PENSIONERS MEDICAL SCHEME
DRAFT ESIC-PENSIONERS' MEDICAL SCHEME
1. INTRODUCTION
These rules will be known as ESIC-Pensioners' Medical Scheme Rules and will collectively form the ESIC-Pensioners' Medical Scheme (ESIC-PMS). It will be
effective from 01/04/06.All the decisions / instructions issued before its implementation regarding provision of medical facilities to ESIC-Pensioners will stand superseded by this scheme.
2. SCOPE
(A) Facilities under this scheme will be available to all the pensioners and family pensioners of ESI Corporation including their dependant family members subject
to fulfillment of conditions laid down in this scheme.
(B) The term "dependant family member" under sub rule (A) shall include members as defined by the Govt. of India for its pensioners.
3. E.S.I.C.-PMS AN OPTIONAL SCHEME
The Employees State Insurance Corporation-PMS will be an optional scheme and a pensioner may or may not opt for this scheme.
A. A pensioner will be required to apply within 3 months from the date of retirement if he/she wants to become a member of the ESIC-PMS. Applications
received after 3 months of date of retirement will not normally be entertained.
B. Pensioners who have retired before the introduction of this scheme but have not opted for life time membership of any of the earlier medical schemes will be
given one time option to apply for the membership of this scheme within 3 months from the date of its implementation and, after that no request of such
pensioner will normally be considered for membership of ESIC-PMS.
C. ESIC-Pensioners who are already life time members of an earlier medical scheme of ESIC Pensioners will automatically become members of ESIC-PMS
unless they opt otherwise, subject to fulfillment of conditions given in this scheme.
D. A pensioner not opting for this Scheme within the prescribed period of three months and if the authority considers his joining the scheme subsequently, he
shall be entitled for super specialty treatment only after the “waiting period” of six months from the date of his joining of the scheme.
E. A pensioner not opting for this scheme shall be paid a Fixed Medical Allowance of Rs. 100/-P.M. subject to revision from time to time.
4. CONTRIBUTION AND BENEFIT PERIOD
A. All pensioners who opt to avail medical facilities under this scheme will have to pay contribution on the basis of option based either on basic pay last
drawn original pension at the rates given in Schedule 1 which is subject to revision from time to time:
(i) If contribution is paid on the basis of original pension, all elements except dearness relief shall be taken into account. The entitlement would be in
accordance with the rate of contribution paid.
(ii) If contribution is paid as a one time lump sum it will be ten times the annual contribution payable at the time of retirement and permanent whole life medical
card will be issued.
(iii) In respect of those beneficiaries who have already retired, the lump sum amount will be worked out on a pro-rata basis, at current rates assuming
average life expectancy at 68 years.
B.(i) The benefit period will be the same as in the case of Central Govt. Pensioners i.e. from 1 st January to 30th June and from 1st July to 31st December.
Contribution is required to be paid for the entire benefit period irrespective of date of joining the Scheme. The Contribution should be deposited by the
beneficiaries by 30th November and 31st May for the benefit periods of January to June and from July to December respectively.
(ii) Contribution shall be deposited in ESIC Fund Account No.1 in advance for a minimum period of six months.
5. MEDICAL CARD AND INDEX CARD
(A) The Card Issuing Authority shall obtain duly filled in application forms and requisite documents from the applicant three months before the date of
retirement of the official. The cost of photographs will be borne by the pensioners concerned.
(B) The applications so received will be processed and card will be issued to the concerned office 30 days before the date of retirement of the official. If the
official intends to get a medical card for whole life he / she should send bank draft / challan for an amount equivalent to the subscription for the period of ten
years. Where contribution has been paid for some years under the existing scheme medical card for the whole life shall be issued on payment of
contribution for the remaining years at a time.
(C) The issuing authority for medical card will also issue an index card to the pensioner in the prescribed format . The index card will be handed over by the pensioners
to the Incharge of concerned dispensary/hospital. The Medical Officer Incharge/ / Medical Superintendent of the concerned Dispensary / Hospital shall keep a
record of treatment provided to the pensioners in the index card.
(D)Duplicate medical card in place of card lost shall be issued by the authority who had issued the original medical card to the pensioner on receipt of report
regarding loss of medical card and an application for the issue of duplicate medical card along with following documents :-
(i) Copy of FIR/ Complaint lodged with the Police Station.
(ii) A bank draft in favour of ESIC fund A/c no. 1 or challan for Rs. 25/- as cost of duplicate Card alongwith photographs.
