CHAPTER III - BENEFITS CLAIMS



CHAPTER III - BENEFITS CLAIMS

44. Claims for benefits 

Every claim for a benefit payable under the Act shall be made in writing, in accordance with these regulations, to the appropriate Local Office on the form appropriate for the purpose of the benefit for which the claim is made or in such other manner as the appropriate office may, subject to its being in writing, accept as sufficient in the circumstances of any particular case or class of cases. Assistance for filling in the form of claim in case of insured persons who cannot do so themselves shall be provided at the local offices of the Corporation.


45. When claim becomes due

A claim for any benefit under the Act shall for the purposes of section 77 of the Act, become due on the following days--

(a) For sickness benefit or for disablement benefit for temporary disablement for any period, on the date of the 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 certificate of excepted 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 in which an insured person is declared as permanently disabled in accordance with the Act and these regulations; and

(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 dependant's benefit, the last day of the month to which the claim relates;

(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.


46. Availability of claim 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 the purpose, and shall be supplied free of charge.


47. Claim 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.


48. 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.


49. 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.


50. 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.


51. Authority for certifying eligibility of claimants

The authority which is to certify the eligibility of claimants shall be the appropriate local office in respect of maternity, sickness, temporary disablement benefits and funeral expenses and the appropriate Regional Office, in respect of permanent disablement and dependant's benefits.


52. 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 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 Dependents' Benefits not later than 3 months,

after the claim therefore together with the relevant medical or other certificates and any other documentary evidence which may be called for under these Regulations has been furnished completed in all particular to the appropriate office.

(2) Second and subsequent payments in respect of any maternity, temporary disablement, permanent disablement or dependents' 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 Local 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.

(5) Where the payment of a benefit is to be made at a local 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.


52A. 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 No. 28 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 28A and within such time as the said office may in writing require in the said form. 


CERTIFICATION AND CLAIMS FOR SICKNESS AND TEMPORARY DISABLEMENT

53. Evidence of sickness and temporary disablement

Every insured person, claiming sickness benefit or disablement benefit for temporary disablement, shall furnish evidence of sickness or temporary disablement in respect of the days of his sickness or temporary disablement by means of a medical certificate given by an insurance medical officer in accordance with these regulations in the form appropriate to the circumstances of the case :

PROVIDED that in areas where arrangements for medical benefit under the Employees' State Insurance Act have not been made or otherwise if in its opinion the circumstances of a particular case so justify, the Corporation may accept any other evidence of sickness of temporary disablement in the form of a certificate issued by the medical officer of the State Government, local body or other medical institution, or a certificate issued by any registered medical practitioner containing such particulars and attested in such manner as may be specified by the Director-General in this behalf.


54. Persons competent to issue medical certificate

No medical certificate under these regulations shall be issued except by the Insurance Medical Officer to whom an insured person has been allotted or by an Insurance Medical Officer attached to a dispensary, hospital, clinic or other institution to which an insured person is allotted and such Insurance Medical Officer shall examine and if in his opinion the condition of the insured person so justifies, issue to such insured person free of charge, any medical certificates reasonably required by such insured person under or for the purposes of the Act or any other enactment for these regulations :

PROVIDED that an Insurance Medical Officer may issue a medical certificate under these regulations to a insured person who is not allotted to him or to the dispensary, hospital, clinic or other institution to which he is attached, if such officer is satisfied that in the circumstances of any particular case the insured person cannot reasonably be expected to get medical benefit from the Insurance Medical Officer or the dispensary, hospital, clinic or other institution to which such insured person has been allotted; and such certificate shall also be issued free of charge :

PROVIDED FURTHER that an insured person shall not be granted a medical certificate unless he produces to the Insurance Medical Officer his identity card or some other "documents" as under these regulations, may have been issued in lieu thereof.


55. Medical certificate

The appropriate form of a medical certificate shall be filled in ink or otherwise as may be specified by the Director-General by the Insurance Medical Officer in his own handwriting and shall contain a concise statement of the disease or disablement which in the opinion of the Insurance Medical Officer necessitates abstention from work on medical grounds or renders the person temporarily incapable of work. The statement of the disease or disablement in the medical certificate shall specify the nature thereof as precisely as the Insurance Medical Officer's knowledge of the condition of the insured person at the time of the examination permits.


56. Time of granting medical certificate

(a) An Insurance Medical Officer shall give the medical certificate to an insured person at the time of the examination to which it relates; where he is prevented from so doing he shall send the certificate to the insured person within twenty-four hours thereafter.

