Condition (A)
Insured Person should have contributed for not
less than 78 days during the corresponding contribution period and should thus
be eligible for sickness benefit, during the relevant benefit period
(in which
the spell of sickness requiring speciality treatment falls)
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Illustration (A) |
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Contribution Status |
Eligibility |
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Contributed for 80 days during contribution period from 1.10.03 to
31.3.04 |
YES
for spell of sickness falling in benefit period from 1.7.04 to 31.12.04,
since Sickness Benefit is admissible during the period. |
|
contributed 76 days during the above period |
NO for
spell of sickness falling in the above period, since
Sickness Benefit is not admissible during the period. |
ESI Corporation may relax the condition in
highly deserving cases, depending on the contribution history, circumstances of
sickness, continuing treatment, if any, and other indispensable factors.
Condition (B)
In the case of a new entrant (into insurable
employment), insured person and/or his family will not be eligible for
speciality / super speciality treatment , till start of first benefit period
irrespective of payment of contribution for not less than 78 days in the relevant
/current contribution period
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Illustration (A) |
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Contribution Status |
Eligibility |
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Contributed for 79 days in the first contribution period from 01.01.04
to 31.3.04 (date of entry into insurable employment being 01.01.04) |
NO till
30.9.04 since benefit period starts from 1.10.04
only. (Normal OP/IP medical facilities will however be available
for insured person / family from 01.01.04 itself) |
|
-do-
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YES for
spell of sickness falling in benefit period from 1.10.94 to 31.12.04. |
Condition (C)
All arising cases including emergent /
outstation cases, are subject to medical/specialist opinion by ESI Hospital and
confirmation of title to medical benefit by ESI Corporation.
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Odd man out
Beneficiaries
covered by medical scheme under Rule 60 & 61 of the ESI (Central) Rules 1950 are
not eligible for speciality/ super speciality facilities, since they do not
qualify for Sickness Benefit at any stage. |
|
Family of a deceased
insured person, who is not entitled for sickness benefit at the time of
death, is not eligible for speciality / super speciality treatment.
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