ESI Reimbursement Form Download | ESIC Medical Reimbursement Claim form

By | August 9, 2017

ESI Reimbursement form is used to claim medical expenses when insured person gets treatment in private hospitals. Here you can do ESI reimbursement form download and you can also know about how to fill ESI reimbursement form. But before submitting ESIC Medical Reimbursement Claim form insured person should know some important points on ESIC medical reimbursement claim process.

It is always advisable that insured person or employer of the insured person should intimate the ESI dispensary before joining the patient in the prviate hospital and in most of the cases if the private hospital not referred by insurance officer of the particular ESIC dispensary then the claim will get rejected.

In general, we couldn’t get facilities provided by multi specialty hospitals in ESI hospitals. In such cases, it is better to give prior intimation to ESI medical officer and take their reference.

ESI Reimbursement Form Download | ESIC Medical Reimbursement Claim form

↓ Download ESI Reimbursement Form

ESI Reimbursement Form Download | ESIC Medical Reimbursement Claim form

You may also like: Is it possible to do ESI number search by name

How To Fill ESIC Accident Report Form 12 In Online

Important Documents To Be Submitted Along With ESI Reimbursement Form

  1. All the medical bills like operation charges, pharmacy charges, room service charges and ICU charges etc.
  2. Discharge card from the private hospital where insured person got treatment.
  3. Emergency Certificate.
  4.  ESIC Pehchan Card of the insured person.
  5.  A letter from the employer side regarding accident cause and request to release claim amount.
  6. Bank passbook xerox copy of insured person.

After doing ESI Reimbursement Form download we need to know how to fill this ESIC reimbursement form. This form consists mainly Two parts one part has to be filled by IMP ( Insurance Medical Practitioner ) or IMO ( Insurance Medical Officer ) and the second part has to be filled by hospital authorities where the insured person was treated. Do share your doubts and opinions on ESI Reimbursement form download.

9 thoughts on “ESI Reimbursement Form Download | ESIC Medical Reimbursement Claim form

  1. vijay

    Please provide any format for ” letter from the employer side regarding accident cause and request to release claim amount.”

  2. anant

    i have a query regarding ESIC medical reimbursement. I have an employee who was covered under esic. he admitted his mother to an esic tie-up hospital in emergency situation. He informed the ESI dispensary after 3 days. The esic dispensary gave him the referral letter to the tie-up hospital where his mother was admitted. But the irony was that the tie-up hospital refuse to accept the referral letter. he was told by hospital authority that they had stopped taking esic patients as esic is delaying/not paying their payments for months. he had no other choice but to pay the bills himself. Now is there any way to claim reimbursement from esi.If yes whats the complete procedure to claim it.

    1. Rajesh Post author

      Hi Anant,
      Submit ESI reimbursement form along with all the required bills to your ESIC office through your employer.

  3. Vinod p

    Hi I have one dout I did not informed esi dispensery and I have admitted my mom in some private hospital.. I need to discharge with in 4 days.. The bill is more than 60k.. Can I reimbusrement Now.. Pls help me….

    1. Rajesh Post author

      Hi Vinod,
      You can try but in majority cases, they will refuse it.

  4. saurabh sancheti

    Hello Sir,

    one of our employee is not well and the esic hospital is very far from her home. and is these possible to take treatment from private hospital and afterward claim to esic office???

    1. Rajesh Post author

      Hi Saurabh Sancheti,
      You have to inform ESIC dispensary, they will direct you to a private hospital.
      In emergency cases you can take him to the private hospital but on the same day as an employer you have to inform ESIC dispensary.

      1. saurabh sancheti

        Ok…. thank you rajesh sir for giving quick reply… 🙂


Leave a Reply

Your email address will not be published. Required fields are marked *