ALL INDIA ESIC PENSIONERS' FEDERATION

1402 SECTOR 8 , FARIDABAD 121006 INDIA

 
 

 

ESIC PENSIONERS MEDICAL SCHEME

PENSIONERS MEDICAL SCHEME came into force wef 01.04.2006. After the meeting of the standing committee held on 31.01.2007consolidated clarifications were issued by the HQ vide letter no D-12-16-1-03-E-IV dated 01.03.2007. Important clarification are given below:-
1.Rates of monthly contribution to the scheme:-
(i) Grade pay upto 1650/-PM                                                                                                                        Cont. 50/- PM
(ii)Grade pay of 1800/-,1900/-,2000/-2400/- & 2800/-                                                                       Cont. 125/-PM
(iii)Grade pay of 4200/- PM                                                                                                                           Cont.225/-PM
(iv)Grade pay 4600/-,4800/-,5400/-& 6600/-                                                                                        Cont.325/-PM
(v)Grade pay 7600/-and above                                                                                                                   Cont.500/-PM
                    Pensioner has the choice to make the contribution on an annual basis or by making the contribution for 10 (Ten) years for getting the life time validity of ESIC Medical Card. A pensioner who has contributed for certain years under old/new PMS wants to become life member shall have to pay only for the balance years (10-years for which already paid). Contribution is on the basis of last pay drawn.Cont. can be paid in Regional Office/Branch Offices(HQ letter no.D-12/16/1/2003-E VI  dated 05.08.2008)

Entitlement of wards in Private Hospitals empaneled under ESIC

Pay Drawn in Pay Band upto Rs. 13950/-                                                                                                 General Ward
                                                   Rs 13960 to 19530/-                                                                                  Semi Private ward
                                                   Rs  19540/- and above                                                                              Private Ward.
Reference to PAY relates to the pay drawn in the pay band.
PENSIONERS WHO HAVE PAID IN LUMP SUM SHALL NOT NEED TO PAY ANY ARREARS IN CASE THE CONTRIBUTION IS REVISED AT LATER DATE
PENSIONERS JOING AFTER 6 MONTHS OF THE RETIREMENT SHALL BE ENTITLED TO SUPER SPECIALITY TREATMENT AFTER A WAITING PERIOD OF 6(SIX)MONTHS FROM THE DATE OF JOINING.
EXTENT OF TREATMENT
HQ HAS CLARIFIED THAT PENSIONER WHO ARE MEMBERS OF THE SCHEME ARE ENTITLED TO ALL KIND OF THE TREATMENT WHICH ARE ADMISSIBLE TO THE SERVING EMPLOYEES.THEY ARE ALSO ENTITLED TO SUPERFICIALITY TREATMENT FROM THE TIE UP HOSPITALS FOR THE INSURED PERSONS.REIMBURSEMENT UNDER THE SCHEME SHALL BE RESTRICTED TO THE RATES AS ACTUALLY CHARGED BY THE RECOGNISED INSTITUTION/RATES PRESCRIBED BY THE CGHS/CSMA AS THE CASE MAY BE OR THE RATES AT WHICH THE NODAL OFFICER HAS ENTERED INTO AN AGREEMENT WITH SUCH INSTITUTION,WHICHEVER IS LESS.
APPOINTMENT OF THE NODAL OFFICERS;-
Regional Directors/Jt.Directors I/Cs of the SROs shall be nodal officers for reference to the other approved hospitals,in case such facilities are not available in ESI hospitals/Govt.Hospitals on the basis of certificate from such hospital.System of approaching nodal officer before admission is to ensure necessary checks and proper accounting.In cases of emergency the pensioner can directly go to the medical institution bypassing the nodal officer for which he shall grant relaxations.As far as possible nodal officer should permit the pensioners to avail treatment from recognized institution of the pensioner's choice.
TREATMENT AT OTHER PLACES THAN PENSIONER'S RESIDENCE
Pensioner may inform the nodal officer about his tour and get proper authorisation. The nodal officer shall forward such request /intimation received from the pensioner to the nodal officer of the area where the pensioner is likly to be on tour and respective nodal officer shall permit the treatment through recognized institution. In emergency treatment even while on tour the provision of relaxation exists.
WHERE TO MAKE CONTRIBUTION OF PMS?
PAYMENT OF THE CONTRIBUTION CAN BE MADE AT REGIONAL OFFICE OR THE BRANCH OFFICES AS THE CASE MAY BE.
MIGRATION
The PERMISSION CAN BE GRANTED IN CONSULTATION BETWEEN THE RESPECTIVE NODAL OFFICERS
APPOINTMENT OF THE AMAs.
All the AMAs providing medical treatment to the serving employees are also recognised for the purpose of Pensioner' Medical Scheme. In the event of scheme being misused by pensioner he shall be debarred from the membership of the scheme.Under the rules the pensioners are entitled to take treatment only from an ESIC Dispensary/hospital in the first instance wherever it is available. Consultation with AMA is not permissible even if he is available within such radius.

