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E.Sal MEDICAL MANUAL• (Incorporating Instructions Issued up to March 2600)

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E.Sal MEDICAL MANUAL• (Incorporating Instructions Issued up to March 2600) E.Sal MEDICAL MANUAL• (incorporating instructions issued up to March 2600) 1, 2 4th Edition (Revised) Sept. 2002 5T-1 Published by : Director General EMPLOYEES' STATE INSURANCE CORPORATION KOTLA ROAD, NEW DELHI Website : www.esic.india.org I •'•• • • • • •%„..1 . • • • • FOREWORD Over the last 50 years, ESE Corporation has . ernerged as tho country's leading multi- dimensional health insurance organisation. Today, it has a vast network of ESI hospitais, disponsaries and panol clinics for providing primary, specialist and in-patient services to • (' • about 32 million ESI beneficiaries ail over . the country. ES.IC has also, recently'decidod to set up atleast one model hospital in each Stato. With the thrust on overall irnprov.ement in service delivery, it has become necessary that 'insurance medcal . officers and Medical adrniniStrators, working for the scheme, are v.ieN acquainted with•the corporate policies, instructions and related guidelines, including the . cornplexities of social insurance-and documentation thereof. Medical certification, for instance, is one of the critical areas where caution has to be exercised by the certifying authority. This revised and up-dated edition of the Medical Manual should serve ats, a usofui 'reference book for adhering to stipulatecl . Processes and procedures. Whife appreciating The hard vi,fork that has gone into updating this exhaustive Manual, r look forward to its meaningful and productive use by thefield offices and establishments of the totporation. - 1_ Now. Qeihi Noy Dua Dated: 23-1-2003, Dfroclor GerEert ' ; I C Medirmf • PREFACE (To This Edition) "••• . The third edition of the ESI Medical Manual. was last published in 1989. In view oi the changes that have taken place in the scope of service under the ESI scheme, as well as, simplification r_if procedures undertaken over the fast decade, it was felt 'necessary to • come up with an updated and 'revised edition of the Manual, . C. Easy access to various instructions and guidelines is of paramount importance in speeding up the process of service delivery, more.so , in a social 'security set up like ours . where benefits are generatly.inter-linked and medical certification is an integral part of the day-to-day activity. Medical manual, a comprehensive compilation of norms and procedures incorporating the latest instructions is the most important corporate publication to depend upon for all information related to various aspects of medical benefit, . This, the fourth edition of the Manual, is the outcorrie of the hard work of a senior team of ESC officers. Here; I would ,particularly, appreciate the level of involvement of Dr.D.K.Kapoor, Director (Medical) Headquarters, Dr.A.K.Khokhar, Dy.Medicar Commissioner and Di.T.K.GoeL Additionsi Director(DMD) in revising, recasting and updating this Manual. am equally appreciative of the efforts Shri P.L.Kaui, Director Public Relations for his contribution in reformatting the manuaf with a new look, layout and design. While all care ,ras- been taken to make it a comprehensive reference book on matters medical. within the 'scheme, there could still be room for some improvements. Suggestions that could further enhanbe the - usefulness of this Manual are, therefore, .vielcoririe. New Delhi Dr.(Mrs.)S.Singh Dated: 23-1-2003, Medical Commissioner • RiBcPonl Manub] ABBREVIATIONS Act • Employee's .State Insurance Act, 1948.. • AMC Administrative .Medical Officer • Corporation Employee's State Insurance Corporation f••••• .; Director Director,ESI Scheme El . Employment Injury • El Court Employees' Insurance Court • ESB . Extended Sickness Benefit ESIS Employees State Insurance Scheme IMO Insurance Medical Officer . • IMP Insurance Medical Practitioner IP Insured Person IW Insured Woman • LC Local Committee LO Local Office MAT Medical Appeaf Tribunal. MB Medical Board .• MBC Medicaf Benefit Council MR Medical Referee • MRE Medical Record Envelope MRC Medical Record Card 00 Occupational Disease POB . : • Permanent Disablement Benefit RO Regional Office Regulations Employees' State Insurance (Central) Regfulations; 1950 Rules • Employees' State Insurance (Central) Rule, 1950. • SB Sickness Benefit • SLO Sub Local Office •SM8 Special Medical Board SRO Sub Regional Office TDB Temporary Disablement Benefit _) TIC Temporary Identification Certificate' ' Lii ESA. Medical Mariutal ■Az..1!1 I : CONTENTS Cop . Contents Para No. Page No. • Rert.. Md CHAPTE R--i kie:a Introduction err.:.. • Sociai Security - an introduction 1.1-1.2 1 Intr•. ESI Act, 1948 - Rules & Regulations 1.3-1.4. 2 • • Med. Administration of the Scheme 1.5-1.6 3 Re', Administrative set up 1.7 5 •Prq".) ; Infrastructure 1.8 6 to tyl . i...• --= Finances of the Corporatfon 1.9 7 •Acth . 1.10 • ai Implementation of the Scheme Re ;• Enr CHAPTER Ent II . Coverage, Registration and.Contribution Ann! . Introduction 2.1 r -, Coverage of the Factories 2.2 . 