(b) No further medical certificate relating to the same examination shall be issued, except where a duplicate of such certificate is required, in which case it shall be issued free of charge and clearly marked "duplicate".


57. Medical certificate on first examination

Where the examination is the first examination in respect of a spell of sickness or a spell of temporary disablement, the medical certificate shall be in the form of a first certificate (Form 8) and shall be only in respect of the date of examination:

PROVIDED that where the insured person, who needs abstention from work on the day of examination, states that he has been actually sick or temporarily disabled on a day earlier than the date of his first examination, the Insurance Medical Officer may, if he is satisfied as to the truth of the statement that the insured person was unable to present himself for medical examination earlier for reasons beyond his control, certify incapacity for work on the date preceding the date of examination:

PROVIDED FURTHER that where in the opinion of the insurance medical officer, the insured person is likely to become fit to resume work on a date not later than the third day after the date of the examination, the first certificate may be issued in respect of the entire spell of sickness or temporary disablement, and, in such a case, it shall specify the date on which the insured person will, in his opinion, be fit to resume work; such a certificate shall, notwithstanding anything contained in the regulations, be also treated as a final certificate.


58. Final medical certificate

If at the date of the examination to which a medical certificate other than a first certificate relates, the insured person in the opinion of the insurance medical officer is, or will become on a date not later than the third day after that date, fit to resume work, that certificate shall be in the form of a final certificate (Form 9).


59. Intermediate certificate

If the final certificate is not issued within seven days of the date of the first certificate, an insured person shall, except where the case is covered by regulation 61, submit certificates in the form of intermediate certificates (Form 10) at intervals of not more than seven days each, commencing from the date of the first certificate.


60. Final medical certificate before commencing work for wages

Every insured person shall obtain a medical certificate in the form of a final certificate before he takes up any work for wages.


61. Intermediate certificate for a longer period

When temporary disablement or sickness has continued for not less than twenty-eight days and the Insurance Medical Officer is satisfied that such disablement or sickness is likely to continue for a long period and that, owing to the nature of the disablement or sickness examination and treatment at intervals of more than one week will be sufficient, the insured person may, unless otherwise directed by the appropriate office, furnish medical certificates in the form of special intermediate certificate (Form 11) at intervals of such longer periods not exceeding four weeks as may be specified by the Insurance Medical Officer.

62 . [Omitted ]


63. Form of claim for sickness or temporary disablement

An insured person intending to claim sickness benefit or disablement benefit for temporary disablement shall submit to the appropriate local office by post or otherwise, a claim for benefit in one of the Forms 12, 13 and 14, appropriate to the circumstances of the case together with the appropriate medical certificate :

PROVIDED that where only one claim in Forms 13 and 14 is submitted in respect of more than one certificate, such Form 13 or 14 shall be deemed to be appropriate to all such certificates.


64. Failure to submit medical certificate

If a person who intends to claim sickness benefit or disablement benefit for temporary disablement fails to submit to the appropriate local office by post or otherwise the first medical certificate or any subsequent medical certificate within a period of three days from the date of issue of such certificate he shall not be eligible for that benefit in respect of any period (i) in the case of a first certificate, more than three days before the date on which the certificate is submitted to the appropriate local office; (ii) in the case of a subsequent certificate, more than fourteen days before the date on which such subsequent certificate is submitted to the appropriate local office :

PROVIDED that the appropriate regional office or other office as authorised by the Director-General may relax all or any of the provisions of this regulation in any particular case, if it is satisfied that the delay in submitting a certificate was due to bona fide reasons.

DISABLEMENT BENEFIT

65. Notice of accident

(i) Every insured person who sustains personal injury caused by accident arising out of and in the course of his employment in a factory or establishment shall give notice of such injury either in writing or orally, as soon as practicable after the happening of the accident :

PROVIDED that any such notice required to be given by an insured person may be given by some other person acting on his behalf.

Explanation : No such notice shall be required to be given by an insured person if an employment injury is caused by any Occupational Disease specified in Schedule III to the Workmen's Compensation Act, 1923.

(ii) Every such notice shall be given to the employer or to a foreman or to other official under whose supervision the insured person is employed at the time of the accident or any other person designated for the purpose by the employer and shall contain the appropriate particulars.

(iii) Any entry of the appropriate particulars of the accident made in a book kept for the purpose in accordance with the next following regulation shall, if made as soon as practicable after the happening of the accident by the insured person or by some other person acting on his behalf, be sufficient notice of the accident for the purposes of these regulations.

