Scores of patients seeking medical reimbursement benefits from the Employee State Insurance Corporation (ESIC) have been put on long wait, as the claims have not been cleared since 2014-15.
Officials attribute the delay to the discontinuation of the Corporation’s contribution to the revolving fund from which the reimbursement claims were being met.
State government, which should have come to the rescue of the beneficiaries, has further delayed the reimbursement owing to technical reasons.
Pending payment
As per the information shared by the Directorate of Insurance Medical Services, claims worth ₹ 30-40 crore have not been realised since April 2015. The number of total bills pending payments stands at 550, though it is possible that a single beneficiary might have submitted more than one bill.
Employees of factories, shops, hotels, restaurants, cinemas, newspapers and other establishments who are drawing wages less than ₹21,000 per month (before 2017, it had been ₹15,000 per month) are eligible for the social security benefits under the ESI scheme. Construction workers too have been included in the scheme two years ago.
Contributions from employees as well as employers fund the scheme, with those earning less than ₹137 per day as wages being exempted from paying their part of the contribution.
The ESIC pays ₹2,000 per insured person per year, and in whichever states the they are operational, part of the contributions are paid into the revolving funds.
Besides availing free medical services at the ESIC dispensaries, empanelled clinics and hospitals, the beneficiaries are also eligible for secondary care in super speciality hospitals outside the ESIC facilities. These apart, they can also claim reimbursement of medical bills after getting treated at any other hospital.
Reimbursement up to ₹10 lakh can be cleared by the state directorate, while those over and above the limit are referred to a panel of experts in New Delhi.
Technical issues
“With the discontinuation of ESIC’s contribution to the revolving fund, the total ₹2000 contribution per person is being credited to the Pay and Accounts Office of the State government. But the reimbursement from PAO cannot exceed ₹2 lakh per bill, as per the policy. Hence, all the bills over and above ₹2 lakh have been stranded,” Director Insurance Medical Services C.H.Devika Rani said. Separate government orders have to be issued through the Department of Medical Education (DME) for all the payments over ₹2 lakh. However, the DME officials are apprehensive as there was no precedent of doing it.
After prolonged delay and communication with various departments, the issue has been resolved with the intervention by the State Medical Commissioner, ESIC. The bills will be sent on priority to the Commissioner and cleared on quarterly basis, Dr. Devika Rani informed.