Tuesday, 11 October 2016

Rules Relating to Dependents, Medical, Maternity and Funeral Benefits under ESI

DEPENDANTS’ BENEFIT

Rule (ESI GENERAL RULES) 77. Report of death of employee by employment injury.— In case of death of an employee 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 Branch Office and to the nearest dispensary, hospital, clinic or other institution where medical benefit under the Act is available.

Rule (ESI GENERAL RULES) 78. Disposal of body of an employee dying by employment injury. — Where an employee dies as a result of an employment injury sustained as an employee under the Act, the body of the employee 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).

Rule (ESI GENERAL RULES) 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 died, shall issue free of charge a death certificate in Form 13 to the dependants of the deceased and shall send a report to the appropriate Regional Office.

Rule (ESI GENERAL RULES) 80.     Submission of claim for dependants’ benefit. — (1) A claim for dependants’ benefit shall be submitted to the appropriate Branch Office by post otherwise in Form 15 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 dependent 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 cir-cumstances of a particular case.

Rule (ESI GENERAL RULES) 81.     Notice for dependants’ benefit. — On receipt of a claim or claims for dependants’ benefit in respect of the death of an employee and, after making such enquiries 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 dependants’ benefit.


Rule (ESI GENERAL RULES) 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 dependant concerned or to his legal representative, or, in the case of a minor, to his guardian.

Rule (ESI GENERAL RULES) 83. Date of accrual of dependants’ benefit. — The dependants’ benefit shall accrue from the date of the death in respect of which the benefit is payable or, where disablement benefit was payable or where wages were payable for that date from the date following the date of death.

Rule (ESI GENERAL RULES) 83-A. 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 Branch 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 16. Such claim may be made by the legal representative of a beneficiary or in the case of a minor, by his guardian.


Rule (ESI GENERAL RULES) 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 child.

MATERNITY BENEFIT

Rule (ESI GENERAL RULES) 87.     Notice of pregnancy. — An insured woman, who decides to give notice of pregnancy before confinement, shall give such notice in Form 17 to the appropriate Branch Office, by post or otherwise and shall submit, together with such notice, a certificate of pregnancy in Form 17 given in accordance with these regulations on a date not earlier than seven days before the date on which such notice is given.

Rule (ESI GENERAL RULES) 88.     Claim for maternity benefit commencing before confinement. — Every insured woman claiming maternity benefit before confinement shall submit to the appropriate Branch Office by post or otherwise —

(i)          a certificate of expected confinement in Form 18 given in accordance with these regulations, not earlier than fifty days before the expected date of confinement ;
(ii)           a claim for maternity benefit in Form 19 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 con-finement in Form 18 given in accordance with these regulations.

Rule (ESI GENERAL RULES) 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 19 together with a certificate of confinement or miscarriage in Form 18 given in accordance with these regulations.

Rule (ESI GENERAL RULES) 89-A. 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 20 within 30 days of the death of the insured woman together with a death certificate in Form 21 given in accordance with those regulations.

Rule (ESI GENERAL RULES) 89-B. 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 Form 9 appropriate to the circumstances of


the case together with the appropriate medical certificate in Form 7 or 8 as the case may be, given in accordance with these regulations.

(2) The provision 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 these regulations.

Rule (ESI GENERAL RULES) 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 miscarriage by an Insurance Medical Officer, if in its opinion, the circumstances of any particular case so justify.

Rule (ESI GENERAL RULES) 91.     Notice of work for remuneration. — Except as provided in Regulation 89-B every insured woman who has claimed maternity benefit shall give notice in Form 19 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.

Rule (ESI GENERAL RULES) 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.

Rule (ESI GENERAL RULES) 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.

Rule (ESI GENERAL RULES) 94. Authority which may issue certificate. — No certificate required under any of the Regulations 87 to 89-B 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 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 purposes 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 pre-natal 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 the death of the insured woman or the child :

Provided further that a certificate of pregnancy, of expected confinement, of confinement or miscarriage required under these regulations may be issued by a registered mid-wife which shall be accepted by the Corporation on countersignature by the Insurance Medical Officer.

Rule (ESI GENERAL RULES) 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 his opinion, the condition of the woman so justifies, issue free of charge a certificate of pregnancy, of expected confinement, of confinement or miscarriage or of a 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



Rule (ESI GENERAL RULES) 95-A. 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 upto 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 add in Form 4, Form 4-A, the particulars of the family entitled to medical benefits.


FUNERAL EXPENSES

Rule (ESI GENERAL RULES) 95-B. 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 (sic.) may, immediately, report the death to the Branch Office of the deceased insured person.

Rule (ESI GENERAL RULES) 95- C. 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 13 to the person entitled and intending to claim funeral expenses.

Rule (ESI GENERAL RULES) 95 -D. 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.

Rule (ESI GENERAL RULES) 95-E. Submission of claim for Funeral Expenses. — (1) A claim to funeral expenses shall be submitted to the appropriate Branch Office by post or otherwise in Form 22 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 employer of the deceased insured person ; or

(vi)          9 member of the Regional Board ; or

(vii)         A member of Local Committee ; or

(viii)          An official of the Trade Union ; or

(ix)         An Insurance Medical Officer or Insurance Medical Practitioner.


(b)        Any other evidence or declaration acceptable to the appropriate office in the circumstances of a particular case. 

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