Eligibility And Family Coverage
Identify the controlling facts, current Code/Rule requirement, saved operational detail, evidence and responsible owner.
Medical benefit and treatment administration
Current Code, 2026 Central Rules, saved regulation controls, evidence and remedies.
Decision path
Allocation/Referral
Identify the controlling facts, current Code/Rule requirement, saved operational detail, evidence and responsible owner.
Reimbursement Exception
Identify the controlling facts, current Code/Rule requirement, saved operational detail, evidence and responsible owner.
Continuing Medical Entitlement
Identify the controlling facts, current Code/Rule requirement, saved operational detail, evidence and responsible owner.
Implementation controls
- Lock the insured-person, employer and event identifiers before computation or claim.
- Separate current Code/Rule law from saved 1950 procedure and later ESIC directions.
- Reconcile payroll/contractor, medical, family and contribution data according to the benefit.
- Preserve submission, deficiency, decision, payment, review and appeal timestamps.
- Restrict medical/dependant data access and retain a reasoned exception trail.
Current Code and Rules
Saved operational regulations
Regulation 95AMedical benefit to families of insured personsRegulation 96AReimbursement of expenses incurred for medical treatmentRegulation 103Medical benefit during disablementRegulation 103AMedical benefit after contribution ceases to be payableRegulation 103BMedical benefit after insurable employment ceases due to permanent disablementRegulation 104Production of document for medical benefitRegulation 105Further certificates