Executive Summary:
This notification from the Employees' State Insurance Corporation (ESIC) announces an amendment to the Employees' State Insurance General Regulations, 1950, specifically regarding regulation 96C. This regulation concerns referrals for super-speciality treatment to tie-up hospitals and the direct expenditure incurred by ESIC. It defines eligibility criteria based on the duration of insurable employment and contribution periods. The notification was issued on April 15, 2019, and is effective immediately.
Key Points / Main Content:
Super Speciality Treatment Referral:
* ESIC or the State Government may refer a beneficiary to tie-up medical facilities for super-speciality treatment, with costs borne directly by ESIC, contingent on fund availability.
Insured Person Eligibility:
* An Insured Person requires a minimum of six months of insurable employment from registration and contribution for at least 78 days in the relevant contribution period, including the registration period.
Family Member Eligibility:
* For family members to be eligible, the Insured Person needs a minimum of one year of insurable employment and contributions for at least 78 days in each of the two contribution periods. Benefits are available in the corresponding benefit period.
Exceptions to Contributory Conditions:
* Insured Persons with employment injury, Insured Women with maternity complications, or those receiving extended sickness benefits are eligible as per relevant contributory conditions.
* Families of extended sickness beneficiaries are eligible as long as the benefit period corresponds to a contribution period covered by extended sickness for more than half the contribution period.
Impact Analysis:
Insured Persons and their Families:
* Impact: Defines eligibility criteria for accessing super-speciality treatments at tie-up hospitals, affecting access to healthcare benefits.
* Action Required: Insured Persons need to ensure they meet the minimum employment and contribution requirements to be eligible for referrals and that they are aware of the additional condition to meet requirements for their family to be eligible.
Employees' State Insurance Corporation (ESIC):
* Impact: Requires ESIC to manage and administer the referral process and directly bear the costs of super-speciality treatments at tie-up hospitals.
* Action Required: ESIC needs to implement the amended regulation, manage funds, and establish processes for referrals and direct payments.
State Governments:
* Impact: May be involved in referring beneficiaries to tie-up medical facilities.
* Action Required: State Governments may need to coordinate with ESIC and establish referral processes as per the amended regulation.
Tie-up Hospitals:
* Impact: May receive referrals from ESIC for super-speciality treatments, with costs covered directly by ESIC.
* Action Required: Tie-up Hospitals may need to coordinate with ESIC on billing and treatment protocols.
Key Entities Referenced
Employees State Insurance Corporation: A statutory body responsible for administering the Employees' State Insurance scheme in India, as mentioned throughout the document.
Employees State Insurance General Regulations, 1950: A set of regulations governing the Employees' State Insurance scheme, frequently referenced in the document as being amended.
New Delhi: The city where the notification was issued, indicating the location of the relevant authority.
Employees State Insurance Act, 1948: The primary legislation governing the Employees' State Insurance scheme, providing the legal basis for the regulations and amendments.
Gazette of India: The official government publication in which the notification and draft regulations were published.
Regulation 96C: The specific regulation being added to the Employees' State Insurance General Regulations, 1950, concerning referral for super speciality treatment.
State Government: Refers to the government of a State in India, mentioned in the context of referring beneficiaries to medical facilities.
S. RAVICHANDRAN: Additional Commissioner, the signatory of the notification.
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2648GI/2019 (1)2 THE GAZETTE OF INDIA : EXTRAORDINARY [PART III—SEC. 4]
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[िव(cid:14)ापन-III/4/असा./59/19]
EMPLOYEES’ STATE INSURANCE CORPORATION
NOTIFICATION
New Delhi, the 15th April, 2019
No. N-12/13/1/2016-P&D.—WHEREAS the draft regulation 96C to the Employees’ State Insurance (General)
Regulation, 1950 were issued on 26th November, 2018 vide notification No.470 dated 6th December, 2018 in the Gazette
of India, Extraordinary Part III Section 4, objections and suggestions were called by the Employees’ State Insurance
Corporation.
And WHEREAS The said Gazette Notification was made available to the public on 06.12.2018 vide
notification No.470 dated 6th December, 2018 in the Gazette of India, Extraordinary Part III Section 4.
And WHEREAS objections and suggestions were received and the same has been examined and addressed. The
necessary amendment is being incorporated as proviso to the Regulation.
Now, THEREFORE, in exercise of the power conferred by Section 97 Sub Section 1 of the Employees’ State
Insurance Act, 1948 (34 of 1948), the Employees' State Insurance Corporation, do hereby notify Regulation 96C further
to amend the Employees' State Insurance (General) Regulations, 1950, and is hereby published under section 59A of the
said Act.
REGULATION
In the Employees’ State Insurance (General) Regulations, 1950, a new Regulations 96C shall be inserted as
under :
REGULATION REFERRAL FOR SUPER SPECIALITY TREATEMENT TO TIE-UP HOSPITALS AND
96C EXPENDITURE TO BE INCURRED BY EMPLOYEES’ STATE INUSRANCE
CORPORATION DIRECTLY
Subject to the provisions of the Act and the Regulations, the Corporation or State Government may refer a beneficiary to
any tie-up arranged medical facilities, where cost of such facility is borne directly by the Corporation and where the fund
permits; an Insured Person should have completed a minimum of six months of insurable employment from the date of
registration and have contributed not less than seventy eight (78) days in the relevant contribution period including in
which registration was made. However, where the facility has been extended to his family members, an Insured Person
should have completed a minimum of one year of insurable employment and have contributed for not less than seventy
eight (78) days in each of the two (2) contribution period and such benefit shall be available to an Insured Person or a
beneficiary in the corresponding benefit period.
Provided further that an Insured Person with employment injury or Insured Woman with complications arising out of
maternity or those in receipt of extended sickness benefit under the Act shall be eligible as per the relevant contributory
conditions and in case of family of extended sickness beneficiaries, they shall also be eligible as long as the benefit
period corresponding to contribution period covered in extended sickness by more than half of the contribution period.
S. RAVICHANDRAN, Addl. Commissioner (P&D)
[ADVT.-III/4/Exty./59/19]
Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064
and Published by the Controller of Publications, Delhi-110054.