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55. Sickness benefit
(1) Subject to the provisions of the Act and the regulations, a person shall be qualified to claim sickness benefit for sickness occurring during any benefit period if the contribution in respect of him were payable for not less than seventyeight days in the corresponding contribution period and shall be
entitled to receive such benefit at the daily standard benefit rate for the period of his sickness:
PROVIDED that in case of a person who becomes an employee within the meaning of the Act for the first time and for whom a shorter contribution period of less than 156 days is available, he shall be qualified to claim sickness benefit if the contribution in respect of him were payable for not less than half the number of days available for working in such contribution period:
PROVIDED FURTHER that sickness benefits shall not be paid to any person for more than ninety-one days in any two consecutive benefit periods.
(2) The daily rate of sickness benefits in respect of a person during any benefit period shall be the "standard benefit rate" specified in rule 54 corresponding to the average daily wages of that person during the corresponding contribution period.
56. Maternity benefits
(1) An insured woman shall be qualified to claim maternity benefits for a confinement occurring or expected to occur in a benefit period, if the contributions in respect of her were payable for not less than seventy days in the immediately preceding two consecutive contribution periods.
(2) Subject to the provisions of the Act and the regulations, if any, an insured woman who is qualified to claim maternity benefits in accordance with sub-rule (1) shall be entitled to receive it at the daily rate specified in sub-rule (5) for all days on which she does not work for remuneration during a period of twelve weeks of which not more than six weeks shall precede the expected date of confinement:
PROVIDED that where the insured woman dies during her delivery or during the period immediately following the date of her delivery for which she is entitled to maternity benefits, leaving behind in either case, the child, maternity benefits shall be paid for the whole of that period but if the child also dies during the said period, then for the days up to and including the day of the death of the child, to the person nominated by the insured woman, in such manner as may be specified in the regulations, and if there is no such nominee, to her legal representative.
(3) An insured woman who is qualified to claim maternity benefits in accordance with sub-rule (1) shall, in case of miscarriage or medical termination of pregnancy, be entitled, on production of such proof, as may be required under the regulations, to maternity benefits at the rates specified in sub-rule (5), for all days on which she does not work for remuneration during a period of six weeks immediately following the date of her miscarriage or medical termination of pregnancy.
(4) An insured woman who is qualified to claim maternity benefits in accordance with sub-rule (1), in case of sickness arising out of pregnancy, confinement, premature birth of child or miscarriage or medical termination of pregnancy shall, on production of such proof as may be required under the regulations, be entitled, in addition to the maternity benefits, payable to her under any other provisions of the Act, for all days on which she does not work for remuneration to maternity benefits at the rates specified in the sub-rule (5) for all days on which she does not work for remuneration during an additional period not exceeding one month.
(5) The daily rate of maternity benefits payable in respect of confinement occurring or expected to occur during any benefit period shall be equal to twice the "standard benefit rate" specified in rule 54 corresponding to the average daily wages in respect of the insured woman during the corresponding contribution period or rupees twenty, whichever is higher.
56A. Medical bonus to an insured woman and an insured person in respect of his wife shall be paid a sum of rupees two hundred and fifty per case as medical bonus on account of confinement expenses:
PROVIDED that the confinement occurs at a place where necessary medical facilities under the Employees’ State Insurance Scheme are not available.
57. Disablement benefits
(1) A person shall be qualified to claim disablement benefits for temporary disablement for not less than three days (excluding the days of accident) for the period of such disablement sustained as an employee under the Act.
(2) A person shall be qualified to claim periodical payment for permanent disablement sustained as an employee under the Act, whether total or partial, for such disablement:
PROVIDED that where permanent disablement, whether total or partial, has been assessed provisionally for a limited period or finally, the benefit provided under this rule shall be payable for that limited period, or as the case may be, for life.
(3) (a) The daily rate of disablement shall be forty per cent more than the standard benefit rate specified in rule 54 rounded to the next higher multiple of five paise corresponding to the average daily wages in the contribution period corresponding to the benefit period in which the employment injury occurs.
