The Employees’ State Insurance (ESI) scheme is a government-backed social security program that provides medical, disability, maternity, and dependent benefits to workers in India. Many employees and employers are aware of the scheme but unsure about how much financial help one can actually receive.
This blog breaks down the maximum claim limits under ESI covering medical expenses, sickness benefits, maternity claims, and more to help you understand how much support is available and under what conditions.
Introduction
The ESI scheme, managed by the Employees’ State Insurance Corporation (ESIC), plays a vital role in supporting workers who fall sick, meet with accidents, or need maternity or medical care. Both the employer and employee contribute a small percentage of wages each month, and in return, the employee becomes eligible for a range of benefits.
While the benefits are broad, there is often confusion about how much an employee can actually claim under ESI. Whether it is for hospital bills, cash during sick leave, or maternity benefits, understanding the maximum claim limits helps in planning and using the scheme more effectively.
Who Can Claim ESI Benefits?
To be eligible for any of these ESI benefits, the employee must –
- Be registered under the ESI scheme
- Have a valid ESIC Pehchan card
- Have contributed for the minimum required period
- Take treatment or certification through ESIC-authorized hospitals or doctors
Different Types of Benefits Offered under ESI and Claim Limits
1. Medical Benefit – No Maximum Limit
Under the ESI scheme, medical treatment is provided free of cost to the insured person and their family at ESIC dispensaries and hospitals. This includes –
- OPD (Outpatient care)
- IPD (Inpatient care)
- Specialist consultations
- Medicines, diagnostic tests, and surgeries
- Emergency treatments
Maximum Limit – No cap — the treatment cost is fully borne by ESIC, as long as it is taken in an approved ESI hospital or clinic.
Note- If treatment is taken at a private hospital without ESIC referral, reimbursement is not guaranteed unless it’s an emergency and later approved by ESIC.
2. Sickness Benefit – 70% of Wages (up to 91 days per year)
If you are unable to work due to illness and your absence is certified by an ESIC doctor, you are entitled to a cash benefit.
- Paid at 70% of average daily wages
- Can be availed for a maximum of 91 days in a year
- Requires a contribution for at least 78 days in a contribution period
Maximum Limit – Based on your wages. For example, if your daily wage is Rs 500, you can get Rs 350/day for up to 91 days.
3. Extended Sickness Benefit – Up to 80% of Wages (up to 2 years)
This benefit applies to people suffering from long-term serious illnesses such as tuberculosis, cancer, chronic asthma, or mental disorders (as listed by ESIC).
- Paid at 80% of wages
- Valid for up to 2 years with proper medical documentation
- Only available to those who have contributed for at least 2 years
Maximum Limit – 80% of your average daily wage for up to 730 days.
4. Maternity Benefit – 100% of Wages (up to 26 weeks)
Women insured under ESI are eligible for full wage compensation during maternity leave. The duration depends on the number of children –
- 26 weeks for the first and second child
- 12 weeks for the third child onwards
- 6 weeks in case of a miscarriage
- 1 month for complications or confinement-related illness
Maximum Limit – 100% of your full salary for the eligible duration. There’s no fixed cap, but you must have contributed for at least 70 days in the last two contribution periods.
5. Temporary Disablement Benefit – 90% of Wages (till recovery)
If you get injured while on duty and are temporarily unable to work –
- You are eligible for 90% of your average daily wages
- Paid for as long as you are unable to work
- Certified by ESIC doctors
Maximum Limit – No cap on duration, it continues until the worker fully recovers.
6. Permanent Disablement Benefit – Lifelong Monthly Payment
If the injury results in permanent disability (full or partial), you are eligible for a monthly pension, calculated based on –
- The percentage of disability assessed by a medical board
- 90% of wages are proportionate to the extent of loss in earning capacity
Maximum Limit – No maximum monetary cap; it continues for life or until recovery (if partial).
7. Dependent Benefit (for the family of the deceased worker)
If a worker died due to an employment injury or occupational hazard –
- Dependents (spouse, minor children, parents) are eligible for monthly pensions
- The total amount is shared among dependents
- The family gets 90% of the insured person’s wages
Maximum Limit – No upper limit on the claim; benefit continues till the dependent’s eligibility expires (e.g., child turns 25, spouse remarries, etc.)
8. Funeral Expenses – Up to Rs 15,000
In case of the death of an insured person –
- A one-time payment of Rs 15,000 is given to the person who performs the last rites
- This amount may be revised by ESIC from time to time
Maximum Limit – Rs 15,000
9. Vocational Rehabilitation and Free Aids
For disabled insured persons, ESIC also provides:
- Free rehabilitation training at vocational centers
- Supply of wheelchairs, hearing aids, artificial limbs, etc.
Maximum Limit: Varies case-by-case, but expenses are covered fully by ESIC within guidelines.
Conclusion
The ESI scheme provides a wide range of benefits, many of which come with no maximum limit, especially when it comes to medical care, disability support, or dependent compensation. While benefits like sickness and maternity have time or wage-based limits, they still offer substantial financial protection compared to private insurance.
Knowing the maximum claim limits under ESI helps employees understand their entitlements and use the scheme fully when needed. It is not just a deduction from your salary, and it is a lifeline during medical emergencies, job-related accidents, or personal health issues.
If you are covered under ESI, make sure your KYC is up to date and you know which hospital or dispensary is linked to your coverage so that when the need arises, you do not just hope for help, you know where to get it.
Related Services
References
The Employees’ State Insurance Act, 1948
https://www.icsi.edu/home/
