CHAPTER IV MISCELLANEOUS


CHAPTER IV MISCELLANEOUS

96. Authority for determining benefits

The authority for determining for purposes of sub-section (2) of section 70 of the Act, the value of benefits other than cash payment shall be the Medical Commissioner of the Corporation.


96A. Reimbursement of expenses incurred in respect of medical treatment

Claims for reimbursement of expenses incurred in respect of medical treatment of insured person and (where such medical benefit is extended to his family) his family may be accepted in circumstances and subject to such conditions as the Corporation may by general or special order specify.


97. Discontinuation or reduction of benefits

An employer may discontinue or reduce benefits payable to his employees under conditions of their service which are similar to the benefits conferred by the Act to the extent specified below, namely--
(a) from the date of the commencement of the first benefit period following the appointed day for his factory or establishment--
(i) sick leave on half pay to the full extent;
(ii) such proportion of any combined general purposes and sick leave on half pay as may be assigned as sick leave but in any case not exceeding 50 per cent of such combined leave;
(b) any maternity benefits granted to women employees to the extent to which such women employees may become entitled to the maternity benefit under the Act :

PROVIDED that where an employee avails himself of any leave from the employer for sickness, maternity or temporary disablement, the employer shall be entitled to deduct from the leave salary of the employee the amount of benefit to which he may be entitled under the Act for the corresponding period.


98. Discharge, etc. of employee under certain conditions

If the conditions of service of any employee so allow, an employer may discharge or reduce on due notice an employee--

(i) who has been in receipt of disablement benefit for temporary disablement, after he has been in receipt of such benefit for a continuous period of six months or more;

(ii) who has been under medical treatment for sickness other than tuberculosis, leprosy, mental and malignant diseases or has been absent from work as a result of illness duly certified in accordance with these regulations to arise out of the pregnancy or confinement rendering the employee unfit for work, after the employee has been under such treatment or has been absent from work for a continuous period of six months or more;

(iii) who has been under medical treatment for any of the following diseases, duly certified in accordance with these regulations, after the employee has been under such treatment for a continuous period of 18 months or more, notwithstanding provisions of clauses (i) and (ii) :

DISEASES
I. Infectious Diseases
1. Tuberculosis
2. Leprosy
3. Chronic Empyema
4. Bronchiactesis
5. Interstitial Lung Disease
6. Aids

II. Neoplasms
7. Maligant Diseases

III. Endocrine Nutritional and Metabolic Disorders
8. Diabetes mellitus with proliferative retinopathy/diabetic foot/nephropathy

IV. Disorders of Nervous System
9. Monoplegia
10. Hemiplegia
11. Paraplegia
12. Hemiparesis
13. Intracranial Space Occupying Lesion
14. Parkinson's disease
15. Spinal Cord Compression
16. Myaesthenia Gravis/Neuromuscular Dystrophies

V. Diseases Of Eye
17. Immature Cataract with vision 6/6 or less
18. Detachment of Retina
19. Glaucoma

VI. Diseases of Cardiovascular System
20. Coronary Artery Disease
(a) Unstable Angina
(b) Myocardial infraction with ejection less than 45%
21. Congestive Heart Failure:
22. Cardiac Valvular Diseases with failure/complications
23. Cardiomyopathies
24. Heart Disease with Surgical Intervention along with complications

VII. Chest Diseases
25. Chronic Obstructive Lung Disease (COPD) with congestive heart failure (Cor Pulmonale)

VIII. Diseases of the Digestive System
26. Cirrhosis of liver with ascities/chronic active hepatitis

IX. Orthopaedic Diseases
27. Dislocation of vertebra/prolapse of intervertebral disc
28. Non-union or delayed union of fracture
29. Post Traumatic Surgical amputation of lower extremity
30. Compound fracture with chronic osteomyelitis

X. Psychoses
31. Sub-group under this are listed for clarification
(a) Schizophrenia
(b) Endogenous depression
(c) Manic Depressive psychosis (MDF)
(d) Dementia

XI. Others
32. More than 20% burns with infection/complication
Chronic Renal Failure
34. Reynaud's disease/Burger's disease.


99. Suspension of sickness or temporary disablement benefit

Sickness benefit or disablement benefit for temporary disablement may be suspended, if a person who is in receipt of such benefit fails to comply with any of the requirements of section 64 of the Act, and such suspension shall be for such number of days as may be decided by the authority authorised by the Director-General in this behalf.


