ESIC Treatment Denied? Use RTI to Unstick the Claim

The account below is illustrative: a realistic pattern of denial and recovery, not a reported case. The rules and the paperwork are exactly as described.

This is far from rare. Denial at the counter followed by a reimbursement run-around is among the most common complaints insured persons raise — and what usually moves the file is a written, reasoned demand. The RTI Act is the cleanest way to make one.

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 — a statutory corporation first created by the ESI Act 1948 and now continued under the Code on Social Security, 2020 — so 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 scheme governed by the Code on Social Security, 2020. 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 circumstances and conditions under which claims for reimbursement of medical treatment expenses of an IP and family are accepted under Regulation 96-A of the ESI (General) Regulations 1950 (which continue in force during the transition to the Code on Social Security, 2020), including emergency cases, with copies of any internal circular limiting or 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 scheme governed by the Code on Social Security, 2020. 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.
• Your State's ESI medical directorate — in most states ESIC hospitals and dispensaries are run by the State's ESI medical machinery, which has its own grievance channel.

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.

New to RTI? Start with RTI in 12 simple steps, and keep the helplines list handy while you wait.

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 in writing. The outright exclusions are narrow; most conditions are covered with an appropriate package or referral. Make them name the exact provision and date.
• “No prior approval, claim rejected.” — Cite Regulation 96-A of the ESI (General) Regulations 1950 and the conditions ESIC has laid down under it: where an insured person hit by a serious emergency — sudden heart attack, spine fracture, cerebral haemorrhage and the like — is taken straight to a private or non-recognised hospital because a scheme hospital would have risked health, reimbursement is a recognised ground. Similar grounds cover treatment during dispensary off-hours, when all reserved ESI beds are occupied, and when prescribed medicines are out of stock. Claims must be submitted within one year.
• “Cashless tie-up exhausted budget.” — Budget exhaustion is not a ground in any regulation. Your entitlement is statutory — ask for the written order that denied it.
• “You're no longer in insurable employment.” — Even if you've left the job, extended medical benefit under Regulation 103-B of the ESI (General) Regulations 1950 can continue for specified long-term diseases. Family entitlement continues during the contribution period.
• “Information is third-party (medical staff names).” — Names and designations of public servants acting in official duty are not “personal information” under §8(1)(j) merely because a person is named. The Supreme Court has consistently read the RTI exemptions narrowly — see CBSE v. Aditya Bandopadhyay, (2011) 8 SCC 497.

This list is for cross-checking the right benefit (rates as published by ESIC):

• Medical Benefit — full medical care for IP + family, including hospitalisation, drugs, super-specialty referral.
• Sickness Benefit — 70% of average daily wages for up to 91 days in two consecutive benefit periods (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% of wages.
• Maternity Benefit — 26 weeks for the first two children (12 weeks for a third or subsequent child) + ₹5,000 confinement expenses if the delivery happens outside an ESIC facility.
• Disablement Benefit — for employment injury, from day one. Temporary: 90% of wages. Permanent: lifelong pension based on loss of earning capacity.
• Dependants' Benefit — monthly pension to family if IP dies due to employment injury.
• Funeral Expenses — ₹15,000 lump sum on death of IP.
• Vocational rehabilitation and physiotherapy services run by ESIC for disabled insured persons.
• Unemployment Allowance (Atal Beemit Vyakti Kalyan Yojana) — 50% of average daily wages for up to 90 days (once in a lifetime) 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. In an emergency the scheme treats first and sorts the paperwork later — the temporary IP slip / employer-issued letter is enough for emergency treatment.

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 falls within a recognised ground under Regulation 96-A and ESIC's conditions under it — direct admission in a serious emergency, off-hours treatment, all scheme beds occupied, prescribed medicines out of stock, and similar. Verbal assurances by hospital staff are not binding. Ask for a 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 the old ESI Act 1948 this was §85B; the protection continues under the Code). Cite this in your RTI.

Q. My maternity benefit is only paying for 12 weeks — should it not be 26?
Under the ESI scheme's maternity rules (aligned with the 2017 maternity amendment), ESIC maternity is 26 weeks for the first two children. For the third or subsequent child, it is 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 — out-of-stock medicines forced on the market are a recognised reimbursement ground. Submit the bill within ESIC's one-year claim window; sooner is safer. 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. In the illustrative story above, the written reply came in 26 days — and ₹1.62 lakh followed in five weeks. The same path is open to you.

For the full journey in plain language, read The RTI Playbook. The same method works for EPF deducted but not deposited, Ayushman Bharat claim denial and widow pension not credited.

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.