(E) The duplicate medical card shall also be issued in place of a mutilated card. The pensioner/family pensioner shall send the mutilated card along with application
form to the card issuing authority. The authority shall prepare a duplicate card in place of the mutilated one containing exactly the same particulars that was
available in the mutilated card. No charge will be collected for the issue of duplicate card in lieu of mutilated Card, if the card was issued five years prior to
the date of application for such request. In other cases, a fine of Rs. 25/- will be collected.
(F) The pensioner must apply for issue of medical card within three months from the date of the retirement and in cases where the pensioner is already holding
medical card, he should renew the card within three months from the date of expiry of card. If the medical card is renewed after the expiry of three months
(grace period), the pensioner will not be entitled for any medical reimbursement / benefits for that period of treatment between the actual date of renewal of the
card and the date on which the card was due for renewal. The renewal of medical cards of pensioners will be done from the date of payment of
contribution by them and not with retrospective effect, in case the card is not got revalidated within the grace period of three months.
The pensioners will not be eligible for reimbursement of medical expenditure for the period for which the medical card has not been renewed.
(G) No change of dispensary is permissible except on change of residence of the card holder. When there is a change of residence involving change of
dispensary, the pensioner should present an application in duplicate to the card issuing authority in the prescribed form together with medical card. The card
issuing authority shall make entry in the medical card and attest the same in the appropriate column. Then the pensioner shall submit two forms to the Medical
Officer Incharge of the concerned dispensary. The Medical Officer Incharge will make entry in his records and then handover the index card to the card holder
with the direction to handover the index card to the Medical Officer Incharge of the new dispensary.
(H) The Regional Director/ Medical Superintendent will be the authority to decide as to which will be the nearest Dispensary / Hospital under these Rules and he
will also issue medical card to such pensioner under intimation to the Incharge of the concerned Dispensary or Medical Superintendent of the concerned hospital
as the case may be .
6.
MEDICAL INSTITUTIONS AVAILABLE FOR TREATMENT OF ESIC
PENSIONERS.
A. Pensioners residing within eight kilometers of an ESIC/ESIS Dispensary/ESIC/ESIS Hospital shall avail medical facilities through that dispensary/ hospital
in the first instance.
B. If the residence of the pensioner is at a distance of more than 8 kms. from thenearest ESIC/ESIS dispensary / ESIC/ESIS hospital, he will have the option to
avail medical facilities through any other approved* dispensary/ hospital nearest to his residence.
C. In case any particular treatment is not available in such a Dispensary and hospital, the hospital may refer the patient to any of the recognized *hospitals
where such treatment is available .
D. In the event of emergency the ESIC pensioners / eligible family members may report to nearest hospital where required facility is available and inform the
recognized* dispensary/ hospital and card issuing authority about the admission to the non-recognized hospital. In case a pensioner takes treatment from a
hospital to which he is not attached in emergent circumstances, the reimbursement within the ceiling for such treatment in a recognized*/* approved
hospital shall be considered only when emergency is certified by the competent authority of ESIC.
E. If a pensioner while at outstation requires emergency treatment, he will avail the same from the nearest hospital and the amount shall be reimbursed as per rates
of the nearby approved *hospital as provided in
Schedule 2.
F. The members of ESIC-PMS will be eligible for medical facility from any approved*hospital under any system of medicine recognized for employees of the
Corporation.
G. If a pensioner, takes treatment from a hospital which is not recognized under the scheme, in non- emergent circumstances, no reimbursement shall be made
and the entire expenses will be borne by the pensioner.
Note:- For the purpose of these Rules, a recognized/approved dispensary/hospital shall include all ESIS dispensaries and Hospitals, any other
Hospitals recognized by ESIC/ESIS for the Insured Persons, or for the employees of ESIC/ESIS including those recognized under CGHS and
CS(MA) Rules in respect of which the Director General or any other authority has entered into an agreement under Rule 9, in addition to
ESIC Institutions. A dispensary shall also include an AMA appointed under the above Rules or appointed by the Competent Authority
specifically under these Rules.
7. ENTITLEMENT TO VARIOUS CLASS OF ACCOMMODATION FOR INDOOR TREATMENT
(i) Pensioners who are provided medical facilities through ESI institutions shall remain entitled to the ward available irrespective of their contribution slab or
status.
(ii) A Pensioner who is referred by the ESI Hospital to any other recognized /approved hospital shall be entitled to the class of accommodation as per the
schedule-3
(iii) In cases where reimbursement is allowed after relaxation, reimbursement of accommodation charges shall be as per entitlement to various wards or actual
amount spent by the pensioner, whichever is less.
