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ESIC - Employees' State Insurance Scheme: Eligibility, Coverage And Benefits

Team AckoDec 12, 2024

To empower the social security for workers in independent India, the Employees State Insurance Act, 1948 was promulgated by the Government of India through the Parliament. With the industrial revolution during the 1950s, manufacturing industries began employing several workers to speed up manufacturing processes. The legislation’s objective was to provide a security system to these vast numbers of workers, especially during health-related eventualities. Read on to know about the Employees State Insurance Scheme’s eligibility, coverage and benefits.

Contents

What Is Employees’ State Insurance Scheme?
Employees State Insurance Act, 1948:
Applicability of the ESI Scheme
What is Covered Under Employees’ State Insurance Scheme?
What Is Not Covered Under Employees State Insurance Scheme?
Infrastructure of Employees State Insurance Scheme (ESIS):
Features And Benefits of Employees State Insurance Scheme (ESIS):
When is ESI Registration Required?
- Documents Necessary For ESI Online Registration:
Procedure For ESI Registration:
How To Apply an ESI Card (Pehchan Card)?
Employees State Insurance Scheme Hospital List:
Progress of 2nd Generation Reforms of ESIC (ESIC: 2.0):
Do’s and Don’ts of ESI Scheme:
How To Claim ESI Benefits?
- How To Check Claim Status of ESIC Online?
ESI Head Office And Helpline Number:
- Buy ACKO Health Insurance
Conclusion
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Frequently Asked Questions:

What Is Employees’ State Insurance Scheme?

The primary objective by the Government of India to launch the ESI scheme is to cover workers from certain health-related contingencies such as permanent or temporary disablement, sickness, death due to employment injury or occupational disease, which impacts the earning capacity of the worker or leads to loss of income. This scheme enables workers to negate the financial burden due to such unfortunate eventualities. The scheme also offers maternity benefits to the beneficiaries.

ESI scheme is a cover for workers that protects them with medical care(travel medical insurance) for the insured and their dependents as well as offer a variety of cash benefits during loss of wages or disablement. Also, the scheme offers pension known as dependent benefit to the family members of the insured person in case of death or injury due to occupational hazards while at work.

Employees State Insurance Act, 1948:

The Employees’ State Insurance Act, 1948 or popularly known as the ESI Act was notified by the Parliament and it was the first major legislation on the Social Security for workers post-independence of the country. The ESI Act 1948 provides medical cover and other essential benefits to workers and employees who are working in factories, business establishments and organisations such as hotels, road transport, cinemas, newspapers, educational or medical institutions, and shops wherein 10 or more persons are employed.

The ESI scheme offers benefits to both the workers and their dependents in case of any unfortunate eventualities at work. Under the ESI Act, employees or workers employed at the above-mentioned categories earning wages up to Rs. 21,000 per month are entitled for this social security scheme. The ESI Act aims at respecting human dignity during crises by protecting them from destitution, deprivation and social degradation.

Applicability of the ESI Scheme

The Employees' State Insurance (ESI) Act applies to non-seasonal factories with 10 or more workers. It also covers shops, hotels, restaurants, cinemas, transport services, media, private hospitals, educational institutions, and municipal bodies employing 10 or more, including contract and casual workers, as per Section 1(5). State governments oversee its implementation in various regions.

Shops.
Hotels and restaurants.
Road motor transport establishments.
Cinemas, including preview theatres.
Newspaper establishments.
Establishments engaged in the insurance business.
Non-banking financial companies (NBFCs).
Port trusts.
Airport authorities.
Warehousing establishments employing 20 or more persons.

Applicable where the Central Government is the appropriate governing authority.

What is Covered Under Employees’ State Insurance Scheme?

Initially, the ESI Scheme (ESIS) was implemented in Kanpur and Delhi in 1952 which were the two major industrial centres at that time. However, the scheme found itself being adopted across the country with the industrial revolution picking up pace. With the increase in industrialization over the years, the ESIS as of 31 March 2019, has been implemented in more than 34 states and Union Territories.

The ESI Act now covers nearly 12 lakh factories and business establishments and benefits more than 3 crore workers or family units. The scheme currently benefits more than 13 crore beneficiaries.