(iv) In this regulation and the next following regulation, the expression `appropriate particulars' means the particulars indicated below--

(a) full name, insurance number, sex, age, address, occupation, department and shift of the injured person;
(b) date and time of accident;
(c) place where accident happened;
(d) cause and nature of injury;
(e) name, address and occupation of the person giving the notice, if he is other than the injured person;
(f) a statement of what exactly the injured person was doing at the time of injury;
(g) name, address and occupation of two persons who were present at the spot when accident happened; and
(h) remarks, if any.


66. Maintenance of accident book

Every employer shall--

(i) keep a book readily accessible (hereinafter called `the Accident Book') in Form 15, in which the appropriate particulars of any accident causing personal injury to an insured person may be entered;

(ii) preserve every such book when it is completed for a period of five years from the date of the last entry thereon :

PROVIDED that it shall be necessary to enter in the said Accident Book particulars of any employment injury caused by an occupational disease specified in Schedule III to the Workmen's Compensation Act, 1923.


67. Notice otherwise than by an entry in accident book

If notice of an employment injury under regulation 65 is given otherwise than by an entry in the accident book it shall be the duty of the employer or any other person to whom such notice is given under that regulation to make an appropriate entry in the book in respect of the accident to which the notice relates immediately after such notice is received, and where the notice is received otherwise than in writing, read over the particulars to the person who gives the notice and obtains his signature or thumb-impression on the accident book.


68. Report of accident by an employer

Every employer shall send a report in Form 16 to the nearest Local Office and to the nearest insurance medical officer--

(i) immediately if the injury is serious, i.e. it is likely to cause death or permanent disablement or loss of a member; and

(ii) in any other case within 24 hours after the receipt of the notice under regulation 65 or of the time when the accident came to the notice of the employer or of a foreman or other official under whose supervision the insured person was employed at the time of the accident or any other person designated for the purpose by the employer :

PROVIDED that in case of a serious injury, and particularly when the injury results in death at the place of employment, the report to the Insurance Medical Officer and the Local Office shall be sent through a special messenger, or otherwise, as speedily as may be practicable under the circumstances :

PROVIDED FURTHER that where a report of the accident is made by the employer under the Factories Act, 1948, the report to the local office and to the insurance medical officer may be made in the same form as is prescribed under the Factories Act, 1948, provided that all the additional information required under Form 16 is added thereto :

PROVIDED FURTHER that it shall not be necessary for the employer to send a report in Form 16 if an employment injury is caused by any occupational disease specified in Schedule III to the Workmen's Compensation Act, 1923; but the employer shall furnish on demand to the appropriate local office, within such reasonable period as may be specified, such information and particulars as shall be required of the nature of and other relevant circumstances relating to any employment specified in Schedule III to the Workmen's Compensation Act, 1923.


69. Employer to arrange first aid

Every employer shall arrange for such first aid and medical care and transport for obtaining such aid and care as the circumstances of the accident may require till the injured person is seen by the Insurance Medical Officer and such employer shall be entitled to reimbursement in respect of expenses thereby incurred by him but not exceeding such scale of expenses as may be specified by the Corporation from time to time :

PROVIDED that if the employer is required to provide such medical aid free of charge under any other enactment, he shall not be entitled to any reimbursement of expenses.


70. Employer to furnish further particulars of accident

Every employer shall furnish to the appropriate office such further information and particulars of an accident and within such time as the said office may, in writing, require.


71. Directions by the Corporation

Every claimant for and every beneficiary in receipt of disablement benefit shall comply with every direction given to him by the appropriate regional office which requires him either--

(i) to submit himself to a medical examination by such medical authority as may be appointed by that office for the purpose of determining the effect of the relevant employment injury or the treatment appropriate to the relevant injury or loss of faculty, or

(ii) to attend any vocational training courses or industrial rehabilitation courses provided by any institution maintained by any government, local authority or any public or private body, recognised for the purpose by the Corporation and considered appropriate by it in his case.


72. Reference to a Medical Board

A reference to the Medical Board may be made--
(a) at any time not later than twelve months, in cases where claim for temporary disablement benefit is made for an employment injury, from the date of the final certificate issued in respect of the spell of temporary disablement commencing on or immediately after the day of the occurrence of that injury, or from the date of the occurrence of an employment injury in cases where temporary disablement benefit not having been claimed, for permanent disablements is made on the basis thereof by the appropriate regional office, at the instance of the disabled person or the employer or any recognised employee's union :

PROVIDED that such reference may be made by the appropriate regional office after the expiry of the period prescribed as aforesaid if it is satisfied that the applicant was prevented by sufficient cause from applying for the making of the reference in time :

PROVIDED FURTHER that in the event of the claim for Temporary Disablement Benefit being rejected by the Corporation but afterwards granted by the Employees' Insurance Court in respect of injuries resulted in permanent disablement, the limit of 12 months will apply from the date of the order of the Employees' Insurance Court granting the claim of the insured person for Temporary Disablement Benefit, or

(b) by the Corporation,

(i) at any time, on the recommendation of an insurance medical officer, and
(ii) on its own initiative, after the expiry of the period of twenty-eight days from the first date on which the claimant was rendered incapable of work by the relevant employment injury.


