ASSAM EMPLOYEES' STATE INSURANCE (MEDICAL BENEFIT) RULES, 1958

PART I

Rule - 1. Short title, extent and commencement.

(1)     These Rules shall be called the Assam Employees' State Insurance (Medical Benefit) Rules, 1958.

(2)     They shall come into force in any area or areas on the date or dates from which Chapter V of the Employees' State Insurance Act comes into force.

Rule - 2. Definitions.

In these Rules unless there is anything repugnant in the subject or context-

(1)     "the Act" means the Employees' State Insurance Act, 1948 (34 of 1948);

(2)     "Director of Health Service" means the Principal Medical Officer appointed by the State Government to administer medical benefit in the State;

(3)     "Drugs" includes all medicines for internal or external use of human beings and all substances intended to be used for or in the treatment, mitigation or prevention of disease in human beings;

(4)     "medical practitioner" means a person holding a qualification granted by any authority specified or notified under Section 3 of the Indian Medical Degrees Act, 1916 (7 of 1916), or specified in the Schedule to the Indian Medical Council Act, 1933 (32 of 1933), or a person registered or eligible for registration in a medical register of the statement for the registration of persons practicing allopathic, modern or scientific system of medicine;

(5)     "miscarriage" means expulsion of the contents of a pregnant uterus at any period prior to or during the twenty-sixth week of pregnancy;

(6)     "State Insurance dispensary" means a dispensary established in a separate building or part of an existing dispensary, hospital or any other building set apart for the exclusive use of insured persons either during all hours or during certain specified hours; provided that in the latter case drugs are maintained and dispensed separately in accordance with these Rules;

(7)     "State Insurance Medical Formulary" means a list of prescriptions and injections laid down by the Corporation from time to time;

(8)     "State Government" means the Government of the State of Assam;

(9)     All other words and expressions used herein and not defined shall have the meanings assigned to them in the Act, the rule made under Section 95 or the regulations under Section 97 as the case may be.

PART II

Rule - 3. Establishment of State Insurance dispensaries.

The State Government shall establish one or more State Insurance dispensaries for the medical treatment of insured persons at any place where there is a concentration of not less than one thousand insured persons, with a whole time or part time Medical Officer-in-charge as the State Government may think suitable according to the concentration of insured persons.

Rule - 4. Provision of medical benefit where there are no State Insurance dispensaries.

The State Government shall make arrangements for providing medical treatment to insured person residing at places where there are no State Insurance dispensaries within a reasonable distance :

(a)      by making arrangements for a mobile dispensary to visit a central spot near the places of residence of such persons;

(b)      by making arrangements for an Insurance Medical Officer to visit any specified dispensary in the area for any part of the day;

(c)      by making arrangements for the treatment of such persons by part-time Insurance Medical Officers appointed for the purpose; or

(d)      by making arrangements for the provision of such treatment at any hospital, dispensary, clinic or other institution maintained by the State Government, a local body a private institution or a private individual on such terms as may be agreed to by the Corporation.

Rule - 5. Medical service provided by employers.

Where an employer is providing medical services not lower than those provided to insured persons by the State Government, arrangements may be made for the continuance of such services for providing medical benefit to insured persons under such terms and conditions as may be agreed upon between the Government, the Corporation and the Employer.

Rule - 6. Separate hospitals or beds

The State Government may also establish separate hospitals or other medical institutions for the examination and treatment of insured persons or any reserve on such scales and terms as may be agreed upon between the Corporation and the State Government from time to time, separate beds for the exclusive use of insured persons in the hospitals or other medical institutions under its control, or a local body, private institutions or individual.

Rule - 7. Abolition of dispensary, etc.

The State Government may, with the consent of the Corporation, abolish any State Insurance dispensary, cancel any of the arrangements made under Rules 4 and 6 or effect such alteration as may be considered necessary in the location of any dispensary.

Rule - 8. Allotment of insured persons.

An insured person in any factory or establishment to which the Act applies, may at the time of filing the declaration from under Employees' State Insurance (General) Regulations, 1950, or at any subsequent time, indicate the State Insurance dispensary or other medical institution where arrangements for the provisions of medical benefit are made to which he desires to be allotted or reallotted and the State Government shall so far as practicable and subject to such conditions as may be fixed, allot or reallot such insured persons to the dispensary or the institution indicated by him :

Provided that where in the opinion of the State Government, the circumstances so justify, it may allot or reallot an insured person to a dispensary or institution other than the one indicated by him.

Rule - 9. Failure to indicate dispensary or institution.

(1)     An insured person who does not indicate the dispensary to which he desired to be allotted shall be allotted to such dispensary as the State Government may consider suitable.

(2)     Intimation, of the dispensary or institution to which an insured person is allotted or reallotted either under sub-rule (1) or under Rule 8, as the case may be, shall be sent to the insured person by the State Government.

Rule - 10. Procedure for obtaining medical benefit.