REVISED GUIDELINES OF ESIC- PMS 2006 DATED 21.05.2021

 

 

,

EMPLOYEES‘  STATE INSURANCE CORPORATION

-      -    •   -    (Ministry of Labc›ur & Employment, Govt. of India)

  1. No: D-12/16/1/2012-E-VI.Vol.II

MEMORANDUM

 

/HEADQUARTER

j          -110002

Panchdeep Bhawan, CIG Marg, New Delhi- 110002

Phone: 011-23234092, VOIP: 10011067

Website: www.esic.nic.in / www.esic.in

Dated:   25 May, 2021

 

 

Revised guidelines relating to implementation of ESIC Pensioner Medical Scheme- 2006.

Subject :

The ESIC- Pensioners’ Medical Scheme came into force w.e.f. 01/04/2006. Instructions

/ clarifications have been issued from time to time to smoothen the delivery of Medical Facilities under the scheme. However, there were certain issues in the implementation of the scheme and there has been constant demand from the pensioners to provide them medical facilties at par with CGHS. Accordingly a committee was constituted with a view to consolidating and rationalising the instructions of ESIC-PI IS.

The recommendations of the Committee has been placed before the ESI Corporation in it’s 184th meeting held on 22/02/2021. Consequent upon the approval by Corporation the revised guidelines relating to implementation of ESIC-PNS 2006 is attached at Annexure-A.

In the revised guidelines significant changes have been made over the existing provisions relating to entry to the ESIC-PMS, regulation of payment of Fixed Medical Allowance, eligibility of Super Speciality Medical treatment, modalities for providing medical treatment to the beneficiaries, provision of tie-up arrangement with private hospitals etc. The revised guidelines would become applicable from the date of its issue.

The implementation of the revised guidelines would ensure that the medical facilities to our esteemed pensioners and their family members are provided in a hassle free manner almost at par with CGHS. Accord in• ! gall concerned authorities are directed to ensure the

implementation of the revised guidelines in the proper manner.                                                                                      y

 

 

 

 

 

To,

 

P.B. MANI) INSURANCE COMMISSIONER (P&A)

 

All Regional Directors/Dir.(I/c)/Jt. Dir. (I/c)/Dy. Dir.(1/c) of ROs/SROs.

  1. D(M)D/D(M) NOIDA/ K. Nagar.
  2. All Medical Superintendents ESIC Hospitals/ESIC Model Hospitals/ODCs.
  3. All Deans, Medical Educational
  4. Director/Dy. Director (Fin.) of all Regional Offices/ Sub-Regional Offices/Hospitals/ Medical Educational Institutions.
  5. Director, E-V, Hqrs. Office.
  6. PPS/PS to DG/FC/CVO/M.C./I.C.(P&A)/I.C.(NTA)/I.C.(Revenue)/I.C.(PMD)/IC{ICT).
  7. ESIC Pensioners’ Federation / Associations through concerned
  8. Website Content Planager for uploading on the website of ESIC.