99A. Sickness or temporary disablement benefit during strike

No person shall be entitled to sickness benefit or disablement benefit for temporary disablement on any day on which he remains on strike except in the following circumstances--

(i) if a person is receiving medical treatment and attendance as an indoor patient in any Employees' State Insurance Hospital or a hospital recognised by the Employees' State Insurance Corporation for such treatment; or

(ii) if a person is entitled to receive extended sickness benefit for any of the diseases for which such benefit is admissible; or

(iii) if a person is in receipt of sickness benefit or disablement benefit for temporary disablement immediately preceding the date of commencement of notice of the strike given by the employees' Union(s) to the management of the factory/establishment.

(iv) If an insured person/insured woman has undergone operation on account of vasectomy/tubectomy, he/she shall be entitled to enhanced sickness benefit on any day on which he/she remains on leave during the period of strike or remains on leave, or on holiday for which he/she receives wages.


100. Relaxation

The Director-General may by special or general order relax any regulation under such circumstances and subject to such conditions, as he may deem fit.


101. [Omitted]


102. Certain officers to have powers of inspection

 



The Director-General, the Insurance Commissioner, the Joint Insurance Commissioner, a Deputy Insurance Commissioner, a Regional Director, a Deputy Regional Director, an Assistant Insurance Commissioner, and Assistant Regional Director and a Local Office Manager shall have all the powers of an Inspector specified in sub-sec. (2) of sec. 45 of the Act. In addition to the officers mentioned above, the Director General may, by a written order, confer upon any employee of the Corporation or any government officer the powers of an inspector for such period or periods as he may think fit.


102A. Inspection book

(i) Every principal employer shall maintain a bound inspection book and shall be responsible for its production, on demand by an inspector or any other officer of the Corporation duly authorised to exercise the powers of an Inspector irrespective of the fact whether the principal employer is present in the factory or establishment or not during the inspection.

(ii) A note of all irregularities and illegalities discovered at the time of inspection indicating therein the action, if any, proposed to be taken against the principal employer together with the orders for their remedy or removal passed by an inspector or any other officer of the Corporation duly authorised to exercise the powers of an inspector, shall be sent to the principal employer who shall enter the note and orders in the inspection book.

(iii) Every principal employer shall preserve the inspection book maintained under this regulation, after it is filled, for a period of 5 years from the date of the last entry therein.


103. Medical benefit during disablement

A person who is in receipt of disablement benefit shall be entitled to medical benefit while he is in receipt of such benefit :

PROVIDED that after the disablement has been declared as a permanent disablement, the person shall not be entitled to medical benefit, if he is not otherwise entitled to such benefit, except, in respect of any medical treatment which may be rendered necessary on account of the employment injury from which the disablement resulted.


103A. Medical benefit after contribution ceases to be payable

(1) A person on becoming an insured person for the first time shall be entitled to medical benefit for a period of 3 months provided that where such a person continues for 3 months or more to be an employee of a factory or establishment to which the Act applies, he shall be entitled to medical benefit till the beginning of the corresponding benefit period.

(2) The person in respect of whom contributions have been paid in a contribution period for not less than half the number of days in the said contribution period shall be entitled to medical benefit till the end of the corresponding benefit period:

PROVIDED that in case of a person who becomes an employee within the meaning of the Act, for the first time, and for whom a shorter contribution period of less than 156 days is available, he shall be entitled to medical benefit till the end of the corresponding benefit period if the contributions in respect of him were payable for not less than half the number of days available for working in such contribution period:

PROVIDED FURTHER that where a person suffering from any of the following diseases, before the commencement of the spell of sickness in which any such disease was diagnosed being in continuous service for a period of two years or more or where he did not have two years continuous service but by virtue of relaxation granted by the authority competent in this behalf, the insured person qualifies to claim extended Sickness benefit, he shall be entitled to Medical Benefit till the end of the relevant extended benefit period:

I. Infectious Diseases
1. Tuberculosis
2. Leprosy
3. Chronic Empyema
4. Bronchiactesis
5. Interstitial Lung Disease
6. Aids

II. Neoplasms
7. Maligant Diseases

III. Endocrine Nutritional and Metabolic Disorders
8. Diabetes mellitus with proliferative retinopathy/diabetic foot/nephropathy

IV. Disorders of Nervous System
9. Monoplegia
10. Hemiplegia
11. Paraplegia
12. Hemiparesis
13. Intracranial Space Occupying Lesion
14. Parkinson's disease
15. Spinal Cord Compression
16. Myaesthenia Gravis/Neuromuscular Dystrophies

V. Diseases Of Eye
17. Immature Cataract with vision 6/6 or less
18. Detachment of Retina
19. Glaucoma

VI. Diseases of Cardiovascular System
20. Coronary Artery Disease
(a) Unstable Angina
(b) Myocardial infraction with ejection less than 45%
21. Congestive Heart Failure:
22. Cardiac Valvular Diseases with failure/complications
23. Cardiomyopathies
24. Heart Disease with Surgical Intervention along with complications