(iv) Any amount spent over and above the rates applicable as per entitlement will be borne by the applicant pensioner.
(v) The pensioner shall apply in the prescribed proforma enclosing the requisite documents to the Card Issuing Authority for reimbursement of expenses for
treatment taken from an eligible hospital.
8. COST OF FOOD / TONIC ETC. AND SOME RESTRICTED MEDICINES NOT REIMBURSABLE.
(i) The cost of preparations which are not medicines but primarily food, tonics, toilet preparations or disinfectants shall not be reimbursed.
(ii) Expensive drugs, laxatives and proprietary preparations for which drugs of equal therapeutic value are available, shall not be reimbursed.
9. POWERS OF THE DIRECTOR GENERAL TO REMOVE DIFFICULTIES
Notwithstanding any thing contained in these Rules, the Director General may adopt any provisions as applicable to the pensioners of the Govt. of India or
otherwise from time to time and exercise such powers and delegate any of them to authorities subordinate to him. The Director General or any other authority to
whom the power is delegated may also enter into agreement with the appropriate authority in respect of a dispensary/hospital/AMA for providing
medical facilities to ESI pensioners on terms and conditions as mutually agreed upon.
10. POWER TO RELAX.
The Director General shall have the power to relax any of the provisions laid down in the rules. A pensioner, however, can not claim relaxation of the rule
as a matter of right. The reimbursement of medical expenditure after relaxation of the rules by the Director General shall be restricted to the approved rates.
11. TRANSITIONAL PROVISIONS
These rules shall be effective from 01.04.06. Reimbursement claims already decided shall not be reopened. Cases wherein the contingencies have
arisen on or before 31/03/06 shall be regulated in accordance with the instructions then applicable in those cases.
SCHEDULE – 1
The rates of contributions chargeable under ESIC-PMS are given below.
However, these rates may be revised from time to time by the Director General.
Pay Range(last pay drawn) Pension / Family Pension Rate of monthly contribution
Pay upto Rs. 3,000 Upto Rs. 1,500 15
Rs. 3,001 to Rs, 6,000 Rs. 1,501 to Rs. 3,000 40
Rs. 6,001 to Rs. 10,000 Rs. 3,001 to Rs. 5,000 70
Rs. 10,001 to Rs, 15,000 Rs. 5,001 to Rs, 7,500 100
Rs. 15,001 and above Rs, 7,501 and above 150
A pensioner will have option to pay contribution either based on his last pay drawn or based on his present pension (excluding Dearness Relief).
SCHEDULE – 2
STATEMENT SHOWING THE CEILINGS ON THE VARIOUS ITEMS OF TREATMENT WHERE REIMBURSEMENT IS ALLOWED IN RELAXATION.
(1) The rates approved by the ESIC in respect of the hospitals recognized by ESIC.
(2) The rates approved by State Govt./CGHS/CS(MA)Rules whichever is lower or applicable.
SCHEDULE – 3
S.No. Rate of Monthly contribution paid orresponding Ward in approved Hospitals
1 Upto Rs. 15/ - General
2 Rs. 40 /- General
3 Rs. 70/ - General/Semi-private as available
4 Rs. 100/ - Private
5 Rs. 150/ - Private or above as available
The eligibility of pensioners covered under clause 3 (C) for the purpose of Schedule 3 shall be reckoned on the rates per month at which whole life
contribution was then paid by the pensioner
EMPLOYEES' STATE INSURANCE CORPORATION
PANCHDEEP BHAWAN, C.I.G. ROAD, NEW DELHI
No:- D-12/16/1/2003-E-VI Dated 13.01.2006
M E M O R A N D U M
Subject:- Extension of medical facilities to E.S.I.C pensioners through the E.S.I.C
Pensioners' Medical Scheme (E.S.I.C.- PMS).
The Standing Committee of the ESI Corporation, in its meeting held on
13th Dec., 2005, has approved certain medical facilities to the pensioners of the
E.S.I.C. under the name and style of "The E.S.I.C. Pensioners' Medical Scheme,
2006" which shall come into force w.e.f. 1st April, 2006.
The Scheme is optional and contributory in nature. Pensioners opting for the scheme shall be required to apply within 3 months from the date of retirement, if they want to avail of the scheme. Those who have retired before introduction of this scheme but are not life time members of any earlier medical schemes will be given one-time option to apply for the membership of this scheme within 3 months from the date of its implementation i.e., 1/4/2006.Pensioners who are already life time members of an earlier medical scheme for E.S.I.C. Pensioners shall automatically become member of E.S.I.C. Pensioners'Medical Scheme unless they opt otherwise. The option once exercised by apensioner shall be final and cannot be revoked.