     

 

ANNEXURE-A to Circular No. F. No.:D-12/16/1/2012-E-VI.Vol.II Dated: 25 May, 2021

 

REVISED GUIDELINES RELATING TO IMPLEMENTATION OF ESIC PENSIONER MEDICAL SCHEME- 2006- CONSEQUENT UPON THE APPROVAL OF THE RECOMMENDATIONS OF THE COMMITTEE CONSTITUTED FOR CONSOLIDATENGANDRATIONALISINGTHEINSTRUCTIONSRELATEDTO ESIC-PMS SCHEME, 2006 BY ESI CORPORATION IN  IT’S  184th MEETING HELD ON 22/02/2021

 

The ESIC- Pensioners’ Medical Scheme came into force w.e.f. 01/04/2006. Instructions / clarifications have been issued from time to time to smoothen the delivery of Medical Facilities under the scheme. However, there were certain issues in the implementation of the scheme and there has been constant demand from the pensioners to provide them medical facilities at par with CGHS. Accordingly a committee was constituted with a view to consolidating and rationalising the instructions of ESIC-PNS.

The recommendations of the Committee were placed before the ESI Corporation in it’s 184th meeting held on 22/02/2021. Consequent upon the approval by Corporation the revised guidelines relating to implementation of ESIC-PMS 2006 is as under.

 

A- Provisions relating to Entry / Exit, Regulation of payment of FMA, Regulation of Treatment in Private Empanelled / Non empanelled hospital.

SI No

Issue.

Revised guidelines.

1

Entry to ESIC-PMS

•     Pensioners would have to exercise their option regarding

ESIC-PMS mandatorily  by the date of their retirement.

•     If no option is received by the last date of retirement/ opts for FMA, Pensioner would become eligible for receipt of FMA from the next month of retirement.

•     If the pensioner submits his option for PMS after the date of retirement he would be required to pay an admission fee of Rs. 30 and refund the FMA received by him.

2

Fixed I ledical Allowance

(FMA)

•       In case no option is submitted at the time of retirement,

the pensioner shall be automatically eligible for Fixed Medical Allowance.

•        Pensioner will not be eligible for FMA again once ESIC-

PMS Scheme is opted out after acceptance.

(FMA-PMS--Opt out--No FMA)

 

 

 

3

Exit from ESIC-PMS

Pensioners who opts for ESIC-PMS at the time of retirement can opt out once. After opting out, such Pensioners can re-enter the scheme for only one more time after paying a registration fee of Rs. 30 and refund of the FPIA received by him.

(PMS---OptOut--FMA---Re-entry after Refund of FMA--Opt Out-- No FMA and No further entry to PMS)

4

Super Speciality

Treatment.

Pensioners would be eligible for all kinds of medical

treatment including SST from the date of entry / re- entry into the scheme.

 

As per the existing provision, in cases where a pensioner becomes the member of the ESIC PMS sometime after retirement, he becomes eligible for SST only after a waiting period of Six months. Now this condition is being withdrawn

5

Medical Treatment

The revised guidelines   regarding                                     provision of medical

treatment to pensioners shall be as under.

1 Cashless Medical Treatment.

 

(a)          Treatment in emergency.

In case of emergency, the pensioner can go directly to any of the nearby empanelled hospital. For this purpose, instructions may be issued by the Nodal Officer to the tie-up hospital to accept admissions in emergency for cashless treatment for ESIC pensioners on production of medical cards.

 

(b)          Treatment at ESIC Hospital.

 

The medical treatment to pensioner shall be provided as under.

•       The pensioner can take the treatment as per the facility available in the ESIC hospital.

•       In case the facility in ESIC hospital is not available as per his entitlement then he can opt to have treatment from empane)Ied hospital and the referral to private hospital shall not be denied.

 

 

(c)      Treatment from private hospital empanelled

with ESIC :

•    The pensioners shall be entitled for cashless medical treatment in Private Empanelled hospital on the basis of advice of ESIC Doctor / Govt Specialist for specific listed procedure / investigation. No other permission letter shall be required to be submitted to Tie-up hospital.

(As per CGHS OM dated 18-07-18}

 

2 Treatment on re- imbursement basis.

i.    In case no tie-up hospital is available for emergency treatment, the pensioner may take treatment from any nearby Govt./ Private hospital for which reimbursement is to be made restricting the claims to the ceiling of CGHS/CS(MA} Rules or actual, whichever is less.

