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.
0 comments:
Post a Comment