Rule 25: Qualification and other conditions of insured person and family for claiming medical benefit

Finin2min analysis — operative rule mechanics

Full notified text — Rule 25

25. Qualification and other conditions of Insured Person and his family for claiming medical
benefit.–(1) A person shall be entitled to medical benefit during any period for which contributions
are paid or payable in respect of him or in which he is qualified to claim sickness benefit or maternity
benefit.

(2) A person who is in receipt of disablement benefit shall be entitled to medical benefit while he is in
receipt of such benefit:

          Provided that after the disablement has been declared as permanent disablement, the person
shall not be entitled to medical benefit, if he is not otherwise entitled to such benefit, except in respect
of any medical treatment which may be rendered necessary on account of the employment injury from
which the disablement resulted.

(3) A person on becoming an Insured Person for the first time shall be entitled to medical benefit for a
period of three months provided that where such a person continues for three months or more to be an
employee of an establishment to which the Chapter IV of the Code applies, he shall be entitled to
medical benefit till the beginning of the corresponding benefit period.

(4) The person in respect of whom contributions have been paid in a contribution period for not less
than seventy-eight days in the said contribution period shall be entitled to medical benefit till the end
of the corresponding benefit period:

         Provided that in case of a person who becomes an employee within the meaning of the Code,
for the first time, and for whom a shorter contributory period of less than one hundred and fifty six
days is available, he shall be entitled to medical benefit till the end of the corresponding benefit period
if the contributions in respect of him were payable for not less than half the number of days available
for working in such contribution period.

(5) When a person qualifies for extension of sickness benefit as per provision of clause (b) of sub-rule
(2) of rule 22 and regulations made on the subject under section 157, he shall be entitled to medical
benefit till the end of the relevant extended benefit period.

(6) An Insured Person, whose entitlement to medical benefit has ceased under this rule, shall again be
entitled to medical benefit from the date of his re-employment as an employee under Chapter IV of
the Code by an establishment to which the Code applies immediately on registration on specified
portal for such purpose and such an Insured Person shall, unless he is covered by sub-rule (4) or (5),
be entitled to medical benefit till the commencement of the benefit period corresponding to the
contribution period in which he is re-employed.

(7)The family of an Insured Person shall become entitled to medical benefit from such date as may be
specified by the Corporation, by notification and shall continue to be so entitled so long as the Insured
Person is entitled to receive medical benefit for himself, or in the case of death of the Insured Person
till such date up to which the Insured Person would have remained entitled to medical care, had he
survived.

(8) An Insured Person and his family shall be entitled to receive medical benefit only of such kind and
on such scale as may be provided by the State Government or by the Corporation, as the case may be,
and an Insured Person or his family shall not have a right to claim any medical treatment except such
as is provided by the dispensary, hospital, clinic or other institution to which he or his family is
allotted, or as may be provided by the regulations made under section 157.

(9) Nothing in these rules shall entitle an Insured Person and his family to claim reimbursement from
the Corporation of any expenses incurred in respect of any medical treatment, except as may be
provided by the regulations made under section 157.

(10) 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 to be provided under sub-rule (8), 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 in such manner as may be authorised by the Corporation;

        (ii) the payment of contribution at the rate of fifty rupees per month in lump sum for one year
        at a time in advance to the concerned office of the Corporation in the manner specified by it;
        and

        (iii) after demise of disabled Insured Person, his spouse shall be eligible to receive medical
        benefit at the scale as provided in sub-rule (8), subject to payment of contributions specified
        in clause (ii).

(11) The widow or widower, as the case may be, of an insured person in receipt of dependant benefits
shall be eligible to receive medical benefit at the scale to be provided in sub-rule (8) subject to the
payment of contribution at the rate of rupees fifty per month in lump sum for one year at a time in
advance to the concerned officer of the Corporation in the manner specified by it.

(12) The employer may avail the facility of free annual medical examination in respect of Insured
Person of the age of forty years and above through the Corporation from its own dispensaries or
hospitals on the scale as provided in the Occupational Safety, Health and Working Conditions
(Central) Rules, 2026.

Application and evidence

1. Primary statutory test — (1) A person shall be entitled to medical benefit during any period for which contributions are paid or payable in respect of him or in which he is qualified to claim sickness benefit or maternity benefit.
2. Additional operative limb — (2) A person who is in receipt of disablement benefit shall be entitled to medical benefit while he is in receipt of such benefit:
3. Qualification / exception to test — Provided that after the disablement has been declared as permanent disablement, the person shall not be entitled to medical benefit, if he is not otherwise entitled to such benefit, except in respect of any medical treatment which may be rendered necessary on account of the employment injury from which the disablement resulted.
4. Numerical or timing control — (3) A person on becoming an Insured Person for the first time shall be entitled to medical benefit for a period of three months provided that where such a person continues for three months or more to be an employee of an establishment to which the Chapter IV of the Code applies, he shall be entitled to medical benefit till the beginning of the…
5. Code Section mapping — 39, 40. Read the mapped provision together with this text rather than treating the concordance as a substitute for it.
6. Evidence file — retain facts and records proving the role/status of: Employer, Employee / worker, State Government, Corporation / EPFO / Board.

Cross-references & prescribed forms

Worked example

Q&A — Rule 25

Primary sources