73. Report of Medical Board

The Medical Board shall after examining the disabled person send its decision on such form as may be specified by the Director General, to the appropriate regional office. The disabled person shall be informed in writing of the decision of the Medical Board and the benefit, if any, to which the disabled person shall be entitled.


74. Occupational disease

Any question whether an employment injury is caused by an occupational disease specified in the Third Schedule to the Act shall be determined by a Special Medical Board which shall examine the disabled person and send a report in such form as may be prescribed by the Director General in this behalf to the appropriate Regional Office stating--

(a) whether the disabled person is suffering from one or more of the diseases specified in the said schedule;
(b) whether the relevant disease has resulted in permanent disablement;
(c) whether the extent of loss of earning capacity can be assessed provisionally or finally;
(d) the assessment of the proportion of loss of earning capacity and in case of provisional assessment, the period for which such assessment shall hold good.

All assessments which are provisional may be referred to the Special Medical Board for review by the appropriate regional office not later than the end of the period taken into account by the provisional assessment. Any decision of the Special Medical Board may be reviewed by it at any time. The disabled person shall be informed in writing of the decision of the Special Medical Board by the appropriate regional office and the benefit, if any, to which the insured person shall be entitled.


75. Constitution of Medical Board/Special Medical Boards

Medical Boards for the purposes of the Act and the Special Medical Boards for the purposes of regulation 74 shall be constituted by the Corporation and where it so desires it may approach the State Government for setting up the same and shall consist of such persons, have such jurisdiction and follow such procedure as the Director-General may from time to time decide.


76. Appeal Tribunals

For the purposes of regulation 74, an Appeal Tribunal shall be constituted by the State Government and shall consist of a judicial officer of the State Government being a person other than the judge of an Employees' Insurance Court, who shall be assisted by the following persons to be selected by him as assessors--
(a) One or more medical experts;
(b) One or more officials of or members of trade union or unions.


76A. Submission of claims for permanent disablement benefit

An insured person who has been declared to be permanently disabled by a Medical Board or by an Appeal Tribunal shall submit, by post or otherwise, to the appropriate local office a claim, covering, except in the case of a first payment, a period of one or more complete calendar months in Form 25 for claiming permanent disablement benefit.


76B. Commutation of permanent disablement benefit

(1) An insured person whose permanent disablement has been assessed as final and who has been awarded permanent disablement benefit at a rate not exceeding Rs. 5.00 per day may apply for commutation of permanent disablement benefit into a lump sum :

PROVIDED that the insured person whose permanent disablement has been assessed as final and the benefit rate exceeds Rs. 5.00 per day may also apply for commutation of permanent disablement benefit into lump sum subject to the condition that the total commuted value of the lump sum permanent disablement benefit does not exceed Rs. 30,000 at the time of commencement of final award of his permanent disability :

PROVIDED FURTHER that the cases falling under clause (3) of this regulation where commutation has been refused because the insured person did not have average expectation of life, shall not be reopened.

(2) Where such an application is made within 6 months of the date on which he can opt for commutation hereafter called the "date of possible option" the permanent disablement benefit shall be commuted into a lump sum.

(3) Where such an application is made after expiry of six months from the date of possible option, the permanent disablement benefit may be commuted into lump sum if the Corporation is satisfied that the insured person has an average expectation of life for his age. For this purpose, the insured person shall, if so required by the appropriate office, present himself for examination by such medical authority as the Director-General may, by general or special order, specify.

(4) For the purpose of this regulation, the date of possible option shall mean--

(i) in the case of a person who, on the date on which this regulation comes into force, is in receipt of permanent disablement benefit covered by sub-regulation (1) the date of coming into force of this regulation;
(ii) in the case any other insured person, the date on which assessment of permanent disablement covered by sub-regulation (1), is communicated to him by the appropriate regional office.