9 • Coverage of the Employees 2:3 9 Med Contribution, ,Contributiop period and Benefit period • 2.4-2.6 • ' 10 SySt Registration of Factories ad Establishments 2.7 11 • Registration . of Employees, TIC 2,82.10- 11 . ScL, • ! Preparation of Documents • 2.11 12 .. LI Permanent Identity Card (Fo.n.n. 4) . 2.12 •12 Certificate of Employment, validityirevafidity of TLC 2.13-2.15 •13 Duplioate Permanent Identity Card. 2.16 14 Cases of Impersonation . 2.17 14 , Exf,- FTxr, Change of oispensars! • 2.18 . 1 Change of Name/Date of Birth 2.19 1,5. Expl Treatment of family Members of Insured Persons 220 • . 1-5—, 064 , . (.. E5.11.1dTarilcal Manual Contents Pala No. Page No. • Reciprocal Medical Arrangement ' 2,21 17 Medical Treatment IP and families at out-station 2,22 17 Medical treatment to insured Person after leaving the 2.23 19 employment and moving to another area till entitlement Inter Regional transfer with different employers 2.24 20 Medical Benefit after contribution ceases to be payable- 2.25 20 Regulation 103 A Procedure for enforcement of dis-entitlement and re-entitlement 2,26 21 '15 to Medical Benefit, ESIC 37, 166. r Action by lIVIO/IMP on receipt of Exit Cards/Exit List 2.27 22 (. Re-entitlement 2.28 23 Entitlement and dis-entitlement of Family MeMberS 2.29 24 Entitlement to Medical Benefit in certain special cases 2.30 25 Annexures (Annexure 2.1 to 2,9) • g ;::CI-IAPT.E11.7 Medical Benefit • Medical Benefit under the ESI Scheme 3.1. 37 System of treayrient 3.2 •37 Scale of Medical Benefit — Def. of Family 3,3 37 For the purpose of Medical Benefit 3.4 • ..39. Medical Benefit/0 Retired Insured Person and Permanent 3.5 39 Disabled IF's Administration of Medical. Benefit in a State 3.6 40 A. Expenditure on Medical Care-Ceiling and Sharing 3.7 40 Expenditure of Medical .Care Outside the ceiling 3.8 ). Expenditure on Medical Care-Furly borne by the Corporation 3.9 42 Outpatients Medical Care through Dispensaries 3,10 43 E.3.1. ModlcaE rulsiluar _Contents Para No. Page No. Coni Arrangement for Medical dare with State Govt./Local Bodies/ 3.11-3.12 •45-46 . Ten Employees'. Utilisation Dispensaries AccP , Domiciliary. Treatment 3.13 46. Rem . Specialists Consultation/Hospital/Specialist's Centres 3,14-3,15 46-48 Proit.A' Management of Occupational Diseases in ESI:Scheme 3.16 48. Remuneration to the Speciarists/PT specialists 3.17 49 Exit, - - In-patient treatment (Hospitalisation)/Diet for In-patients 3.18 . 50 Assy, Drugs and Dressing • . 3.19 52. IMO Artificial Limbs, Aids and Appliances, . 3.20 53 Lirrn Terre Imaging Services and Laboratory investigations 3.21 53 integrated Family Welfare, Immunisation and Maternity Child 3.22 54 Hearth Programme Disk Ambulance Service, Reimbursement of conveyance charges 3.23 55 Pao Hearse Van 3.24 66 Super Speciality Treatment 3.25 56 • ; • Physical and . vocational Rehabilitation 3.26 56 Bar( '• Grant of ex-gratia payment 3.27 57 Sich Medical Certification 3.28 57 Extsr Reimbursement to employers under Regulation 69 3.29 57 Enria Reimbursement of expenses incurred in respect of medical 3.30 57 treatment under Regulation 95A Dist -.; CHAPTEFt..7! IV Panel System Depe Insurance Medical Practitioners 4.1 61 MaL,.? Allocation Scheme and Committee 4.2-4.4 61-62 Fur( Selection of Panel Doctors .4.5 62 Medical List 4.6 62 - Voca iv (.. j, E.S.I. Medical Ellinnol smwrmll Contents Para No. Page No: Terms and Conditions of Service of Panel Doctors 4.7 63 Acceptance of Insured Person by the IMP 4.8 66. Removal of IPs from Panel Doctor's list 4.9- • 68 Procedure for Doctors List in the office of the Director/AMO 4.10 68 . Change of Panel Doctor/IMP 4.11 69. Exit and re-entry in Panel areas 412 70 Assignment of iPs who ere unable to obtain acceptance by an 4.13 70 Ityle Limitation of the Doctor's List . 4.14 71 Temporary ArrangeMents 4.15 71 Measures to check over prescribing and excessive prescribing 4,16 72 Dispute between Insured Person and the IMP 4.17 72 Panel IDOctors Ledger End payment of Capitation Fee 4.18 73 CHAPTER — V Cash Benefits Benefits under the ESI Scheme 5.165.2 76 SioknesS Benefit • 5.3 76 Extended Sickness Benefit . 5.4 76 Enhanced Sickness Benefit 5.5 82 Disablement Bengt .• 5.6 82 I{ Temporary Disablement Benefit (TDB) 5.7 82 Permanent Disablement Benefit (PDB) 5.8 83 Dependants Benefit 5.9 84 Maternity Benefit. 5.10 84 Funeral Expenses , 6.11. 86 Physical Rehabilitation Allowances 5.12 85 Vocational (Occupational) Rehabilitation Scheme -5.13 85 vi E.5.I Mdia1ManuRE • COntents Para No. Page No. Cont.. Suspension of Sickness or Temporary Disablement Benefit 5.14 86 Ceft, Sickness Benefitifemporary Disablernent Benefit during Strike 5,15 86 Lax.f,•- • (Regulation e9 A) .Contn: High Incidence of Sickness Benefit-Sharing of Expenditure - 5.16 ' 87 Adm), Occupational Diseases and list of occupational diseases and 5.17 : 87 Anne The third schedules to ESI Act :CHAPT' Medical Certification Medlcai Certification 6.1 93 Tab'' Certificate 'Books 6.2 95 Recor General Principles of Certification 8.3 96 • Regi First Certificate.and Combined First & Final Certificate 6.4-6.5 • 101-102 Mon Intermediate Certificate .
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