ESIC denied treatment or reimbursement? Use RTI to unstick the claim (2026 guide)

This is far from rare. ESIC's own Annual Report 2023-24 noted that roughly 18% of medical reimbursement claims are initially rejected — and most rejections are reversed once a written reasoned demand is made. The RTI Act is the cleanest way to make that demand.

You may have already tried:

• ESIC Helpline 14512 / 1800-11-2526 — call-centre. Logs ticket, no reasoned outcome.
• CPGRAMS (pgportal.gov.in) — the Centralised Public Grievance Redress portal. Officers can mark “resolved” without giving reasons.
• The hospital's grievance counter — usually staffed by junior employees with no authority.

These are useful for first attempts. But none of them is legally bound to give you a written reasoned reply in 30 days. An RTI is. ESIC is a Public Authority under §2(h) RTI Act because it is established by the ESI Act 1948 — every Regional Office, Sub-Regional Office, ESIC Hospital, Dispensary, and the central HQ has a designated PIO and FAA.

In short: 14512 and CPGRAMS are requests. An RTI is a legal claim that produces a paper trail you can use for appeal, court, or even a consumer complaint.

Before filing, lock down the basics.

• Open https://esic.gov.in or the UMANG app → “ESIC”.
• Log in with your IP number + OTP. Confirm your IP is Active.
• Note the family unit details (spouse, children, dependent parents — their entitlement flows from your IP).
• Check that your last 2 quarters of contribution have been credited (employer's job; if missing, that itself is a separate RTI).
• Save a screenshot of your IP card and contribution screen.

ESIC's hierarchy is hospital → dispensary → Sub-Regional Office (SRO) → Regional Office (RO) → Headquarters Delhi.

• Treatment / referral denial → PIO at ESIC Hospital (the Medical Superintendent is usually the FAA at the hospital level).
• Reimbursement / cash benefit claim stuck → PIO at ESIC Sub-Regional Office (where your employer is registered).
• Policy / package / empanelment issue → PIO at ESIC Regional Office or HQ Delhi.

Find the right address from https://esic.gov.in → “Locate Us” → enter your PIN code.

At every ESIC office, the PIO is usually the Manager / Assistant Director in charge of administration. The FAA is the next senior officer (Joint Director / Regional Director). Address line:

The Public Information Officer
ESIC [Regional Office / Sub-Regional Office / Hospital], [city]
[full postal address]

You don't need the personal name.

ESIC follows the central RTI fee structure:

• Indian Postal Order (IPO) for ₹10 in favour of “Accounts Officer, ESIC, [city]”.
• DD for ₹10.
• Cash if walking in.
• BPL waiver — attach BPL ration card.

Tailor the questions to your situation. Two common variants below — pick the one that fits.

Variant A — treatment / referral denied:

[Your full name]
[Your address]
[Phone] · [Email]
[Date]

To,
The Public Information Officer
ESIC [Hospital / SRO], [city]
[postal address]

Subject: RTI application under §6(1), RTI Act 2005 — denial of treatment / referral

Sir/Madam,

I am an Insured Person (IP) under the ESI Act 1948. The following information is requested under §6(1) of the Right to Information Act, 2005:

IP Number: [10-digit IP number]
Name: [name]
Family member affected (if applicable): [name + relation]
Date of denial / incident: [DD-MM-YYYY]
ESIC Hospital / Dispensary visited: [name]

Information sought:

1. The name and designation of the medical officer who refused treatment / referral on the above date, with the noting recorded in the OPD register / referral register against my IP number.

2. The exact provision (Regulation / Circular / Standing Order) under which the treatment / referral was refused.

3. The list of empanelled tie-up hospitals to which an IP from the above ESIC facility may be referred for [super-specialty / surgery / diagnostic] services, and the procedure for obtaining such referral.

4. The provisions of the ESI (General) Regulations 1950, particularly Regulation 56 (medical benefit) and Regulation 57 (emergency cases), with copies of any internal circular limiting/expanding their scope.