VII. Chest Diseases
25. Chronic Obstructive Lung Disease (COPD) with congestive heart failure (Cor Pulmonale)

VIII. Diseases of the Digestive System
26. Cirrhosis of liver with ascities/chronic active hepatitis

IX. Orthopaedic Diseases
27. Dislocation of vertebra/prolapse of intervertebral disc
28. Non-union or delayed union of fracture
29. Post Traumatic Surgical amputation of lower extremity
30. Compound fracture with chronic osteomyelitis

X. Psychoses
31. Sub-group under this are listed for clarification
(a) Schizophrenia
(b) Endogenous depression
(c) Manic Depressive psychosis (MDF)
(d) Dementia

XI. Others
32. More than 20% burns with infection/complication
Chronic Renal Failure
34. Reynaud's disease/Burger's disease.

(3) An insured person, whose title to medical benefit has ceased under this regulation shall agian be entitled to medical benefit from the date of his re-employment as an employee under the Act by a factory or establishment to which the Act applies, if he produces a certificate from the employer in the form which may be specified by the Director-General for the purposes, such an insured person shall, unless he is covered by sub-regulation (2), be entitled to medical benefit till the commencement of the benefit period corresponding to the contribution period in which he is re-employed.

(4) An employer shall, on demand, issued the certificate referred to in sub-regulation (3) to an employee who has been employed by him after cessation of his previous insurable employment.


103B. Medical benefit to insured person who ceases to be in insurable employment on account of permanent disablement 

(1) An insured person who ceases to be in insurable employment on account of permanent disablement caused due to employment injury shall continue to receive medical benefit for himself and his/her spouse till the date on which he would have vacated the employment on attaining the age of superannuation had he not sustained such permanent disablement, if produces a certificate from the employer/a declaration in the form which may be specified by the Director-General for the purpose.

(2) Medical benefit to retired insured persons--An insured person who has attained the age of superannuation shall be eligible to receive medical benefit for himself and his/her spouse, if he produces a certificate from the employer in the form which may be specified by the Director-General for the purpose.

(3) An employer shall, on demand, issue the certificate as referred to in sub-regulations (1) and (2) to an employee who had been employed by him.


104. Production of document for medical benefit

A person intending to claim medical benefit, and who is otherwise entitled to such benefit, shall produce his identity card or such other document as may have been issued in lieu thereof at the time of claiming such benefit if demanded by the insurance medical officer and if he fails to do so medical benefit may be refused to him.


105. Further certificates

Where any question arises as to the correctness of any certificate by virtue of which an insured person claims, or is entitled to, any benefit under the Acts, he shall, on being so required in writing or otherwise by the appropriate office submit himself, with a view to obtaining a further certificate, to medical examination by such medical authority as the Corporation may appoint in this behalf. if the further certificate specifies the date on which the insured person is or will be fit to resume work, any certificate which is or has been issued by the insurance medical officer for the same spell of incapacity shall, to the extent to which it relates to any period after and including the said date on the further certificate, be deemed not to have been issued in accordance with these regulations and such further certificate shall, notwithstanding anything contained in these regulations, be deemed to be a final certificate issued under regulations 58 and 60.
Notwithstanding anything contained in these regulations, such further certificate in so far as it relates to sickness or temporary disablement, may be issued at such interval and in respect of such periods as may be specified by such medical authority.


106. Change of circumstances to be notified

Every person to whom any benefit is payable under the Act shall, as soon as may be practicable, notify the appropriate office of any change of circumstance which he may be expected to know and which might affect the continuance of his right to receipt of such benefit.


107. Certificate in respect of a person claiming permanent disablement benefit

Every person whose claim for any permanent disablement benefit has been admitted shall submit at six-monthly intervals, with the claim for December and June every year, a certificate in Form 26 attested by such authority or persons and in such manner as may be specified by the Director-General.


107A. Declaration by and certificate in respect of a person claiming dependants' benefit

Every person whose claim for any dependants' benefit has been admitted shall submit at six-monthly intervals, with the claim for December and June every year, a declaration and a certificate in Form 27 attested by such authority or person and in such manner as may be specified by the Director-General.


107B. Personal attendance of a person claiming permanent disablement benefit or dependants' benefit

In the case of claimant for permanent disablement benefit or dependants' benefit, the appropriate local office manager may require personal attendance and due identification of any claimant, other than a person incapacitated by bodily illness or infirmity or a purdanashin lady at the appropriate Local Office or at any other office of the Corporation provided that such appearance shall not be required more frequently than once in every six months.

108 . [Omitted w.e.f. 15-6-1991]


109. Submission of additional information by employer or insured person

Employer or insured person, as the case may be, shall, on demand from the appropriate office submit information in such form as may be specified by Director General.


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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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