Pensioners not opting for the scheme shall continue to be eligible for payment of fixed medical allowance @ Rs. 100/- per month.
Pensioners opting for this scheme shall pay contribution in advance for a minimum period of six months at the following rates:-
Pay Range Pension/FamilyPension Rate ofmonthlycontribution
Pay upto Rs. 3000 /Upto Rs. 1500 15
Rs. 3001 to Rs. 6000 /Rs. 1501 to Rs. 3000 40
Rs. 6001 to Rs. 10000 /Rs. 3001 to Rs. 5000 70
Rs. 10001 to Rs. 15000/ Rs. 5001 to Rs. 7500 100
Rs. 15001 and above Rs. 7501 and above 150
A pensioner will have the option to pay contribution either based on his last pay drawn or based on his present pension (excluding Dearness Relief).
For entry in the scheme, pensioners shall be required to apply in the prescribed application form (Annexure-A) along with a photograph to the
designated card issuing authority. The cost of photograph will be borne by the pensioner. The card issuing authority shall intimate the pensioner about the
medical card and the index card for submission to the Medical Officer Incharge etc. The procedure for obtaining a duplicate medical card shall also be issued by
the card issuing authority.
Pensioners residing within eight kilometers of an E.S.I.C./ESIS Dispensary/Hospital shall avail medical facilities through that dispensary/hospital
in the first instance, in absence of which he will have the option to avail the facilities through any other approved dispensary/hospital nearest to his
residence. In case, any particular treatment is not available in such dispensaries/hospitals, they m ay refer the patient to any of the recognized
hospitals where such treatment is available. If a pensioner takes treatment from a hospital which is not recognized in non-emergent circumstances, no
reimbursement shall be made and the entire expenditure will be borne by the pensioner. Pensioners who are provided medical facilities through ESI institutions shall remain entitled to the available ward irrespective of their entitlement.
Those who are referred to any other recognized hospitals shall be entitled to the class of accommodation as shown below:-
Sl.No. Rate of Monthlycontribution paid Corresponding Ward inapproved Hospitals
1. Upto Rs. 15/- General
2. Rs. 40/- General
3. Rs. 70/- General/Semi-private as available
4. Rs. 100/- Private
5. Rs. 150/- Private or above as available
All decisions/instructions issued hitherto shall stand modified upon implementation of this scheme w.e.f. 1/4/2006.
There shall be a designated Nodal Officer for each State/UT who will be empowered for reference to other approved hospital in case the facility is not
available in ESI hospitals. The communication in this regard shall follow shortly.
The reimbursement will be restricted to the rates approved by E.S.I.C./State Govt./CGHS/CS(MA) Rules, whichever is lower or applicable. The
cases where contingencies have arisen on or before 31.03.2006 shall be regulated in accordance with the instructions in force prior to 1/4/2006.
Reimbursement claims already decided shall not be reopened. A copy of the scheme is sent herewith the request to bring the contents of
the scheme to the notice of all concerned.
Encl:- E.S.I.C. Pensioners' Medical Scheme
(S.K. Sinha)
JT. DIRECTOR
For Director General
HEAD-lJ.UARTERS OFFICE
EMPLOYEES' STATE INSURANCE CORPORATION
PANCHDEEP BHAWAN :C.LG MARG: NEW DELHI
(ISO 9001:2008 CERTIFIED)
emaD: Id-admin2@eaie.Di~.fn
No. D-12/16/1I03-E-VI Dated-:2. 6- 8-2010
To
A.C. (NTA), All Regional Diredonl Jt. Dfrectors In-charge,
D(M)DI DM NoidalSSMCI M.S. of ESIC Model Hospitalsl ODCs.
Sub:ESIC Pensioners Medical Scheme - Grant of Fixed Medical Allowance.
Sir,
Consequent upon revision of Fixed Medical Allowance being paid to Central Government Pensioners by Central Govt., the matter regarding revision of FMA was under examination of this office. Accordingly, the decision of ESI Corporation is conveyed for enhancing the Fixed Medical Allowance being paid to Pensioners eligible under ESIC Pensioners' Medical Scheme, 2006 from Rs. 100/- to Rs.3001- per month. Other conditions for grant of FMA shall remain the same.