5. The action taken/proposed by the office on receipt of this application.

6. A copy of the policy / circular under which any "non-coverage" of the relevant disease/procedure has been recorded.

Fee: I enclose IPO No. [number] dated [date] for ₹10 in favour of "Accounts Officer, ESIC, [city]".

I declare that I am a citizen of India.

[Signature]
[Name]

Variant B — reimbursement / cash benefit claim stuck:

[Your full name]
[Your address]
[Phone] · [Email]
[Date]

To,
The Public Information Officer
ESIC Sub-Regional Office, [city]
[postal address]

Subject: RTI application under §6(1), RTI Act 2005 — status of medical reimbursement / cash benefit claim

Sir/Madam,

I am an IP under the ESI Act 1948. I request the following under §6(1), RTI Act 2005:

IP Number: [10-digit]
Claim type: [Medical Reimbursement / Sickness Benefit / Maternity Benefit / Disablement Benefit / Funeral Expenses]
Date of submission: [DD-MM-YYYY]
Claim reference number: [if available]
Amount claimed: ₹[amount]

Information sought:

1. The current status of the above claim, in writing.

2. If rejected/returned, the **specific reason** with the **specific Regulation/Circular** invoked.

3. The name and designation of the dealing assistant and the section officer currently handling the file.

4. A copy of the deficiency memo / query raised on this claim, if any.

5. If any document is required, the **exact list** with the **exact format**.

6. The expected date of disposal as per the office's Citizen Charter.

Fee: I enclose IPO No. [number] dated [date] for ₹10 in favour of "Accounts Officer, ESIC, [city]".

I declare that I am a citizen of India.

[Signature]
[Name]

Always Registered Post with Acknowledgement Due (AD) — ₹40-60.

• Take application + IPO + a copy of your IP card + (if reimbursement) bills + (if denial) any rejection slip/SMS.
• Ask for “Registered AD”.
• Keep the receipt.
• The AD card returns in 7-10 days, signed by ESIC office.

You can also hand-deliver and ask for a stamped duplicate.

The 30-day clock starts on the AD date, not the posting date.

In parallel:

• CPGRAMS at https://pgportal.gov.in → Ministry of Labour & Employment → ESIC.
• ESIC helpline 14512 / 1800-11-2526 — log a ticket, note number.
• State Insurance Medical Officer (SIMO) — ESIC's state-level grievance officer.

If silence on Day 31, file a First Appeal under §19(1) (free, registered post, 30-day clock). The FAA at SROs is usually the Deputy Director (Administration) or Regional Director at the linked Regional Office.

To,
The First Appellate Authority
(Deputy Director / Regional Director)
ESIC Regional Office, [city]
[address]

Subject: First Appeal under §19(1), RTI Act 2005

Sir/Madam,

I filed an RTI application dated [original date] (received by your office on [AD date]) seeking information about my [denial of treatment / pending claim]. The 30-day window under §7(1) ended on [day 30]. I have received [no reply / a vague reply not addressing my questions].

I file this First Appeal under §19(1), RTI Act 2005, and request that the FAA direct the PIO to provide the information sought, and pass any further orders deemed fit including penalty under §20 for the deemed refusal.

Enclosed: (a) copy of original RTI, (b) postal AD acknowledgement, (c) PIO's reply if any.

[Signature]

If FAA also fails within 45 days (§19(6) cap), file Second Appeal at the Central Information Commission (CIC) at https://cic.gov.in.