An insured person who wishes to claim medical benefit shall attend along with his identity card to the State Insurance dispensary, or other hospital, clinic, mobile dispensary, post or any other medical institution to which he is allotted, and claim such benefit from the Insurance Medical Officer-in-charge of the State Insurance dispensary or the Insurance Medical Officer of the hospital, clinic or other institution to which he is allotted :

Provided that in case of an emergency, an insured person may claim medical benefit under these rules from any Insurance Medical Officer whether he is allotted to him or not:

Provided further that where an insured person is unable to attend the Stale Insurance dispensary, hospital, clinic, mobile dispensary post or any other medical institution, to which he is allotted the Insurance Medical Officer will, on intimation being received, visit him at his residence, if he is satisfied, by interrogation or otherwise, that the insured person cannot reasonably be expected to come to the medical institution to which he is allotted :

Provided further that if the insured person or his agent fails to produce his or the insured person's identity card, as the case may be, as proof of the person claiming the benefit being an insured person the medical benefit may be refused to him.

Rule - 11. Scale of medical benefit.

The medical benefit provided under these rules shall be according to the following scale :

(1)     Out-patient treatment shall be provided at a State Insurance dispensary or in the manner indicated in Rule 4 and shall consist of all treatments, other than treatment involving the application of special skill or experience, and shall include-

(i)       such preventive treatment as vaccination and inoculation;

(ii)      ante-natal and post-natal treatment of insured workwoman;

(iii)     the free provision of all drugs and dressings that may be considered necessary; and

(iv)    provision of certificate free of cost, in respect of sickness, maternity, employment injury and death required under the Employees' State Insurance (General) Regulations, 1950 or under the directions or instructions issued from time to time by the Corporation.

(2)     An Insurance Medical Officer shall visit an insured person at his or her residence in accordance with the second proviso to Rule 10 and in addition to all cases of confinement or miscarriage, where the insured woman or the registered midwife in attendance or any other reliable person reports that attendance by a medical practitioner is desirable.

(3)     Where, in the case of a serious emergency or otherwise, inpatient treatment in a hospital is considered necessary by Insurance Medical Officer, the case shall be admitted to the nearest hospital which is established or specified for the purpose by the State Government if accommodation is available and the treatment provided for the patient shall include free maintenance and such specialist and general treatment including treatment at confinement where necessary, as may be available at the general wards of the hospital to which the insured person is admitted as well as those special investigations which are considered desirable and for which facilities exist at the hospital, or at an associated laboratory.

(4)     Facilities for the removal, free of charge of insured persons to and from hospital, where necessary, shall be provided by ambulance or otherwise.

Rule - 12. Conditions of service of full-time Insurance Medical Officer.

(1)     Subject to the provisions of the Act and the rules made thereunder, the State Government may, subject to such conditions as may be laid down by the Corporation, appoint a suitable medical officer already in its service or any person possessing such medical qualifications as may be laid down by the State Government in consultation with the Corporation, as an Insurance Medical Officer.

(2)     An Insurance Medical Officer, shall receive such salary and non-practicing allowance as may be determined by the State Government with the consent of the Corporation.

(3)     An Insurance Medical Officer shall receive such allowance and at such rates as may be sanctioned from time to time for Medical Officers of the State Government on similar grades in the localities in which they are stationed. An Insurance Medical Officer, shall be entitled to leave and leave salary under the leave rules which, from time to time, be applicable to other similar State Government servants.

(4)     An Insurance Medical Officer shall be entitled to travelling allowance for journeys performed on official duties on the scale laid down in the State Government Rules applicable to Medical Officers of the State Government on similar grades.

(5)     Full-time Insurance Medical Officer shall not undertake private practice.

(6)     An Insurance Medical Officer shall be subject to such other conditions of service as may be fixed by the State Government in consultation with the corporation.

(7)     Notwithstanding anything contained in sub-rules (2) to (5) the pay, allowances and other conditions of service of an Insurance Medical Officer shall, if he is a person already in the service of the Government, be such as may be determined, with the consent of the Corporation, by the State Government by a general or special order.

Rule - 13. Allowances for other Insurance Medical Officers.

Where the State Government appoints a part-time Insurance Medical Officer or confers the duties and powers of an Insurance Medical Officer on a Medical Officer in its service in addition to his duties or on any other medical practitioner, such Medical Officer or medical practitioner shall be paid such allowances as may be fixed by the State Government with the consent of the Corporation.

Rule - 14. Staff to be provided at hospital, dispensaries, etc.

Each State Insurance dispensary shall be in the charge of an Insurance Medical Officer :

Provided that in cases where the concentration of Insured persons residing near a State Insurance dispensary so justifies, the State Government shall in accordance with such scale and subject to such conditions as may be agreed upon between the State Government and the Corporation, appoint two or more Insurance Medical Officers to such State Insurance dispensary.

Rule - 15. Notice of the time during which dispensary, hospital, etc., shall be open.