(b) Where an employment injury occurs before the commencement of the first benefit period in respect of a person, the daily rate of disablement shall be–
(i) where a person sustains employment injury after the expiry of the first wage period in the contribution period in which the injury occurs, the rate, forty per cent more than the standard benefit rate rounded off to the next higher multiple of five paise corresponding to the wage group in which his average daily wages during that wage period fall;
(ii) where a person sustains employment injury before the expiry of the first wage period in the contribution period in which the injury occurs, the rate, forty per cent more than the standard benefit rate, rounded off to the next higher multiple of five paise corresponding to the group in which wages are actually earned or which would have been earned, had he worked for a full day on the date of accident, fall.
Explanation : Disablement benefit calculated as aforesaid shall be called "full rate".
(4) The disablement benefits shall be payable to insured person as follows:
(a) for temporary disablement, at the full rate;
(b) for permanent total disablement, at the full rate;
(c) for permanent partial disablement resulting from an injury specified in Part II of the Second Schedule, at such percentage of the full rate which would have been payable in the case of permanent total disablement, as specified in the said Schedule as being the percentage of the loss of earning capacity caused by the injury;
(d) for permanent partial disablement resulting from an injury not specified in Part II of the Second Schedule, at such percentage of the full rate payable in the case of permanent total disablement as is proportionate to the loss of earning capacity permanently caused by the injury.
Explanation : Where more injuries than one are caused by the same accident, the rate of benefit payable under clauses (c) and (d) shall be aggregated but not so in any case as to exceed the full rate and in cases of disablement not covered by clauses (a), (b), (c) and (d) at such rate, not exceeding the full rate, as may be provided in the regulations.
58. Dependants’ benefits
(1) Dependants’ benefit shall be paid to the dependants of the insured person who dies as a result of an employment injury, in the following manner:–
(A) In the case of death of the insured person, the dependants’ benefits shall be payable to his widow, children and widowed mother as follows:–
(a) to the widow during life until remarriage, an amount equivalent to three-fifths of the full rate and, if there are two or more widows, the amount payable to the widows as aforesaid shall be divided equally between the widows;
(b) to each legitimate or adopted son, an amount equivalent to two-fifths of the full rate until he attains the age of eighteen years:
PROVIDED that in the case of a legitimate or adopted son who is infirm and who is wholly dependent on the earnings of the insured person at the time of his death, dependants’ benefits shall continue to be paid while the infirmity lasts;
(c) to each legitimate or adopted unmarried daughter, an amount equivalent to two-fifths of the full rate until she attains the age of eighteen years or until marriage, whichever is earlier:
PROVIDED that in the case of legitimate or adopted unmarried daughter who is infirm and is wholly dependent on the earnings of the insured person at the time of his death, dependants’ benefit shall continue to be paid while the infirmity lasts and she continues to be unmarried:
PROVIDED FURTHER that if the total of the dependants’ benefit distributed among the widow or widows and legitimate or adopted children and widowed mother of the deceased person as aforesaid exceeds at any time the full rate, the share of each of the dependants shall be proportionately reduced, so that the total amount payable to them does not exceed the amount of disablement benefits at the full rate.
(d) to the widowed mother during life an amount equivalent to two-fifth of the full rate.
(B) In case the deceased person does not leave a widow or legitimate or adopted child or widowed mother, dependant’s benefit shall be payable to other dependants as follows:
(a) to a parent other than the widowed mother or grand-parent, for life, at an amount equivalent to three-tenths of the full rate and if there are two or more parents (other than widowed mother) or grand-parents the amount payable to the parents (other than widowed mother) or grand-parents as aforesaid shall be equally divided between them;
(b) to any other–
(i) male dependant, until he attains the age of eighteen years,
(ii) female dependant, until she attains the age of eighteen years or until marriage, whichever is earlier or if widowed, until she attains eighteen years of age or remarriage, whichever is earlier;
at an amount equivalent to two-tenths of the full rate:
PROVIDED that if there be more than one dependant under clause (b), the amount payable under this clause shall be equally divided between them.
(2) (a) The daily rate of dependant’s benefit shall be forty per cent more than the "standard benefit rate" specified in rule 54 rounded off to the next higher multiple of five paise corresponding to the average daily wages in the contribution period corresponding to the benefit period in which the employment injury occurs.
