branch Offices of the ESI Corporation. 


 

When claim becomes due 

 

A claim for any benefit under the Act shall for the purposes of section 77 of the Act, becomes due on the following days : — 

 

(a)  For sickness benefit or for disablement benefit for temporary disablement for any period, on the date of issue of the medical certificate in respect of such periods ; provided that in cases where a person is not entitled to sickness benefit for the first two days of sickness, the due date shall be deferred by such days ;

(b) For maternity benefit: —

 (i) In case of confinement, on the date of issue, in accordance with these regulations, of the certificate of expected confinement or on the day six weeks preceding the expected date of confinement so certified whichever is later or, if no such certificate is issued, on the date of confinement ; and


 (ii)
 In case of miscarriage and in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage, on the date of issue of the medical certificate of such miscarriage or sickness, as the case may be.


 (c) For first payment of disablement benefit for permanent disablement, on the date on which an insured person is declared as permanently disabled in accordance with the Act and these regulations.


 (d) For first payment of dependants’ benefit, on the date of the death of the insured person in respect of whose death the claim for such benefit arises or, where disablement benefit was payable for that date, on the date following the date of death or, where the beneficiary becomes entitled to a claim on any subsequent date, on the date on which he becomes so entitled.


 (e) For subsequent payments of disablement benefit for permanent disablement and for subsequent payments of dependants’ benefit, on the last day of the month to which the claim relates ; and


 (f) For funeral expenses, on the date of the death of the insured person in respect of whose death the claim for such benefit arises.

Benefits when payable

 

(1)   Any benefit payable under the Act shall be paid:-


 (a)      In the case of sickness benefit, not later than 7 days ;


 (b)      In the case of funeral expenses not later than 15 days ;


 (c)      In the case of the first payment in respect of maternity benefit not later than 14 days;


 (d)    In the case of the first payment in respect of temporary disablement benefit not later than one month;


(e)     In the case of first payment of permanent disablement benefit not later than one month;


 (f)      In the case of first payment of dependant’s benefit not later than three months;
 

After the claim therefor together with the relevant medical or other certificates and any other documentary evidence which may be called for under these regulations has been furnished complete in all particulars to the appropriate office.

 

(2)   Second and subsequent payments in respect of any maternity, temporary disablement, permanent disablement or dependants’ benefit shall be paid along with the first payment in respect thereof, or within the calendar month following the month to the whole or part of which they relate, whichever is later subject to production of any documentary evidence which may be required under these regulations.

 

(3)    Where a benefit payment is not made within the time limits specified in sub-regulations (1) and (2) above, it shall be reported to the appropriate Regional Office and shall be paid as soon as possible.


(4)    Benefits under the Act shall be paid in cash at a Branch Office on such days and working hours as may be fixed by the Director-General or such other officer of the Corporation, as may be authorised by him from time to time in this behalf or at the option of the claimant and subject to deduction of the cost of remittance by means of postal money orders or other orders payable through a post office, or by any other means which the appropriate office may in the circumstances of any particular case consider appropriate :

Provided that the Corporation may waive the deduction of the cost of remittance in such cases as the Director-General may, from time to time, specify. Provided further that the Director-General may decide that in respect of certain areas/pay offices as may be specified by him from time to time, the payments shall be remitted through money order also at the cost of the Corporation subject to such restrictions as may be imposed by the Director-General from time to time. 


(5)   Where the payment of a benefit is to be made at a Branch Office, such office may insist upon the production of the Identity Card or other document issued in lieu thereof in respect of the insured person.


Availability of claims forms

 

Claim forms shall be available to intending claimants from such persons and such offices of the Corporation as it may appoint or authorise for that purpose, and shall be supplied free of charge.


 
Claims on wrong form

 

Where a claim for any benefit has been made on an approved form other than the form appropriate to the benefit claimed, the Corporation may treat the claim as if it was made on the appropriate form:


Provided that the Corporation may in any such case require the claimant to complete the appropriate form. 

 

Evidence in support of claim

 

Every person who makes a claim for any benefit shall, in addition to the medical certificate and other forms specifically required under these regulations, furnish such other information and evidence for the purpose of determining the claim as may be required by the appropriate office, and, if reasonably so required, shall for that purpose attend at such office or place as the appropriate office may direct.


Defective claim

 

If, in the absence of due signature or of due certification, a claim is defective on the date of its receipt by an office of the Corporation, the office of the Corporation may in its discretion, refer the claim to the claimant and if the form is returned duly signed and/or certified within three months from the date on which it was so referred, the office may treat the claim as if it had been duly made in the first instance.


Claim for inappropriate benefit

 

Where it appears that a person who has made a claim for any benefit payable under the Act, may be entitled to a benefit other than that which he has claimed, any such claim may be treated as a claim in the alternative for that other benefit.


 Authority for certifying eligibility of claimants

 

The authority which is to certify eligibility of claimants shall be the appropriate Branch Office in respect of sickness, maternity, temporary disablement benefits and funeral expenses and the appropriate Regional Office, in respect of permanent disablement and dependants’ benefits. 

 

Abstention verification

 

(1) Every employer shall furnish to the appropriate office such information and particulars in respect of the abstention of an insured person from work for which sickness benefit or disablement benefit for temporary disablement, as provided under the Act has been claimed or paid, in Form 10 and within such time as the said office may in writing require in the said form. 

 

(2) Every employer shall furnish to the appropriate office such information and particulars in respect of the abstention of an insured woman from work for which maternity benefit as provided under the Act has been claimed or paid, in Form 10 and within such time as the said office may in writing require in the said form.



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