The revision is to be effective from 01.09.08.This issues with the approval of Director General in concurrence with the Financial Commissioner.
The contents of this letter may be sent to all pensioners individually and the pensioners association of your region. This may be placed in your websites also.
The receipt of this letter may please be acknowledged.
Hindi version will follow.
Yours faithfully,
~C"~ .•
( SUNIL TANEJA )
JOINT DIRECTOR
FOR DIRECTOR
It is informed that Ministry of Health & Family Welfare has issued circular dated 14/5/2018 prescribing time-lines for settlement of medical claims of CGHS pensioner beneficiaries. The circular has been issued in CGHS in compliance of the directions of Hon'ble Supreme Court of India in their Judgement in WP (Civil) No. 694 of 2015 between Shiva Kant Jha Vs UOI delivered on 13th April, 2018 and in supercession of earlier guidelines in the matter. The circular was examined in ESI Corporation and guidelines prescribing similar time-lines are issued for pensioners / family pensioners covered under
ESIC Pensioners' Medical Scheme, 2006 as per the details below :
which can be condoned. This issues with the approval of Director General.
The receipt of this letter may please be acknowledged. Hindi version will follow.
Yours faithfully,
2
( Prabha Saini ) Asst. Director
CIRCULERS4
Feary
MEAD QUARTERS OFFICE
HAAN Us SAT fevaraT
EMPLOYEES'STATE INSURANCE CORPORATION
(An I8O 9001-2000 certified organisation)
Gary Haat, O.3TS.sh. Fret, aS fa een-2
No: D-12/16/1/03-E-V! , Dated: 25/08/08
To
All Regional Directors/ Joint Directors I/c Director(M) Delhi/ Director(M) Noida, ES! Corporation.
Sub: _ Salient features of ESIC-Pensioners Medical Scheme — Reg.
Sir, ,
A copy of DO letter of even No. dated 22.08.2008 signed by Add!. Commissioner (P&A) is enclosed herewith on the above subject. All Nodal Officers of ESIC-PMS of ESI Corporation are requested to issue the enclosed DO letter to all the pensioner pertaining to their unit after making requisite number of copies.
This issues with the approval of Add!. Commissioner (P&A).
Yours faithfully,
na * ms B51 R07 (M. NANDA} SECTION OFFICER
. mgt Mia Oo a nesy F ome “ow Soe gs
B.K. SAHU 45105 §) ADDITIONAL COMMISSIONER
EMPLOYEES’ ST. ATE INSURANCE CORPORATION
PANCHDEEP BHAVAN: C.1.G. ROAD:NEWDELHI-110002. http://esic.nic.in
No. D-12/16/1/,2003-E .VI Dated : 22° August,2008
Dear Shri/Smt
It is a matter of immense pleasure to address the elders of the ESIC, each of whom have made a contribution towards building the organisation. It is in regard to your Medical Scheme that I felt the need for addressing you individually. As you are aware, the Standing Committee of ESIC in its meeting held on 13/12/05 approved scheme for medical facilities to the pensioners of ESIC under the name of style of “The ESIC-PMS 2006” and it came into force on 1/04/06. Subsequently, a number of instructions were issued adding more features to the scheme. Publicity was also given through the press so that every pensioner of the Corporation is aware of it.
However, it appears from the queries that are being generated and received, that many of the pensioners are still not aware of the scheme. I availed of the opportunity to address you personally to apprise of its salient features, which are as follows:-
0-l2-0 8 5. poet rit be the Nodal officer the case of pensioners in and around Delhi i in matters regarding references to other Hospitals and RDs/JDs Incharge in the case of pensioners in other states.
o | cr a . a aa (iii) | All Hospitals/Dispensaries/AMA etc. approved/recognized by the ESIC/ESIS , authorities for the treatment of IPs and their employees or any other medical
institution recognized by the Nodal officer specifically under the Rules 9 of the ESIC-PMS
restricted to the rate as actually recognized institution/rates specified by CGHS/CSMA as the case may be or the rates contained in the agreement the Nodal Officer has entered into with such institution whichever is less except in the case of food/tonic some restricted medicines etc..
Corporation has also approved presentation of a memento worth Rs.5000/- (a silver medallion) on superannuation through Regional Directors.
While I am not able to accommodate exhaustive details of the scheme here, | believe | have managed to bring out some of pivotal aspects of the scheme. We have also published all
the instructions issued on the website. I am also sure that our officers will be glad to guide you in case you find difficulty in availing the benefits.
With Y. t ve4 at, Yours Sincerely, eed
(B.K. SAHU)