Details	ESI Coverage (As on 31 March 2019)
Number of Insured Persons/Family Units	3.10 crore
Number of Employees	2.78 crore
Number of Beneficiaries	12.04 crore
Number of Insured Women	58.69 Lakh
Number of Employers, etc.	15.94 Lakh

What Is Not Covered Under Employees State Insurance Scheme?

The ESIC scheme currently does not cover workers or employees earning more than Rs.21,000 per month and in the case of persons with a disability, the maximum wage is capped at Rs.25,000 per month. Also, in Maharashtra and Chandigarh, the current threshold for coverage is still 20 employees and not 10 employees in the case of other states or UTs.

Infrastructure of Employees State Insurance Scheme (ESIS):

Since the inception of the ESI Scheme in 1952, the ESI Corporation has set up several hospitals and annexes for medical services. Below is the ESI infrastructure network through which workers or employees can avail healthcare services:

Particulars	ESI Infrastructure Network
In-Patient Services	151 Hospitals and 42 Annexes
Out-Patient/Primary Services	1450/188 ESI dispensaries/AYUSH units, and 954 panel clinics
Occupational Disease Centers	Mumbai (Maharashtra), New Delhi, Kolkata (W.B.), Chennai (T.N.) and Indore (M.P.)
Payment of Cash Benefits	628/185 Branch Offices/Pay Offices supervised by 62 Regional/Sub-Regional and Divisional offices

Also, read: Maternity Health Insurance

Features And Benefits of Employees State Insurance Scheme (ESIS):

Below are the salient features of the ESI scheme provided the Employees State Insurance Corporation (ESIC):

Medical:

Under the scheme, the insured’s medical expenses are covered through affordable and reasonable health care facilities. Also, the worker or the employee is covered from day one of the person’s employment.

This extensive network offers outpatient and inpatient services, including medicines, diagnostics, specialist consultation and hospitalisation - all free of cost for those registered under ESIS. Recent quality surveys show high levels of patient satisfaction due to good doctor availability and low waiting times.

Maternity:

Under the scheme, the beneficiary can avail 100% of the daily wages for up to 26 weeks which can be extended to a further one month based on the medical advice. In the case of miscarriage, the benefit is 6 weeks, while in the case of adoption it is 12 weeks.

The provision covers pre and post-natal care at ESI hospitals and paid leave, helping expectant mothers safeguard health while maintaining income security. With global research showing the benefits of longer paid maternity leave for child development, the 26 weeks coverage makes ESIS progressive and allows women to nurture without facing financial stress.

Disability:

In case of temporary disablement of the worker, they are eligible for a monthly wage of 90% until they recover. In the case of permanent disability, 90% of the monthly wage can be availed for the entire life.

By providing steady income in times of impairment, ESIS prevents distressed sales of assets or debt traps. Rehabilitation allowances are also offered to upgrade skills and aids are provided to resume work after recovery. The ESIS disability benefits are a comprehensive protection cover for the insured and their dependent families.

Sickness:

During medical leave, the scheme offers cash flow during the said period. The worker can avail 70% of the daily wage for a maximum of 91 days. This can be availed in two consecutive periods.

Unemployment:

For a period of 24 months, the scheme offers a maximum of 50% of the average monthly wage in the case of involuntary loss of non-employment or due to permanent invalidity due to injury.

Dependents:

Through the scheme, dependents of the insured receive financial assistance in case of illnesses or injuries while at work. During such instances, dependents are eligible for monthly payments which are equally distributed among surviving dependents.

Covering household expenses prevents extreme hardships for families who lose their sole breadwinner. Further, in case of insured persons’ death during treatment, ESIS also provides benefits for medical care and rehabilitation of dependents if they were wholly dependent before the accident.

Coverage:

Under the scheme, workers or employees are covered from day one of their employment. This includes both the insured and their dependents. By making enrolment mandatory for all establishments with 10 or more employees, the scheme aims to protect formal sector workers. Individuals can also avail of benefits by paying nominal contributions voluntarily. Portability of coverage while switching jobs allows seamless benefits transition. Further, coverage lasts lifelong post-retirement to secure the elderly.