(5) The amount of lump sum admissible under this regulation shall be determined by multiplying the daily rate of permanent disablement benefit by the figure indicated in column 2 of the Schedule III to these regulations, corresponding to the age on last birthday of the insured person on the date on which his application for commutation is received in the appropriate office and on and from that date the permanent disablement benefit shall cease to be payable to him:

PROVIDED that where no proof of age has been submitted as required by the appropriate office or if submitted, has not been accepted as satisfactory by the appropriate office, the corresponding age as aforesaid of the insured person shall be the age as estimated by the Medical Board on the date of examination adjusted by the period intervening between the date of examination by the Medical Board and the date on which the application for commutation was received in the appropriate office :

PROVIDED FURTHER that the age so estimated by the Medical Board shall also operate against any proof of age that may be submitted after the time allowed for the purpose to the insured person by the appropriate office before reference of his case of the Medical Board.

DEPENDANTS' BENEFIT 

77. Report of death of insured person by employment injury

In case of death of an insured person as a result of an employment injury--
(a) if the death occurs at the place of employment the employer shall, and
(b) if the death occurs at any other place, a dependant intending to claim dependants' benefit shall, or
(c) any other person present at the time of death may, immediately report the death to the nearest local office and to the nearest dispensary, hospital, clinic or other institution where medical benefit under the Act is available. 


78. Disposal of body of an insured person dying by employment injury

Where an insured person dies as a result of an employment injury sustained as an employee under the Act, the body of the insured person shall not be disposed of until the body has been examined by an Insurance Medical Officer, who will also arrange a post mortem examination, if considered necessary, in co-operation with any other existing agency :

PROVIDED that if an Insurance Medical Officer is unable to arrive for the examination within 12 hours of such death the body may be disposed of after obtaining a certificate from such medical officer or practitioner as may be available :

PROVIDED FURTHER that nothing contained in this regulation shall be in derogation of any power conferred on a coroner under any law for the time being in force or on the officer-in-charge of a police station or some other police officer under section 174 of the Code of Criminal Procedure, 1973 (2 of 1974).


79. Issue of death certificate

An insurance medical officer attending the disabled person at the time of his death or the insurance medical officer who examines the body after the death or the Medical Officer who attended the insured person in a hospital or other institution where such disabled person die, shall issue free of charge a death certificate in Form 17 to the dependants of the deceased and shall send a report to the appropriate regional office.


80. Submission of claim for dependants' benefit

(1) A claim for dependants' benefit shall be submitted to the appropriate local office by post or otherwise in Form 18 by the dependant or dependants concerned or by their legal representative or, in case of a minor, by his guardian, and such claim shall be supported by documents proving--
(i) that the death is due to an employment injury;
(ii) that the person claiming is a dependant entitled to claim as provided in rule 58 of the Employees' State Insurance (Central) Rules, 1950.
(iii) the age of the claimant;
(iv) the infirmity of the dependant claiming to be infirm within the purview of rule 58 of the Employees' State Insurance (Central Rules, 1950 by a certificate of such medical or other authority as the Director General may, by a general or special order specify in this behalf.

PROVIDED that where the appropriate regional office is satisfied about the bona fides of the applicant or about the truth of the facts relating to any of the matters mentioned above, one or more of the documents may be dispensed with.

(2) The following may be accepted as proof of age--
(a) certified extract from an official record of births showing the date and place of birth and father's name;
(b) original horoscope prepared soon after birth;
(c) certified extract from baptismal register;
(d) certified extract from school record showing the date of birth and father's name;
(e) such other evidence as may be acceptable to the appropriate Regional Office in the circumstances of a particular case.


81. Notice for dependants' benefit

On receipt of a claim or claims for dependants' benefit in respect of the death of an insured person and, after making such inquiries as may be necessary about the circumstances and cause of death and about all persons, who may be entitled to dependants' benefit, the appropriate regional office shall issue by registered post to such other persons, if any, as appear on enquiry to be entitled to dependants' benefit, and who have not yet submitted a claim for such benefit a notice for submission of claims for dependants' benefit within a period of thirty days from the date of such notice. The notice shall indicate inter alia the relevant provisions of the Act and regulations and the procedure for submission of a claim for dependents' benefit.


82. Intimation of decision regarding dependants' benefit

As soon as possible after the expiry of the period during which claims can be submitted in terms of the notice issued under regulation 81, the appropriate Regional Office shall intimate by registered post the decision of the Corporation in regard to the claim of each of the dependants in writing to the dependants concerned or to his legal representative, or, in the case of a minor, to his guardian.


83. Date of accrual of dependants' benefit

The dependant's benefit shall accrue from the date of the death in respect of which the benefit is payable, or, where disablement benefit was payable for that date from the date following the date of death.


