Medical Benefit to Retired Beneficiaries under ESI – Draft Regulation 103AA Explained in Detail

Published On: April 4, 2025
Category: ESIC | Labour Law | Social Security
Tags: ESI Draft Regulation 2025, Medical Benefit for Retired Workers, ESIC Amendment, Post-Retirement Benefits

🧾 Introduction

In a significant move to ensure healthcare continuity for workers post-retirement, the Employees’ State Insurance Corporation (ESIC) has released a draft amendment to the Employees’ State Insurance (General) Regulations, 1950.

This amendment introduces Regulation 103AA, aiming to provide medical benefits to retired beneficiaries, including those who exited due to wage ceiling limits, superannuation, voluntary retirement, or premature retirement. This blog article provides a comprehensive breakdown of the proposed regulation, eligibility criteria, employer obligations, and implications for insured persons (IPs) and their families.

📘 Legal Background

The amendment is issued under the powers vested in ESIC through the Employees’ State Insurance Act, 1948. The ESI Scheme, which primarily provides health protection to workers earning wages under a notified ceiling, previously had limited options for post-retirement medical benefits.

While Rules 60 and 61 of the ESI (Central) Rules, 1950 covered some categories (superannuation, disablement), the draft Regulation 103AA aims to expand access to medical benefits to a broader class of retired or separated employees.

📜 Regulation 103AA – Medical Benefit to Retired Beneficiaries

The new regulation seeks to extend medical coverage to eligible retired employees and their spouses, ensuring a safety net during their non-earning phase. The medical benefits will be available under the ESIC healthcare system subject to the fulfilment of specific conditions.

✅ Who is Eligible Under Regulation 103AA?

📝 Conditions for Availing the Medical Benefit

In addition to fulfilling the eligibility criteria above, the following conditions must be met:

1. Scheme Conditions
   The retired IP must satisfy other terms laid down in the specific scheme that ESIC will notify (not yet released).
2. Employer Certificate
   A certificate from the employer confirming eligibility is required. This certificate must be in the format prescribed by the Director General, ESIC.
3. Post-Retirement Contribution
   The retired person must pay contributions as specified in the scheme, both in rate and manner.

🔄 Continuation of Benefit for Existing Rule 60/61 Beneficiaries

The proposed Regulation 103AA also accommodates those already availing medical benefits under:

• Rule 60 – Medical benefit to superannuated insured persons.
• Rule 61 – Medical benefit to permanently disabled persons.

These individuals can transition or continue benefits under the new framework provided they:

• Fulfil additional scheme requirements, and
• Continue paying contributions as per notified structure.

🏢 Employer’s Responsibility Under the Regulation

The draft clearly outlines the obligations of employers. Specifically:

• Employers are required to issue the certificate to the eligible former employee on demand, confirming the employee’s contribution details and reason for cessation.
• The certificate is mandatory for the employee to access post-retirement medical benefits.

This makes it essential for employers to maintain accurate ESI records and ensure prompt issuance of certificates to retirees.

🧾 Practical Impact – Who Benefits?

The regulation is expected to benefit:

• Workers who exited ESI coverage due to wage escalation but had long contribution histories.
• Those who retired under VRS or prematurely, often falling into a grey zone for benefits.
• Spouses of insured persons, ensuring family medical security.

This marks a shift towards inclusive social security, acknowledging that healthcare needs do not end with employment.

📬 Implementation and Next Steps

As this is a draft notification, it is open for public and stakeholder comments. Once approved, ESIC is expected to release:

• A detailed scheme notification outlining payment rates, duration, hospital access, etc.
• A certificate format to be used by employers.
• Rules for contribution collection from retired beneficiaries.

🧠 Frequently Asked Questions (FAQs)

🔹 Is this regulation currently in force?

No. As of April 2025, it is a draft regulation pending final notification.

🔹 Is the ₹30,000 wage limit fixed or will it be revised?

The current draft sets ₹30,000/month as the ceiling. Future revisions are possible based on economic indices.

🔹 Can private employers deny issuing the certificate?

No. As per Sub-Regulation (2), employers are legally obligated to issue the certificate upon request.

🔹 What happens if a retired employee worked under multiple employers?

The employee can approach the last employer with the majority contribution period or submit combined service details with supporting evidence.

🧾 Summary Chart

📢 Conclusion

This draft regulation is a progressive step by ESIC to extend the protective umbrella of the ESI Scheme beyond active employment. It recognises the healthcare needs of those who contributed significantly to the scheme and ensures that they and their spouses are not left vulnerable after retirement or wage-based exclusion.

Stakeholders – including employers, HR professionals, and employees – must stay informed, ready their documentation, and respond to ESIC’s final scheme notification once issued.