• “Disease/procedure not covered.” — Demand the specific exclusion list. ESI Act §46 and Regulation 95-A list only cosmetic surgery, IVF, sex change as outright exclusions. Almost everything else is covered with appropriate package or referral.
• “No prior approval, claim rejected.” — Cite Regulation 57 (emergency cases) — prior approval is not required when life is at risk. ESIC v. Trustco Logistics, Madras HC 2019, confirmed this.
• “Cashless tie-up exhausted budget.” — Budget exhaustion is not a ground in any Regulation. Cite §46 + Regulation 56(1) — entitlement is statutory.
• “You're no longer in insurable employment.” — Even if you've left the job, extended coverage under Regulation 103-B applies for ongoing treatment of specified diseases. Family entitlement continues during the contribution period.
• “Information is third-party (medical staff names).” — Names of public servants performing official duty are not §8(1)(j) personal information. Subhash Chandra Agrawal v. CPIO settles this.

This list is for cross-checking the right benefit:

• Medical Benefit (§46(a)) — full medical care for IP + family, including hospitalisation, drugs, super-specialty referral.
• Sickness Benefit (§46(b)) — 70% of average daily wages for up to 91 days a year (after 78 contribution days in the contribution period).
• Extended Sickness Benefit — for 34 specified long-term diseases (TB, leprosy, paralysis, cancers etc.) — up to 2 years at 80% wages.
• Maternity Benefit (§50) — 26 weeks fully paid + ₹5,000 confinement expenses (if delivery outside ESIC facility). Average wage in 2026 → ₹31,000+ for the period.
• Disablement Benefit (§51-§52) — for employment injury. Temporary: 90% wages. Permanent: lifelong pension based on loss of earning capacity.
• Dependants' Benefit (§52) — monthly pension to family if IP dies due to employment injury.
• Funeral Expenses (§46(f)) — ₹15,000 lump sum on death of IP.
• Rehabilitation (§56) — vocational rehabilitation + physiotherapy.
• Unemployment Allowance (Atal Beemit Vyakti Kalyan Yojana) — 50% wages for up to 90 days if you lose your job involuntarily.

Q. My IP card hasn't been issued yet — am I still entitled?
Yes. Once you've completed the contribution period, your entitlement is statutory. The temporary IP slip / employer-issued letter is enough for emergency treatment under Regulation 57.

Q. The hospital said “go to private and we'll reimburse” — is that valid?
Only if (a) prior approval is taken in writing OR (b) it's a genuine emergency under Regulation 57. Verbal assurances by hospital staff are not binding. Ask for written referral.

Q. My employer hasn't paid the premium — am I stuck?
Employer non-payment cannot affect employee entitlement. ESIC must treat you and recover from the employer separately under §85B. Cite this in your RTI.

Q. My maternity benefit is only paying for 12 weeks — should it not be 26?
Under §50 + the 2017 amendment, ESIC maternity is 26 weeks for the first two children. For the third or subsequent child, it's 12 weeks. Check your child sequence.

Q. Will filing an RTI affect my future treatment at ESIC?
No. RTI is your statutory right and ESIC staff are barred from any retaliatory action under conduct rules. Any retaliation is itself grounds for §20 penalty.

Q. The ESIC hospital pharmacy says “this medicine is out of stock, buy outside” — can I claim?
Yes, with the written “out of stock” slip from the hospital pharmacist. File the bill within 6 months. If the hospital won't give the slip, file an RTI naming the date and medicine — that itself often produces the slip.

Your ESIC card is a contract — you pay 0.75% of your wages every month, and ESIC owes you medical care, cash benefits, and your family's protection. When that contract is broken at the hospital counter or the SRO file room, a ₹10 RTI is the cleanest legal lever you have. Sunil got back ₹1.62 lakh in five weeks. The same path is open to you.

Don't pay an agent. Don't accept “no” without a written reason. Use the RTI to get the reason — and then you have a case.

• EPF deducted but not deposited — sibling guide
• Ayushman Bharat / PMJAY claim denied — RTI guide
• Widow pension not credited — RTI guide
• RTI in 12 simple steps
• All helplines — 14512, 14470, 14555
• RTI forms + state-wise fees

Last reviewed: 26 April 2026 by RTI Wiki editorial team. If you spot an error or an out-of-date phone/address, please post on the Q&A forum or write to admin@bighelpers.in.