Funeral Costs:

The ESIC offers an amount of Rs.15,000 towards funeral costs. This is paid to the dependents or to the individual who does the last rites of the insured. This provision greatly relieves bereaved families who may struggle to meet hospitalisation and ceremonial expenses. The lump sum covers the costs of mortuary transfers, religious ceremonies and rites per family customs. Preventing distressed sales of assets or taking loans for funerals allows dignified exit for all insured persons. Further, the funeral cost is immediately disbursed within 2-3 days to the claimant’s bank account, ensuring timely aid.

Confinement Costs:

In case of confinement occurs at a location where required medical care under the scheme is not available, the insured or the dependent can avail confinement costs. This benefit is crucial in remote areas with accessibility issues. The lumpsum amount acts as a contingency fund to begin quality ante-natal treatment without delays while papers are completed for transfer to empanelled institutions. By covering such ancillary expenses, the scheme aims to secure the health of pregnant women and newborns.

Vocational Rehabilitation:

The ESIC provides this benefit based on the requirement of the insured. This is extended to those who are permanently disabled injured individuals for Vocational Rehabilitation (VR) training at VRS.

Physical Rehabilitation:

This benefit is also provided based on the need especially in the case of disability due to employment injury. Insured members who have suffered loss of limbs or bodily functions due to accidents are eligible for free assistive devices and physical rehabilitation. Covering disability aid costs prevents financial distress.

Old Age Medical Care:

When the insured person retires on attaining the retirement age or under VRS or ERS or when a person has to leave work due to permanent disability, the insured and spouse will receive Rs.120 per annum.

Also, read: Arogya Sanjeevani Health Insurance

When is ESI Registration Required?

If a company/organisation/business establishment employs 10 or more employees/workers and in the case of Maharashtra and Chandigarh more than 20 employees ESI registration is required. The company should register itself with the ESIC.

As for workers or employees, they are covered or entitled under ESI when they earn less than Rs.21,000 per month and Rs.25,000 in the case of a person with disability. The worker contributes 1.75% of their salary while the employer contributes 4.75% towards the ESI scheme. Please note that these rates are revised from time to time. Those workers whose daily average wage is up to Rs.50 are exempted from contributing to the ESI fund; however, employers will continue to contribute towards these workers.

Documents Necessary For ESI Online Registration:

Below are the set of documents required for ESI online registration:

The Registration Certificate acquired under the Shops and Establishment Act or Factories Act.
Certificate of Registration in case of a partnership or a company.
Articles of Association and Memorandum of Association of the company.
List of all employees working in the establishment.
Compensation details of all employees.
PAN Card details of the Business Entity and of all employees.
Cancelled cheque of the bank account of the company.
List of shareholders and directors of the company.
Register which includes the attendance details of the employees.
Employer’s Registration Form (Form No.1) which should be downloaded online, filled and uploaded on the ESIC website along with the above mentioned documents.

Procedure For ESI Registration:

The procedure for ESI registration by the employers is completely online and does not require submission of physical application either before or after the registration. Below are the steps to register your establishment or company with the ESIC:

Step 1: Visit the ESIC Portal and click on ‘Login’.
Step 2: On the new page, click on ‘Sign Up’.
Step 3: Enter your company name, employer name, state, region, email ID (which will be your username), and your phone number.
Step 4: Click on the checkbox to confirm your establishment or factory is under an exclusive labour contract, manpower suppliers, security agencies or contractors supplying labour categories.
Step 5: Click on ‘Submit’. An email will be sent with login credentials or details.
Step 6: Now that you have signed up, you need to visit the ESIC Portal to login.
Step 7: Enter the username and password received by email and click on ‘Login’.
Step 8: Click on ‘New Employer Registration’.
Step 9: Select the type of unit and click on submit.
Step 10: On the new page, enter the name of the unit, complete postal address of the factory or the establishment and the police station under whose jurisdiction your unit is.
Step 11: Enter if the building or the premises of the factory or the establishment is owned or hired and click on ‘Next’ to proceed.
Step 12: Enter the nature of the business and category, PAN details, etc. and click on ‘Next’.
Step 13: On the next page, enter the date of commencement of the factory or establishment and licence details (if any).
Step 14: Now, select the constitution of ownership and details of owners and then click on ‘Save’ after entering all the designation of owners and then click on ‘Next’.
Step 15: Here, enter the number of employees working in your establishment or factory and the number of employees earning less than Rs.21,000 and click on ‘Save’.
Step 16: In the new page, enter the date when the first 10/20 employees were employed and then click on ‘Employee Declaration Form’.
Step 17: Select ‘Yes’ if the insured person is already registered and enter IP number and date of joining. Select ‘No’ if IP is not registered and click on ‘Continue’.
Step 18: Enter the name of the IP and father’s name, address, date of birth, gender, marital status, family details and date of joining.
Step 19: Now, click on the checkbox and click on ‘Submit’.
Step 20: Once all details are duly filled, click on ‘Close’ on the new page.
Step 21: On the new page, select the respective ESI branch office and the inspection division.
Step 22: Now, click on the checkbox to declare that information provided is correct and then click on ‘Submit’. You’ll be redirected to a new page.
Step 23: On the new page, you will have to click on ‘Pay Initial Contribution’ and click on ‘Submit’. You will be provided with a Challan Number for future reference.
Step 24: Click on ‘Continue’ to pay through the required payment gateway.