83A. Submission of claims for periodical payments of dependants' benefit

Each dependant whose claim for dependants' benefit is admitted under regulation 82, shall submit to the appropriate local office, by post or otherwise, a claim covering, except in the case of first or a final payment, a period of one or more complete calendar months in Form 18A. Such claim may be made by the legal representative of a beneficiary or in the case of a minor by his guardian.


84. Review of dependants' benefit

(1) The amounts payable as dependants' benefit in respect of the death of any insured person may be reviewed by the appropriate regional office at its own initiative, and shall be so reviewed if an application is made to that effect, under any of the following circumstances--

(a) if any of the beneficiaries ceases to be entitled to the dependants' benefit by reason of marriage, re-marriage, death, age or otherwise, or
(b) if a fresh dependant is admitted to the claim for dependants' benefit by the birth of a posthumous child, or
(c) if, after the previous decision as to the distribution of the dependants' benefit was taken, some facts materially affecting such distribution come to light.

(2) Any review under this regulation shall be made after giving due notice by registered post to each of the dependants, stating therein the reasons for the proposed review and giving them an opportunity to submit objections, if any, to such review.

(3) Subject to the provisions of the Act and these regulations, the appropriate regional office may, as a result of such review, commence, continue, increase, reduce or discontinue from such date as it may decide the share of any of the dependants.

85. [Omitted]


86. Appointment of another guardian

If at any time the appropriate regional office is satisfied that a child who is in receipt of dependants' benefit is being neglected by his guardian, not being a guardian appointed under the Guardian and Wards Act, 1890; and the child's share of the dependants' benefit is not being properly spent on his or her maintenance, the appropriate regional office may direct that such share may be paid subject to such conditions as it may specify to such other person as it deems fit and as in its opinion would utilise it for the care and maintenance of the child.

MATERNITY BENEFIT

87. Notice of pregnancy

An insured woman, who decides to give notice of pregnancy before confinement, shall give such notice in Form 19 to the appropriate local office by post or otherwise and shall submit, together with such notice, a certificate of pregnancy in Form 20 given in accordance with these regulations on a date not earlier than seven days before the date on which such notice is given.


88. Claim for maternity benefit commencing before confinement

Every insured woman claiming maternity benefit before confinement shall submit to the appropriate local office by post or otherwise--

(i) a certificate of expected confinement in Form 21 given in accordance with these regulations, not earlier than fifteen days before the expected date of confinement;
(ii) a claim for maternity benefit in Form 22 stating therein the date on which she ceased or will cease to work for remuneration; and
(iii) within thirty days of the date on which her confinement takes place, a certificate of confinement in Form 23 given in accordance with these regulations.


89. Claim for maternity benefit only after confinement or for miscarriage

Every insured woman claiming maternity benefit for miscarriage shall within 30 days of the date of the miscarriage, and every insured woman claiming maternity benefit after confinement, shall submit to the appropriate office by post or otherwise a claim for maternity benefit in Form 22 together with a certificate of confinement or miscarriage in Form 23 given in accordance with these regulations.


89A. Claim for maternity benefit after the death of an insured woman leaving behind the child

For the purposes of the proviso to sub-section (2) of section 50 of the Act, the person nominated by the deceased insured woman on Form 1 or on such other Form as may be specified by the Director General in this behalf and if there is no such nominee, the legal representative, shall submit to the appropriate office by post or otherwise a claim for maternity benefit, as may be due, in Form 24-A within 30 days of the death of the insured woman together with a death certificate in Form 24B given in accordance with these Regulations.


89B. Claim for maternity benefit in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage 

(1) Every insured woman claiming maternity benefit in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage, shall submit to the appropriate office by post or otherwise a claim for benefit in one of the Forms 12A, 13A and 14A appropriate to the circumstances of the case together with the appropriate medical certificate in Form 8,9,10 or 11, as the case may be, given in accordance with the Regulations.

(2) The provisions of regulations 55 to 61 and 64 shall, so far as may be, apply in relation to a claim submitted and a certificate given in accordance with this regulation as they apply to certification and claims under those regulations.


90. Other evidence in lieu of a certificate 

The Corporation may accept any other evidence in lieu of a certificate of pregnancy, expected confinement, 
confinement death during maternity, miscarriage or sickness arising out of pregnancy, confinement, premature birth of child or misca rriage by an Insurance Medical Officer, if in its opinion, the circumstances of any particular case so justify.


91. Notice of work for remuneration 

Except as provided in regulation 89B every insured woman who has claimed maternity benefit shall give 
notice in Form 24 if she does work for remuneration on any day during the period for which maternity benefit would be payable to her but for her working for remuneration.


