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Condonation in r/o cashless SST treatment rendered by Empanelled Hospitals in case of In-eligible ESI Beneficiaries

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Headquarters Office
Employees’ State Insurance Corporation
Panchdeep Bhawan: C.I.G. Road
New Delhi -110002.

F: U-16/30/640/2017-Pro.Cell (SST)/KK Nagar

Dated: 04/06/2020

To,

The Director (Med.) Delhi / Director (Med.) Noida
Regional Directors/SMO- All States
Medical Superintendents – All ESIC Hospitals.
Deans – All ESI PGIMSR’s & Medical Colleges
Director Insurance Medical Services – All States

Sub : Condonation in r/o cashless SST treatment rendered by Empanelled Hospitals in case of In-eligible ESI Beneficiaries

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Sir/ Madam,

I am to convey that Hqrs. Office has received numerous requests from various Regional Offices/ESIC Institutions over a time for condonation with respect to eligibility of ESI Beneficaries who have been referred and the treatment was rendered by the tie-up hospital but later were found ineligible at the ESIC IP portal while making payment.

The issue has been viewed seriously by Director General and it has been directed that:

1. Respective Referring Authorities of ESI Institutions have to mandatorily check the eligibility criteria of the beneficiary/dependent before issuance of a referral letter. It is to be ensured that no such beneficiary/dependent may be referred to the tie-up hospitals whose eligibility credentials are not fulfilled on the IP eligibility portal.

2. Respective Competent Authorities have to ensure that the directions and guidelines such as eligibility criteria, referrals, etc issued from Hqrs. Office from time to time shall be intimated and incorporated in the MoU’s signed with the tie-up hospitals for strict adherence.

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3. Tie-up hospitals at their end also have to check and ensure the eligibility criteria for the Beneficiary/Dependent for Whom the referral has been generated. In case of missing information/unfulfillment of entitlement criteria in r/o the beneficiary/dependent, the respective Competent Authority to be contacted before commencement of treatment. In case ESI beneficiary is referred to tie up hospital and found to be ineligible then it will be the responsibility of referring unit to make payment or the amount paid by Regional Office shall be deducted from on account payment of referring State.

4. Further, respective Competent Authorities are directed to examine and report above cases (if any) to Hqrs. Office along with the preventive measures been taken in this regard.

This is issued with the approval of Competent Authority.

Yours faithfully

(Dr. ANITA SETHI)
Dy. Medical Commissioner (SST)

Signed Copy

 

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