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Medical Benefit 
Super speciality treatment 

Qualifying conditions for speciality/super speciality treatment


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)

Illustration (A)  
Contribution Status Eligibility
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

Illustration (A)  
Contribution Status Eligibility
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-

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.

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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