Rules Relating To Disabilities Benefits Under ESI Act

Apart from the explanation and procedural part of Disabilities benefits, that yu can find here http://esisimplified.blogspot.in/2016/10/disability-benefits-under-esi.html, There are some rules to be kept in mind.

DISABLEMENT BENEFIT

Under Rule (ESI General Rules) 65. Notice of accident. — (i) Every employee 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 employee person may be given by some other person acting on his behalf.

Explanation. — No such notice shall be required to be given by an employee if an employment injury is caused by any Occupational Disease specified in the Third Schedule to the Act.

(ii)        Every such notice shall be given to the employer or to a foreman or to other official under whose supervision the employee 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 that purpose in accordance with the next following regulation shall, if made as soon as practicable after the happening of the accident by the employee 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)       Names, addresses and occupation of two persons who were present at the spot when acci-dent happened ; and

(h)      Remarks, if any.

Under Rule (ESI General Rules) 66.     Maintenance of accident book. — Every employer shall —

(i)          keep a book readily accessible (hereinafter called ‘ the Accident Book ’) in Form 11, in which the appropriate particulars of any accident causing personal injury to an employee 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 not be necessary to enter in the said Accident Book particulars of any employment injury caused by an Occupational Disease specified in the Third Schedule to the Act.

Provided further that the employer shall be deemed to have complied with this regulation sufficiently if in any register maintained by him, the appropriate particulars are also shown.

Under Rule (ESI General Rules) 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 obtain his signature or thumb impression on the Accident Book.

Under Rule (ESI General Rules) 68. Report of accident by an employer. — Every employer shall send a report in Form 12 to the appropriate Branch Office and to the Insurance Medical Officer of the insured person —

(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 48 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 employee 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 Branch Office shall be sent through a special messenger, or otherwise as speedily as may be practicable under the circumstances :

Provided further that if the accident does not involve absence of the employee from work initially, the employer may not send the report to the Branch Office and the Insurance Medical Officer but shall do so within 48 hours after the absence from work subsequently results from the injury.

Provided further that where a report of the accident is made by the employer under the Factories Act, 1948, the report to the Branch 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 12 is added thereto :

³[Provided further that it shall not be necessary for the employer to send a report in Form 12 if an employment injury is caused by an Occupational Disease specified in the Third Schedule to the Act ; but the employer shall furnish on demand to the appropriate Branch 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 the Third Schedule to the Act.

Under Rule (ESI General Rules) 69. Employer to arrange for 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.

Under Rule (ESI General Rules) 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.

Under Rule (ESI General Rules) 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.

Under Rule (ESI General Rules) 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 date 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, claim for permanent disablement is made on the basis thereof, by the appropriate Regional Office at the instance of the disabled person or the employer or any recognised employees’ 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 the 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.

Under Rule (ESI General Rules) 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.

Under Rule (ESI General Rules) 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.

Under Rule (ESI General Rules) 75.         Constitution of Medical Boards/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.

Under Rule (ESI General Rules) 76.    Medical Appeal Tribunals. — For the purposes of the Act, the State Government shall constitute as many Medical Appeal Tribunals as it thinks fit. Each such Medical Appeal Tribunal shall consist of such persons, exercise such jurisdiction and follow such procedure (save for the manner in which and the time within which the appeals may be filed as may be prescribed by rules framed by the Central Government under the Act) as the State Government in consultation with the Corporation may, from time to time, decide. Notwithstanding the amendments hereby made, all appeals pending before the Appeal Tribunals at the date of coming into force of the provisions of the Act relating to Medical Appeal Tribunals shall be disposed of by the Appeal Tribunals.

Under Rule (ESI General Rules) 76-A. Submission of claims for permanent disablement. — An insured person who has been declared to be permanently disabled by a Medical Board or by a Medical Appeal Tribunal or an Employees’ Insurance Court shall submit, by post or otherwise, to the appropriate Branch Office a claim, covering, except in the case of a first payment, a period of one or more complete calendar months in Form 14 for claiming permanent disablement benefit.

Under Rule (ESI General Rules) 76-B. 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 ’’, permanent disablement benefit shall be commuted into a lump sum.

(3)        Where such an application is made after the expiry of 6 months from the date of possible option, permanent disablement benefit] may be commuted into a 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 of any other insured person, the date on which assessment of permanent dis-ablement covered by sub-regulation (1), is communicated to him by the appropriate Re-gional 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 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 to the Medical Board.

Procedure of Making an ESI Claim

Claim for benefits. — Every claim for a benefit payable under the Act shall be made in writing, in accordance with these regulations, to the appropriate Branch 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 Branch Offices of the Corporation. When claim becomes due. — A claim for any benefit under the Act shall for the purposes of section 77 of the Act, becomes due on the following days : — (a)  for sickness benefit or for disablement benefit for temporary disablement for any period, on the date of 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 the certificate of expected 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 on which an insured person is declared as permanently disabled in accordance with the Act and these regulations ;
 (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 dependants’ benefit, on the last day of the month to which the claim relates ; and
 (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.

Availability of claims 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 that purpose, and shall be supplied free of charge.
 Claims 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 appropriateform. 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.
 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.
 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.
 Authority for certifying eligibility of claimants. — The authority which is to certify eligibility of claimants shall be the appropriate Branch Office in respect of sickness, maternity, temporary disablement benefits and funeral expenses and the appropriate Regional Office, in respect of permanent disablement and dependants’ benefits.
 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 the 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 dependant’s benefit not later than three months ;
 After the claim therefor together with the relevant medical or other certificates and any other documentary evidence which may be called for under these regulations has been furnished complete in all particulars to the appropriate office. (2) Second and subsequent payments in respect of any maternity, temporary disablement, permanent disablement or dependants’ 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 Branch 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. Provided further that the Director-General may decide that in respect of certain areas/pay offices as may be specified by him from time to time, the payments shall be remitted through money order also at the cost of the Corporation subject to such restrictions as may be imposed by the Director-General from time to time. (5) Where the payment of a benefit is to be made at a Branch 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. 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 10 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 10 and within such time as the said office may in writing require in the said form.