92. Date of payment of maternity benefit 

Maternity benefit shall be payable from the date from which it is claimed provided that such date does not precede the expected date of confinement by more than forty-two days, and that no work is undertaken by the insured woman for remuneration.


93. Disqualification for maternity benefit

An insured woman may be disqualified from receiving maternity benefit if she fails without good cause to 
attend for or to submit herself to medical examination when so required; and such disqualification shall be for such number of days as may be decided by the authority authorised by the Corporation in this behalf :

PROVIDED that a woman may refuse to be examined by other than a female doctor or midwife.


94. Authority which may issue certificate 

No certificate required under any of the regulations 87 to 89B shall be issued except by the insurance medical officer to whom the insured woman has or had been allotted or by an insurance medical officer attached to a dispensary, hospital, clinic or other institution to which the insured woman is or was allotted and such insurance medical officer shall examine and if in his opinion if the condition of the woman so justifies or in case of death of the insured woman or the death of the child, if satisfied about such death issue to such insured woman or in case of her death to her nominee or legal representative, as the case may be, free of charge any such certificate when reasonably required by such insured woman or her nominee or legal representative, as the case may be, under or for the purpose of the Act or any other enactment or these regulations :
PROVIDED that such Officer may issue a certificate, as aforesaid, under these regulations, to or in respect of an insured woman who is or was not allotted to him or to the dispensary, hospital, clinic or other institution to which such officer is attached, if such Officer is attending the woman for prenatal care, for confinement, for miscarriage or for sickness arising out of pregnancy, confinement, premature birth of child or miscarriage or in case of death, was attending the deceased insured woman or the child at the time of death of the insured woman or the child :

PROVIDED FURTHER that a certificate of pregnancy, of expected confinement, or confinement or miscarriage required under these regulations may be issued by a regis tered midwife which shall be accepted by the Corporation on counter-signatures by the Insurance Medical Officer :

PROVIDED that such Officer may issue a certificate of pregnancy, expected confinement or confinement under these regulations to an insured woman who is not allotted to him or to the dispensary, hospital, clinic or other institution to which such officer is attached, if such officer is attending the woman for prenatal care or for confinement :

PROVIDED FURTHER that a certificate of pregnancy, of expected confinement or of confinement required under these regulations may be issued by a registered midwife which shall be accepted by the Corporation on counter signature by the Insurance Medical Officer.


95. Obligations of insurance medical officer

Nothing in these regulations shall relieve an insurance medical officer to whom an insured woman has been allotted, or an insurance medical officer attached to the dispensary, hospital, clinic or other institution to which an insured woman is allotted of the obligation to examine and if in her opinion the condition of the woman so justifies, issue free of charge a certificate of pregnancy, of expected confinement, or confinement or miscarriage or sickness arising out of pregnancy, confinement, premature birth of a child or miscarriage during any period in which such insured woman is obtaining treatment or attendance from any other person or from any other hospital or institution.

MEDICAL BENEFIT TO FAMILIES

95A. Medical benefit to families of insured persons

(1) Medical benefit may be extended to the families of insured persons from such date as the Corporation may, in consultation with State Government, notify.

(2) The family of an insured person shall become entitled to medical benefit from the day the insured person himself becomes entitled to medical benefit and shall continue to be so entitled so long as the insured person is entitled to receive medical benefit for himself, or in the case of death of the insured person till such date up to which the insured person would have remained entitled to medical care, had he survived.

(3) The nature and scale of medical benefit to which the family of an insured person shall be entitled shall be such as may be specified by the State Government in consultation with the Corporation from time to time.

(4) The appropriate office shall arrange to prepare a family identity card for each insured person who is entitled to medical benefit for his family in Form 4A, and shall send all such identity cards to his employer. Such employer shall obtain the signature or thumb-impression of the employee on the family identity card and shall deliver the same to the employee and obtain a receipt therefor.

FUNERAL EXPENSES

95B. Report of death of insured person

In case of death of an insured person--

(a) if the death occurs at the place of employment, the employer shall, and
(b) if the death occurs at any other place, the person entitled and intending to claim funeral expenses shall, or
(c) any other person present at the time of death may, immediately report the death to the local office of the deceased insured person.


95C. Issue of death certificate

An insurance medical officer attending the insured person at the time of death or the insurance medical officer who examines the body after the death or the medical officer who attended the insured person in a hospital or other institution where such insured person died, shall issue free of charge a death certificate in Form 17 to the person entitled and intending to claim funeral expenses.


95D. Other evidence in lieu of a certificate 

The Corporation may accept any other evidence in lieu of a death certificate by Insurance Medical Officer if in its opinion, the circumstances of any particular case so justify.


