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Medical Benefit 
Super speciality treatment 

For super speciality treatment such as open heart surgery, neuro surgery, bone marrow transplant, kidney transplant or specialised investigations like CAT scan, MRI angiography etc. referral arrangements are available with the reputed hospitals of the country. The total cost of such treatment, diagnostic facilities or surgical intervention is borne by the ESI Scheme.

Procedure to be followed by the ESI beneficiaries to avail Super speciality medical treatment

Download referral letter & undertaking form

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.

Procedure to be followed by the ESI beneficiaries to avail Super speciality medical treatment

  • The insured person shall approach the ESI Dispensary to which he/she is attached, and the Medical Officer shall issue a referral letter to the IP to approach the concerned empanelled medical institution.
     

  • If the IP/beneficiary need medical attention during the non working hours of the concerned ESI Dispensary, they may directly approach the nearest ESI Hospital for getting referral letter. If there is no ESI Hospital situation nearer to the IPís place of living, the IP shall approach the nearest Govt. Hospital for getting referral letter.
     

  • In the case of an emergency the IP/beneficiary can get Medical attention just by producing his/her ESI identity card at the designated private medical institution, shall produce necessary referral letter and other relevant documents within 48 hours. (If any case referral letter is a must to avail treatment under package deal
     

  • The IP/beneficiary shall produce the referral letter along with the ESI Identity Card at the designated private medical institution and avail the treatment without paying any amount from out of his/her pocket. However any facility, other than the items included in the package deal shall be borne by the IP/beneficiary.
     

  • While referring the IP/beneficiary to the concerned Empanelled Medical institution, Medical Officer incharge has to verify whether the IP/beneficiary is eligible for treatment.
     

  • The IP shall produce all the relevant documents demanded by the designated hospital and extend his/her co-operation to the hospital authorities.
     

  • The designated hospital after imparting treatment to the IP/beneficiary shall raise the claim bill directly to the Directorate where it will be settled.

 

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