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Revised guidelines relating to implementation of ESIC Pensioner Medical Scheme-2006

Revised guidelines relating to implementation of ESIC Pensioner Medical Scheme-2006: ESIC Order dated 25.05.2021

EMPLOYEES’ STATE INSURANCE CORPORATION
(Ministry of Labour & Employment, Govt. of India)
HEADQUARTER
Panchdeep Bhawan, CIG Marg, New
Delhi- 110002

No: D-12/16/1/ 2012-E-VI.Vol.II

Dated: 25 May, 2021

MEMORANDUM

Subject : Revised guidelines relating to implementation of ESIC Pensioner Medical Scheme-2006.

The ESIC- Pensioners’ Medical Scheme came into force w.e.f. 01/04/2006. Instructions/ clarifications have been issued from time to time to smoothen the delivery of Medical Facilities under the scheme. However, there were certain issues in the implementation of the scheme and there has been constant demand from the pensioners to provide them medical facilities at par with CGHS. Accordingly a committee was constituted with a view to consolidating and rationalising the instructions of ESIC-PMS.

The recommendations of the Committee has been placed before the ESI Corporation in it’s 1s4th meeting held on 22/02/2021. Consequent upon the approval by Corporation the revised guidelines relating to implementation of ESIC-PMS 2006 is attached at Annexure-A.

In the revised guidelines significant changes have been made over the existing provisions relating to entry to the ESIC-PMS, regulation of payment of Fixed Medical Allowance, eligibility of Super Speciality Medical treatment, modalities for providing medical treatment to the beneficiaries, provision of tie-up arrangement with private hospitals etc. The revised guidelines would become applicable from the date of its issue.

The implementation of the revised guidelines would ensure that the medical facilities to our esteemed pensioners and their family members are provided in a hassle free manner almost at par with CGHS. Accordingly, all concerned authorities are directed to ensure the implementation of the revised guidelines in the proper manner.

Sd/-
(P.B. MANI)
INSURANCE COMMISSIONER (P&A)

ANNEXURE-A to Circular No. F. No.:0-12/16/1/2012-E-Vl.Vol.11 Dated: 25 May, 2021

REVISED GUIDELINES RELATING TO IMPLEMENTATION OF ESIC PENSIONER MEDICAL SCHEME- 2006- CONSEQUENT UPON THE APPROVAL OF THE RECOMMENDATI ONS OF THE COMMITTEE CONSTITUTED FOR CONSOLIDATING AND RATIONALISING THE INSTRUCTIONS RELATED TO ESIC-PMS SCHEME, 2006 BY ESI CORPORATION IN IT’S 184th MEETING HELD ON 22/02/ 2021

The ESIC- Pensioners’ Medical Scheme came into force w.e.f. 01/04/2006. Instructions/ clarifications have been issued from time to time to smoothen the delivery of Medical Facilities under the scheme. However, there were certain issues in the implementation of the scheme and there has been constant demand from the pensioners to provide them medical facilities at par with CGHS. Accordingly a committee was constituted with a view to consolidating and rationalising the instructions of ESIC-PMS.

The recommendations of the Committee were placed before the ESI Corporation in it’s 184th meeting held on 22/02/2021. Consequent upon the approval by Corporation the revised guidelines relating to implementation of ESIC-PMS 2006 is as under.

A. Provisions relating to Entry / Exit, Regulation of payment of FMA, Regulation of Treatment in Private Empanelled / Non empanelled hospital

SI No Issue. Revised guidelines.
1 Entry to ESIC-PMS
  • Pensioners would have to exercise their option regarding ESIC-PMS mandatorily by the date of their retirement.
  • If no option is received by the last date of retirement/ opts for FMA, Pensioner would become eligible for receipt of FMA from the next month of retirement.
  • If the pensioner submits his option for PMS after the date of retirement he would be required to pay an admission fee of Rs. 30 and refund the FMA received by him.
2 Fixed Medical Allowance (FMA)
  • In case no option is submitted at the time of retirement, the pensioner shall be automatically eligible for Fixed Medical Allowance.
  • Pensioner will not be eligible for FMA again once ESIC- PMS Scheme is opted out after acceptance.

(FMA-PMS–Opt out-No FMA)

3 Exit from ESIC-PMS Pensioners who opts for ESIC-PMS at the time of retirement can opt out once. After opting out, such Pensioners can re-enter the scheme for only one more time after paying a registration fee of Rs. 30 and refund of the FMA received by him.

(PMS—OptOut–FMA—Re-entry after Refund of FMA–Opt Out– No FMA and No further entry to PMS)

4 Super Speciality Treatment. Pensioners would be eligible for all kinds of medical treatment including SST from the date of entry / re­ entry into the scheme.

As per the existing provision, in cases where a pensioner becomes the member of the ESIC PMS sometime after retirement, he becomes eligible for SST only after a waiting period of Six months. Now this condition is being withdrawn

5 Medical Treatment The revised guidelines regarding provision of medical treatment to pensioners shall be as under.

1 Cashless Medical Treatment.

(a) Treatment in emergency.