95E. Submission of claim for funeral expenses 

(1) A claim to funeral expenses shall be submitted to the appropriate local office by post or otherwise in Form 25A by the claimant entitled under the Act and in case of a minor, by his guardian, and such claim shall be supported by documents proving--

(i) the death of the deceased person,
(ii) that the person claiming is the eldest surviving member of the family of the deceased insured person and incurred the expenditure necessary for the funeral of the deceased, or
(iii) in case the claimant is other than the eldest surviving member of the family--
(a) that the deceased insured person did not have a family or that the deceased insured person was not living with his family at the time of his death; and
(b) that the claimant actually incurred the expenditure claimed on the funeral of the deceased insured person :

PROVIDED that where the appropriate office is satisfied about the bona fides of the applicant or about the truth of the facts relating to any of the matters mentioned above, one or more of the documents may be dispensed with. 

(2) The following may be accepted as proof for purposes of clauses (ii) and (iii) of sub-regulation (1) of this regulation--

A declaration of the claimant duly countersigned by--
(i) an officer of the Revenue, Judicial or Magisterial Departments of Government; or
(ii) a Municipal Commissioner; or
(iii) a Workmen's Compensation Commissioner; or
(iv) the Head of Gram Panchayat under the official seal of the Panchayat; or
(v) the employers of the deceased insured person; or
(vi) any other evidence or declaration acceptable to the appropriate office in the circumstances of a particular case.





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APPLICABILITY OF THE ACT & SCHEME:

 Is extended in area-wise to factories using power and employing 10 or more persons and to non-power using manufacturing units and establish-ments employing 20 or more person upto Rs.15,000/- per month w.e.f. 01.04.10. It has also been extend-ed upon shops, hotels, restaurants, roads motor transport undertakings, equip-ment maintenance staff in the hospitals.

COVERAGE OF EMPLOYEES:

 Drawing wages Upto Rs.15,000/- per month Engaged either directly or thru’ contractor

RATE OF CONTRIBUTION OF THE WAGES:

 Employers’ 4.75%

 Employees’ 1.75%

MANNER AND TIME LIMIT FOR MAKING PAYMENT OF CONTRIBUTION:

 The total amount of contribution (employee’s share and employer’s share) is to be deposited with the authorized bank through a challan in the prescribed form in quadruplicate on ore before 21st of month following the calendar month in which the wages fall due.

BENEFITS TO THE EMPLOYEES UNDER THE ACT:

 Medical Benefit
 Sickness Benefit(SB)
 Maternity Benefit(MB)
 Disablement Benefit
 Dependants’ Benefit(DB)
 Funeral Expenses

 In addition, the scheme also provides some other need based benefits to insured workers.

WAGES FOR ESI CONTRIBUTIONS:

 Registers/files to be maintained by the employers

CONTRIBUTION PERIOD:

 If the person joined insurance employment for the first time, say on 5th January, his first contribution period will be from 5th January to 31st March and his corresponding first benefit will be from 5th October to 31st December.

TO BE DEEMED AS WAGES:

• Basic pay
• Dearness allowance
• House rent allowance
• City compensatory allowance
• Overtime wages (but not to be taken into account for determining the coverage of an employee)
• Payment for day of rest
• Production incentive
• Bonus other than statutory bonus
• Night shift allowance
• Heat, Gas & Dust allowance
• Payment for unsubstituted holidays
• Meal/food allowance
• Suspension allowance
• Lay off compensation
• Children education allowance (not being reimbursement for actual tuition fee)

NOT TO BE DEEMED AS WAGES:

• Contribution paid by kthe employer to any pension/provident fund or under ESI Act.
• Sum paid to defray special expenses entailed by the nature of employment – Daily allowance paid for the period spent on tour.
• Gratuity payable on discharge.
• Pay in lieu of notice of retrenchment compensation
• Benefits paid under the ESI Scheme.
• Encashment of leave
• Payment of Inam which does not form part of the terms of employment.
• Washing allowance for livery
• Conveyance Amount towards reimbursement for duty related journey

PENALTIES :

 Different punishment have been prescribed for different types of offences in terms of Section 85: (I) (six months imprisonment and fine Rs.5000), (ii) (one year imprisonment and fine), and 85-A: (five years imprisonment and not less to 2 years) and 85-C (2) of the ESI Act, which are self explanatory. Besides these provisions, action also can be taken under section 406 of the IPC in cases where an employer deducts contributions from the wages of his employees but does not pay the same to the corporation which amounts to criminal breach of trust.

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