 

ii.  All treatment taken in any Government hospital shall be valid for reimbursement irrespective of permission by ESIC.

iii. Treatment in Tie-up / Non tie-up hospital without permission / referral:

If the pensioner takes any elective treatment / investigations from the tie-up / non tie-up hospital in normal circumstances without any advice of ESIC Doctor

/ Govt Specialist or without permission / referral, the request for ex-post facto approval of such treatment shall be considered by the sanctioning authority and re- imbursement shall be limited to CGHS rates.

(As per CGHS OM dated 05-10-16)

 

The ESIC tie up hospitals may be directed to ensure that if a pensioner approaches the ESIC tie up hospital directly for any treatment whether OPD or IPD the hospital shall charge at CGHS rates for all procedures.

 

 

 

6

Direct OPD Consultation

from specialists at CGHS empanelled hospitals in respect of CGHS beneficiaries aged 75 years and above.

The committee has recommended for adoption of OM of

CGHS No Z-15029/35/2019/DIR/CGHS/CGHS(P) dated 29-

05-19. As per this OM CGHS Pensioners aged 75 years and above are allowed direct OPD consultation from specialist of empanelled hospital without referral from CGHS wellness centre on cashless basis etc.

 

Accordingly, ESIC pensioners aged 75 years and above are allowed direct OPD consultation from specialist of ESIC empanelled hospitals without referral from Govt / ESIC Doctor and Hospital on cashless basis.

 

The concerned authority’ shall ensure that necessary instructions are issued to private empanelled hospital and appropriate procedures are developed to ensure availability of medical services to such pensioners accordingly.

7

Medical facility to be

provided to pensioners aged 80 years and above.

ESIC has already adopted the CGHS instruction for Medical

facility to be provided to pensioners aged 80 years and above vide letter No.D-12/16/1/2017-E-VI dated 08/01/2018. The Medical facility to pensioners shall continue to be provided accordingly.

 

The concerned authority shall ensure the proper implementation of the instruction.

8

Applicability    of                    CGHS

Guidelines.

All Instructions issued by CGHS in respect of provision of

medical treatment to pensioners from time to time would stand applicable in ESIC.

 

B As  per  the  recommendations  of  the  Committee  regarding  the provisions relating to identity cards, appointment of Nodal officer, issuance of PMS Medical Cards, responsibilit:y of tie-up arrangement with tie-up hospital, the following guidelines are issued.

SI No

Topic

Revised guidelines

1

Nodal officer for

ESIC PMS

Regional Director of each region shall act as Nodal Officer for

ESIC PMS whose main responsibility shall be to co-ordinate all the activities relating to PMS by the concerned offices of the region.

 

 

Issuance of

Work relating to Issuance of Pensioner Medical cards and

Pensioner I' edical

settlement of claims shall be done by the Head of the office from

Cards and

where the pensioner receives his pension.

settlement of

 

claims.

 

3

PMS Identity cards

The practice as per CGHS shall be followed and individual card for

the pensioner, spouse and other beneficiaries (if any) may be issued. The pensioner id number generated by ERP must be mentioned on the card.

4

Tie-Up

arrangement with Private Hospitals.

Regional Directors including that of Delhi shall ensure necessary

tie-up arrangement with CGHS/CSMA/State Govt approved private hospitals to ensure availability of all medical facilities including tertiary care to pensioners as per their entitlement in consultation with the M.S. of the nearest ESIC Hospital.

If deemed necessary the tie up arrangement may also be done with hospitals other than CGHS/CSMA/State Govt approved private hospitals as per local requirement. The terms and conditions of tie up arrangements shall be similar to that of tie up arrangements made by CGHS for its beneficiaries.

 

 

  • The provisions of the existing ESIC-PMS with respect to the following shall continue to be apply as

 

  1. Contribution required for ESIC-PMS.
  2. Entitlement of Wards for medical
  3. Definition of ’family’.
  4. Meaning of recognised
  5. Appointment of
  6. Reimbursement of claims in emergency
  7. Appointment of AMAs .
  8. Medical
  9. Period prescribed for settlement of claims .
  10. Travelling

 

NO MEETING HELD SINCE MARCH 2020 DUE TO COVID OUTBREAK IN INDIA. VIRTUAL MEETINGS OF THE EXECUTIVE COMMITTEE IS BEING REGULERLY HELD TO SOLVE URGENT ISSUES.

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ALL INDIA ESIC PENSIONERS FEDERATION (REGD) 0