(b) Where an employment injury occurs before the commencement of the first benefit period in respect of a person, the daily rate of dependant’s benefit shall be :
(i) where a person sustains employment injury after the expiry of the first wage period in the contribution period in which the injury occurs, the rate, forty per cent more than the standard benefit rate rounded off to the next higher multiple of five paise corresponding to the wage group in which his average daily wages during that wage period fall;
(ii) where a person sustains employment injury before the expiry of the first wage period in the contribution period in which the injury occurs, the rate, forty per cent more than the standard benefit rate, rounded off to the next higher multiple of five paise corresponding to the group in which wages actually earned or which would have been earned had he worked for a full day on the date of accident/fall.
Explanation : Dependant’s benefit rate calculated as aforesaid shall be called "full rate".
59. Funeral expenses
The amount of funeral expenses for the purpose of clause (f) of sub-section (1) of section 46 of the Act shall be two thousand and five hundred rupees.
60. Medical benefits to insured person who ceases to be in an insurable employment on account of permanent disablement
An insured person who ceases to be in an insurable employment on account of permanent disablement caused due to an employment injury shall be eligible to receive medical benefits for himself and his spouse at the scale prescribed under the Act and the regulations made thereunder till the date on which he would have vacated the employment on attaining the age of superannuation, had he not sustained such permanent disablement, subject to–
(i) the production of proof by such an insured person that he ceased to be in an insurable employment on account of permanent disablement due to employment injury to the satisfaction of such officer as may be authorised by the Corporation; and
(ii) the payment of contribution at the rate of ten rupees per month in lump sum for one year at a time in advance to the concerned office of the Corporation in the manner prescribed by it.
61. Medical benefits to retired insured persons
An insured person who leaves the insurable employment on attaining the age of superannuation after being insured for not less than five years, shall be eligible to receive medical benefits for himself and his spouse at the scale prescribed under the Act and the regulations made thereunder, subject to–
(i) the production of proof of his superannuation and having been in the insurable employment for a minimum of five years to the satisfaction of such officer as may be authorised by the Corporation; and
(ii) the payment of contribution at the rate of ten rupees per month in lump sum for one year at a time in advance to the concerned office of the Corporation in the manner prescribed by it.
62. Bar on grant of cash benefits
Where an insured person is convicted under section 84 of the Act, he shall not be entitled to any cash benefit admissible under the Act for a period of three months for first conviction and six months for each subsequent conviction from the date of receipt of judgement of the court in the concerned office of the Corporation.
FORM I
BANK OR BANKS FOR DEPOSITING THE FUNDS [Rule 21]
Book. No. …………… Receipt No. ……..
Received from ……… the sum of Rs. ………
(in words) ……….. on account of …………….
Rs. …………………………
Chief A/c. Officer/Authorised Officer Entered in Cash Book, Page No. …………… Book. No. …………… Receipt No. ……..
Received from ……… the sum of Rs. ………
(in words) ……….. on account of …………….
Rs. …………………………
Chief A/c. Officer/Authorised Officer Employees’ State Insurance Corporation
Accountant
FORM II
APPLICATION TO MEDICAL APPEAL TRIBUNAL [Rule 20A(2)]
To
Chairman of Medical Appeal Tribunal, Insurance No…………..
I, ………………………… (full name of appellant) of ……………………. (address of appellant)
Appeal against the decision on……………………(date) of the medical board at …………………. (address) notified to me by letter (from………………….) dated………., that:–
*(1) there is no appreciable disablement;
*(2) the disablement should continue to be treated as temporary and the next date when the case should be referred to the Medical Board is; or
*(3) the disablement can be declared to be of a permanent nature; and
(i) the extent of loss of earning capacity can be assessed provisionally or finally,
(ii) the assessment of the proportion of loss of earning capacity whether provisional or final; and
(iii) in case of provisional assessment, the period for which such assessment shall hold good.
The following are the grounds of my appeal:
List of documents, if any :
Date…………
Signature of appellant
*Delete whichever does not apply.
The statement of facts contained in this application is to the best of my knowledge and belief true and correct.
Signature of appellant
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