As an employer, ensuring employee healthcare coverage is both a legal and moral responsibility. In India, two major options often come up the employee state insurance (ESI) and group health insurance (GHI). While both aim to safeguard employees’ wellbeing, their structure, benefits, and costs differ significantly.
ESI full form: Employees’ State Insurance
Employee state insurance is a scheme for employees to help with medical expenses. ESIC stands for Employees’ State Insurance Cooperation. This scheme is regulated by ESIC, a labour welfare organization that operates under the Ministry of Labour and Employment.
ESIC rolled out the ESI act of 1948 to provide for certain benefits to employees in case of sickness, maternity and employment injury and to make provision for certain other matters in relation thereto.
A factory/establishment that wants to provide ESI has to get registered under the ESI act. This can be done in the online portal www.esic.in. By providing all the details of the organization and employees, PAN, state, etc., one can get registered. Registration is mandatory under section 2A of the ESI act to avail of ESI benefits.
The contribution for ESI is built out of the monthly wages of employees. Employers and employees pay monthly at a fixed percentage of 3.25 and 0.75 of the wage. The State Governments bears 1/8th share of the cost of Medical Benefit.
To make employers employ more people with disabilities, employers are exempted from paying their share towards employees with disabilities.
Employees and their dependents get the “pehchan card” which acts as an Identity card for them to get verified and get benefits and treatment at network hospitals. ESI offers a plethora of benefits for employees and their dependents. Here are some of them.
Medical Benefit
Starts from day one of joining insurable employment. Gets comprehensive medical cover and clinical investigation.
Sickness Benefit under ESI act
Must have contributed at least 78 days. Gets 70% of average daily wages when absent from work due to sickness.
Temporary and permanent disablement
Can be availed from day 1. Gets 90% of daily wage based on the loss of earning capacity.
Maternity benefits under ESI act
Must have paid 70 days of wages. Gets 100% average daily wages for up to 26 weeks for 2 children.
Read: Maternity insurance in India
Retired
If retired, employees can pay Rs 120 on a yearly basis to cover themselves and spouse and continue getting the benefits.
ESI eligibility is defined under the Employees’ State Insurance Act, 1948. The scheme applies to certain organizations and employees based on their wages and employment type.
This ensures employees receive comprehensive medical and social security benefits through the Employees’ State Insurance Corporation (ESIC).
While the terms ESI and ESIC are often used interchangeably, they refer to different aspects of the same scheme.
Any employer or association can buy group insurance for employees/members. Group insurance can be group health insurance, group personal accident insurance, group term life insurance or group travel insurance and many more. Employers buy it from insurers or insurtech companies. Now, what’s covered in a group insurance policy is based on what policy is bought by the employer.
Insurance, including group insurance, is regulated by IRDAI, Insurance Regulatory and Development Authority.
We are taking an example of an employer buying group health insurance for easy understanding and comparison.
Employers can state their requirements and buy an insurance policy. They can decide the sum insured and what to cover (maternity, dental, vision, etc). Based on this, the insurer will give a premium that the employer has to pay once a year for an insurance policy that lasts one year. It is up to the organization to decide if they want to pay the full premium or ask employees to pay a share. This is called copay in health insurance where the employer and employee share equal or unequal percentages of the premium.
Employees get a health insurance ID card with a policy number that they can use to get insurance in hospitals. For example, if the sum insured is 5 Lakhs, the employee can get medical expenses worth 5 Lakh covered with cashless and reimbursement facility. However, what’s covered, inclusions and exclusions in a policy are different for each and are based on the underwriting of the policy.
Pre-existing diseases
All pre-existing diseases, that is. diseases employees already have before they are insured by the organization are covered in the policy. Employees can cover medical expenses for the treatment taken for the diseases they already have.
Waiting period
There is no waiting period, whatsoever.
Hospitalization
All hospitalization expenses are covered, including Covid-19. Even expenses during pre-hospitalization and post-hospitalization are covered.
Although the purpose of ESI and GHI are similar, they work in completely different ways. It is not a level playing field to compare these two and call out one better. Both have different sets of advantages and disadvantages from both employer and employee perspectives.
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Yes, ESI covers the insured employee, spouse, dependent parents, and children.
Employees earning a gross salary of up to ₹21,000 per month (₹25,000 for persons with disabilities) are eligible for ESI coverage.
Any organization with 10 or more employees (in most states; 20 in some) must register under the Employees’ State Insurance Act, 1948 and provide ESI coverage to eligible employees.
ESI provides medical care, maternity benefits, disability and sickness benefits, and dependant benefits in case of death due to employment injury.
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