(1)     Subject to the approval of the State Government the Insurance Medical Officer or the senior-most Insurance Medical Officer, as the case may be, shall fix the time at which a State Insurance dispensary, hospital, clinic, mobile dispensary post or any other medical institution specified for the purpose shall remain open for the treatment of insured persons.

(2)     Notice of the time fixed under sub-rule (1) shall be given in such manner as the State Government may, from time to time, direct and in particular shall, be indicated in a notice board displayed prominently at each place where insured persons are provided medical treatment and at each mobile dispensary post.

Rule - 16. Rank and precedence of Insurance Medical Officers.

(1)     Where more than one Insurance Medical Officers have been appointed to a State Insurance dispensary, the State Government shall specify their rank or precedence.

(2)     the senior Insurance Medical Officers for the time being shall, from time to time, make such arrangements as he thinks fit for the distribution of the work at the State Insurance dispensary among the Insurance Medical Officers appointed thereto.

Rule - 17. Appointment of subordinate staff.

(1)     The State Government may, with the consent of the Corporation, appoint such ancillary, technical or non-technical staff and such other subordinate staff as may be necessary for the proper provision of medical benefit, for ensured persons by the State Government.

(2)     The technical, non-technical and subordinate staff shall perform such duties as the Insurance Medical Officer, or, if there are more Insurance Medical Officers than one, the senior Insurance Medical Officer, may, subject to any orders of the State Government from time to time, direct.

(3)     The technical, non-technical and subordinate staff shall be subject to such conditions of service and draw such salaries and allowances and receive such other benefits as may be fixed by the State Government with the consent of the Corporation.

Rule - 18. Maintenance of medical and surgical equipment.

Every State Insurance dispensary, hospital, clinic mobile dispensary or any other medical institution specified for the purpose shall maintain such medical and surgical equipment as may be laid down by the State Government with the consent of the Corporation and all Insurance Medical Officers attached to State Insurance dispensaries or to other medical institutions where provision for out-patient treatment is made under Rule 4 shall prescribe such drugs as are required for insured persons but as far as possible in accordance with the State Insurance Medical formulary laid down by the Corporation.

Rule - 19. Administrative control.

All State Insurance dispensaries, hospitals, clinics, mobile dispensaries and other medical institutions specified for the purpose of providing medical benefit under these rules shall be subject to the administrative control and superintendence of the Director of Health Service.

Rule - 20. Medical Records and statistical returns.

The Insurance Medical Officer-in-charge of each State Insurance dispensary, hospital, clinic, mobile dispensary or other medical institutions specified for the purpose of each Insurance Medical Officer, as the case may be, shall-

(i)       keep such registers, books and accounts as the State Government, or the Director of Health Services, may, from time to time, specify in consultation with the Corporation;

(ii)      maintain a medical record in respect of such insured persons allotted to the dispensary or to the Insurance Medical Officer, as the case may be, in the form laid down and supplied by the Corporation for the purpose and in accordance with the instructions issued by the Corporation in this behalf from time to time; and

(iii)     comply with such requisitions as may be made by the Corporation or the State Government or the Director of Health Services in respect of records, returns and statements in such form and in such manner as the authority making the requisition directs.

PART III

Rule - 21. Provision relating to medical benefit to families-Scale of medical benefit.

The medical benefit provided to the family of an insured person shall be according to the following scale :

(1)     General medical services, which will include treatment at the State Insurance dispensary or at the clinic of an Insurance Medical Practitioner or other authorised institution and shall consist of-

(i)       all treatment other than treatment involving the application of special skill or experience;

(ii)      such preventive treatment as vaccination and inoculation;

(iii)     free provision of drugs and dressings that may be considered necessary, but as far as possible in accordance with the State Insurance Medical Formulary laid down by the Corporation and exclusive of such medicines as can be prescribed only by specialists for insured persons.

(2)     Free maternity service to the wife of an insured person consisting of-

(i)       reasonable ante-natal and post-natal treatment at the aforesaid dispensary or clinic or other authorised institution;

(ii)      attendance by a midwife at the confinement at the residence of the insured person.

Rule - 22. Provision of General Medical Service.

The State Government shall arrange to provide general medical services to the family of an insured person at a State Insurance dispensary, clinic of an Insurance Medical Practitioner or other institution :

provided that the State Government may make arrangement for the family of the insured person separately at an independent State Insurance dispensary or at other institution established or recognised for the purpose.

PART IV

Rule - 23. Delegation of powers.

(1)     The State Government may delegate any of the powers or duties conferred or imposed upon it by these rules to such of its officers as it may, with the consent of the Corporation specify in this behalf.

(2)     Without prejudice to the provision of sub-rule (1) the State Government may delegate all or any of the powers or duties conferred or imposed upon it by Rule 8 or Rule 9 to such officers of the Corporation, as it may deem fit.

Rule - 24. Relaxation.

The State Government may, by special or general order, relax, with the consent of the Corporation any rule under such circumstances and subject to such conditions as they may deem fit.