Insurance and Medical Services Department
Frequently Asked Questions and Answers
- Where should a newly enrolled ESI beneficiary report for benefits and what are the different types of services available?
Medical record envelopes of all ESI beneficiaries are kept in the respective ESI dispensaries. Primary outpatient medical care, certificates for sickness benefits and reference to ESI Hospitals for those who need hospitalization or specialist consultation are given from here. Medical reimbursement claims are settled here. All ESI beneficiaries should first approach the Medical Officer of the ESI dispensary for availing any medical benefit under the ESI scheme except in case of emergencies when they can go directly to the ESI Hospitals.
- What is the procedure to be followed by the ESI beneficiaries to avail super speciality treatment?
The ESI beneficiary should first approach the Medical Officer of the ESI dispensary to which he/she is attached with all his/her medical records including the concerned specialistâ€™s advice that treatment at super speciality hospital is essential.
The Insurance Medical Officer will then give a letter to the beneficiary for getting eligibility certificate from the local office of the ESI Corporation. The IMO informs him/her on all the procedural formalities to be followed, gives him three photo affixed identity certificates and refers him/her to the Superintendent of the nearby ESI Hospital.
The Superintendent of the ESI Hospital will then examine the patient and verify all the records produced by him. If the case is found to be genuine, he will give a reference letter to the concerned department of the super speciality hospital. The reference letter will contain the details such as name of the patient, two identification marks, home address, name of insured person, relationship to the patient, insurance number, name of work place, eligibility, diagnosis, clinical history, investigations done, treatment given and the need for reference.
The patient will then attend the super speciality hospital where he is examined and an estimate of the required treatment is issued.
All the documents are then submitted to the Director of Insurance Medical Services for scrutiny and sanction. The documents are as follows:-
1) The insured personâ€™s request
2) Forwarding letter of the ESI Hospital Superintendent
3) Reference form filled by the Superintendent
4) Entitlement certificate
5) Identification certificate (with photo and two identification marks)
6) Medical records
7) Medical report and estimate from the super speciality hospital
8) Certificate of non-availability of treatment from Medical College in the case of private hospitals
If the application is in order, the DIMS will forward it to the Government for sanction of the estimated amount. Once Govt. sanction is accorded, it will be sent back to DIMS to meet the expenses from the Revolving Fund. The DIMS will forward the sanction order to the Regional Director, ESI Corporation, Thrissur for the issue of cheque. The RD will send the cheque favouring the head of the Medical Institution to the DIMS, who in turn will send it to the concerned hospital and also inform the insured person immediately.
Once the treatment is completed the bills for the utilized amount, demand draft in favour of RD, ESIC, Thrissur for the unutilized amount, utilization certificate an treatment certificate are to be sent to the DIMS by the hospital authority.
- What is the procedure for availing treatment from Regional Cancer Centre? (Treatment on credit)
The reference letter is obtained from the Superintendent, ESI Hospital as above and the patient can straightaway start treatment at the RCC. Copies of the reference letter and other documents are forwarded to the DIMS by the Superintendent.
Once treatment is completed RCC will submit the bills with copies reference letter, entitlement certificate, identification certificate and the treatment certificate to the DIMS. The bills are passed and sent to the Government for sanction. The sanction order is sent to the RD for payment. On receiving the cheque from RD, Thrissur, the DIMS will forward it to the Regional Cancer Centre.
- Which are the Hospitals in the State where ESI beneficiaries can avail super speciality treatment?
1) All Medical College Hospitals (Government)
2) Regional Cancer Centre, Thiruvananthapuram
3) Sree Chitra Thirunal Institute for Medical Sciences And Technology, Thiruvananthapuram
4) Amritha Institute of Medical Sciences and Research Centre, Kochi (private)
5) Fathima Hospital, Kozhikode (private)
What is the procedure for getting money reimbursed for purchasing medicines which are not available in ESI institutions from outside?
First the details of all the drugs purchased should be entered in an essentiality form. The bill and the essentiality form should then be countersigned by the doctor who prescribed it affixing seal. The bill, essentiality form, doctorâ€™s prescription and an application in white paper should then be submitted to the IMO of the dispensary. Treatment from Institutions other than ESI institutions should be on reference.
- How can the ESI beneficiaries help the department to improve its function and service?Cooperate with the staff of the ESI institutions for overcoming their difficulties and limitations to serve you better. The benefactors and the Insurance Medical Service employees should work together to achieve the great aims of this noble scheme. The IMS department welcomes the feedback from the insured persons by way of constructive suggestions and criticism.
- Whom to contact for settling questions of eligibility?
ESI Corporation determines the eligibility of an employee to receive ESI benefits.