Once the payment process is completed, you will receive the system generated ESI Registration Letter known as C-11 to your registered email ID. The C-11 acts as proof of registration of the company with the ESIC.

Also, read: Benefits of Buying Health Insurance Policy Online

How To Apply an ESI Card (Pehchan Card)?

The ESI Card also known as Pehchan Card is an identification card to avail benefits of the ESI scheme at empanelled hospitals and dispensaries. The card includes the beneficiaries name, father’s name, address and the unique ESI insurance number. It also includes the insured person’s photograph and their dependent’s details.

To download the ESI Pehchan Card, the employer needs to login into their account on the ESIC portal and fill the respective employee or worker’s details. Once the process is completed, ESIC will issue the magnetic smart card to either the employee’s address or may need to visit the ESIC branch to collect the same.

Also, the ESIC has made a new option on their portal to download employee’s ESI e-Pehchan card. Below is the process to download the e-Pehchan card:

Step 1: Visit the ESIC Portal and login with your username and password.
Step 2: On the new page, under the ‘Employee’ section, click on ‘e-Pehchan Card’.
Step 3: Select the unit details and click on view.
Step 4: You can view details of all the employees; however, you also have the option to narrow down the search by entering the respective employees’ insurance number and name.
Step 5: On the same page where you can see details of all the employees, select ‘View Counter Foil’ against the respective employee. This ‘Counter Foil’ is the ‘e-Pehchan’ card.
Step 6: On the new page, scroll down and click on ‘Print’ which can be downloaded as a PDF document.
Step 7: On the printout, the respective employee has to sign and affix family or dependents photographs. This photo has to be attested and stamped by the employer or the ESIC official.
Step 8: Ensure to get either the signature and stamp of the employer or the ESIC office on the e-Pehchan Card.

Employees State Insurance Scheme Hospital List:

The Employees State Insurance Corporation has tied with several numbers of hospitals across the country. To know the list of ESI hospitals in India, visit the ESIC Portal which has the complete list of ESI and tie-up hospitals.

Progress of 2nd Generation Reforms of ESIC (ESIC: 2.0):

In 2015, Hon’ble Prime Minister Shri Narendra Modi launched several health reform initiatives of the Employees State Insurance Scheme. Below are the main agenda of the initiatives:

Online availability of Electronic Health Records of ESI Holders
Medical Helpline
VIBGYOR – Operation Indradhanush
Special OPD
Quality Control on Drugs and Medicines
Pathological and X-Ray in PPP Model
Regular Inspection of Hon’ble Member of ESIC to ESIC/ESIC hospitals
Specialities Being Created (CT, ICU, MRI, CAT-Labs, Dialysis).
Behavioral training of doctors and para-medical staffs, Yoga, Ayush, special child and mother care hospitals, queue management, ‘May I Help You’ counters, etc.

Do’s and Don’ts of ESI Scheme:

Below are some of the important aspects that a ESI beneficiary should be aware of:

If you switch a job, ensure you inform the new employer of your ESI Registration Number.
ESI Card/Pehchan Card or e-Pehchan Card is required to avail services at ESI hospitals and dispensaries.
Follow the doctor’s instructions strictly.
Ensure you do not lose the ESI smart card. While you can get the e-Pehchan card, it might be a cumbersome task getting one. Also, report the loss of the card to the ESIC branch office or dispensary.