In case of emergency, the pensioner can go directly to any of the nearby empanelled hospital. For this purpose, instructions may be issued by the Nodal Officer to the tie-up hospital to accept admissions in emergency for cashless treatment for ESIC pensioners on production of medical cards.

(b) Treatment at ESIC Hospital.

The medical treatment to pensioner shall be provided as under.

  • The pensioner can take the treatment as per the facility available in the ESIC hospital.
  • In case the facility in ESIC hospital is not available as per his entitlement then he can opt to have treatment from empanelled hospital and the referral to private hospital shall not be denied.

(c) Treatment from private hospital empanelled with ESIC :

  • •The pensioners shall be entitled for cashless medical treatment in Private Empanelled hospital on the basis of advice of ESIC Doctor / Govt Specialist for specific listed procedure / investigation. No other permission letter shall be required to be submitted to Tie-up hospital.

(As per CGHS OM dated 18-07-18)

2 Treatment on re- imbursement basis.

  1. In case no tie-up hospital is available for emergency treatment, the pensioner may take treatment from any nearby Govt./ Private hospital for which reimbursement is to be made restricting the claims to the ceiling of CGHS/CS(MA) Rules or actual, whichever is less.
  2. All treatment taken in any Government hospital shall be valid for reimbursement irrespective of permission by ESIC.
  3. Treatment in Tie-up / Non tie-up hospital without permission / referral:

If the pensioner takes any elective treatment / investigations from the tie-up non tie-up hospital in normal circumstances without any advice of ESIC Doctor/ Govt Specialist or without permission / referral, the request for ex-post facto approval of such treatment shall be considered by the sanctioning authority and re­ imbursement shall be limited to CGHS rates.

(As per CGHS OM dated 05-10-16)

The ESIC tie up hospitals may be directed to ensure that if a pensioner approaches the ESIC tie up hospital directly for any treatment whether OPD or IPD the hospital shall charge at CGHS rates for all procedures.

6 Direct OPD Consultation from specialists at CGHS empanelled hospitals in respect of CGHS beneficiaries aged 75 years and above. The committee has recommended for adoption of OM of CGHS No Z-15029/35/2019/DIR/CGHS/CGHS(P) dated 29- 05-19. As per this OM CGHS Pensioners aged 75 years and above are allowed direct OPD consultation from specialist of empanelled hospital without referral from CGHS wellness centre on cashless basis etc.

Accordingly, ESIC pensioners aged 75 years and above are allowed direct OPD consultation from specialist of ESIC empanelled hospitals without referral from Govt / ESIC Doctor and Hospital on cashless basis.

The concerned authority shall ensure that necessary instructions are issued to private empanelled hospital and appropriate procedures are developed to ensure availability of medical services to such pensioners accordingly.

7 Medical facility to be provided to pensioners aged 80 years and above. ESIC has already adopted the CGHS instruction for Medical facility to be provided to pensioners aged 80 years and above vide letter No.D-12/16/1/2017-E-VI dated 08/01/2018. The Medical facility to pensioners shall

continue to be provided accordingly.

The concerned authority shall ensure the proper implementation of the instruction.

 8 Applicability Guidelines of CGHS All instructions issued by CGHS in respect of provision of medical treatment to pensioners from time to time would stand applicable in ESIC.

 

B. As per the recommendations of the Committee regarding the provisions relating to identity cards, appointment of Nodal officer, issuance of PMS Medical Cards, responsibility of tie-up arrangement with tie-up hospital, the following guidelines are issued.

SI No Topic Revised guidelines
1 Nodal officer for ESIC PMS Regional Director of each region shall act as Nodal Officer for ESIC PMS whose main responsibility shall be to co-ordinate all the activities relating to PMS by the concerned offices of the region.
2 Issuance of Pensioner Medical Cards and settlement of claims. Work relating to Issuance of Pensioner Medical cards and settlement of claims shall be done by the Head of the office from where the pensioner receives his pension.
3 PMS Identity cards The practice as per CGHS shall be followed and individual card for the pensioner, spouse and other beneficiaries (if any) may be issued. The pensioner id number generated by ERP must be mentioned on the card.
4 lie-Up arrangement with Private Hospitals.

 

Regional Directors including that of Delhi shall ensure necessary tie-up arrangement with CGHS/CSMA/State Govt approved private hospitals to ensure availability of all medical facilities including tertiary care to pensioners as per their entitlement in consultation with the M.S. of the nearest ESIC Hospital.

If deemed necessary the tie up arrangement may also be done with hospitals other than CGHS/CSMA/State Govt approved private hospitals as per local requirement. The terms and conditions of tie up arrangements shall be similar to that of tie up arrangements made by CGHS for its beneficiaries.

 

(C) The provisions of the existing ESIC-PMS with respect to the following shall continue to be apply as such.

  1. Contribution required for ESIC-PMS.
  2. Entitlement of Wards for medical treatment.
  3. Definition of ‘family’.
  4. Meaning of recognised hospital.
  5. Appointment of AMA.
  6. Reimbursement of claims in emergency
  7. Appointment of AMAs .
  8. Medical Advance.
  9. Period prescribed for settlement of claims.
  10. Travelling Allowance.

*****

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