How To Claim ESI Benefits?

As a beneficiary of the ESI scheme, you can claim two types of benefits:

Medical Benefits: You and your dependents can avail medical care. To avail this you need to visit any of the ESI empanelled hospitals.
Cash Benefits: Employees or workers who are beneficiaries of the ESI scheme can avail cash benefits in the case of sickness, disablement (temporary/permanent), maternity, unemployment, dependent, funeral costs, and vocational and physical rehabilitation.

How To Check Claim Status of ESIC Online?

Below are the steps to check the ESI claim status online:

Step 1: Open the UMANG App or download it if you have not installed it on your smartphone.
Step 2: Enter the IP number or the ESIC Insurance Number and click on ‘Get OTP’.
Step 3: Enter the OTP and click on ‘Submit’.
Step 4: Select ‘Claim Status’ under the services menu.
Step 5: If you have raised any claims, you will be able to view the status or you use the advanced search to find the details.

ESI Head Office And Helpline Number:

Below is the ESI Head Office, helpline number and contact details:

ESI Head Office:

Employees’ State Insurance Corporation
Panchdeep Bhawan
Comrade Indrajeet Gupta (CIG) Marg,
New Delhi – 110 002

Phone Number: 011-23234092, 23234093, 23235496, 23234098, 23236051, 23236998, 23235187.

Toll-Free/Help Desk Number: 1800-11-2526

Medical Helpline: 1800-11-3839

E-Mail Address:

For Grievances/Suggestions: [email protected]
For IT Related Issues: [email protected]

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ESIC (Employees' State Insurance Scheme) is a comprehensive social security scheme that provides health insurance to employees and their dependents. This scheme offers various benefits such as medical care, sickness benefits, and maternity benefits. To know more about ESIC, its eligibility, coverage, and benefits, please check out our article on ESIC.

Conclusion

The Employees' State Insurance Scheme is a pioneering social security program providing holistic health and income protections to formal sector workers and families. By covering medical needs, loss of wages, disabilities and deaths through a network of facilities and cash benefits, it cushions against vulnerabilities. Though complex in operations, its low premium and comprehensive cover have enhanced labour welfare significantly since 1952. Continued upgrades aligned to changing needs and easier processes can further boost its national impact.

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Frequently Asked Questions:

Below are some of the common questions about Employees State Insurance Scheme:

Here are few questions asked about Employees' State Insurance Scheme (ESIC)

Should employers register under the ESI scheme?

Yes, it is mandatory for establishments with ten or more employees earning less than Rs. 21,000 per month to register under the ESI scheme.

What is the salary limit under the ESI scheme?

The current monthly salary limit is Rs. 21,000 to be eligible as an insured person under the ESI scheme. This limit is Rs. 25,000 per month for employees with disabilities.

Is overtime work done by the worker or employee included in the income limit for ESI coverage?

No, overtime allowance is not included while calculating wages for checking ESI income limit eligibility. Only basic wages and dearness allowance constitute income.

Is there any time limit to pay the contribution towards ESIC?

Yes, the employer must deposit contributions before the 21st of the next month after deducting the employee's share from wages paid. Late payment attracts interest.

What is the interest charged for late payment of ESI contribution?

If the contribution payment is delayed beyond the due date, penal interest at the rate of 12% per annum is charged on the defaulted amount.

What types of records should the employer maintain for the ESIS?

The employer must maintain registers showing details of employed workers, wages, and contributions deducted and remitted with payment evidence for inspection.

Can the ESI beneficiary claim an amount in ESI if they have taken treatment in a private hospital?

No, to avail benefits, insured persons must take treatment at ESI empaneled hospitals, dispensaries or clinics. Treatment at private hospitals is not reimbursable.

What types of establishments can avail the ESI scheme?

Factories, hotels, restaurants, cinemas, shops, educational institutions, road transport agencies, etc., with 10+ employees paying less than the threshold monthly wages can avail of the ESI scheme.

What is an ESI code number?

The ESI code number is a 17-digit unique identification code allotted to every registered establishment after the completion of ESI registration formalities.