ESIC Medical Reimbursement Form PDF [Download]

ESI Reimbursement form is used to claim medical expenses when the insured person gets treatment in private hospitals. The Insured person or employer of the insured person should intimate the ESI dispensary before joining the patient in the private 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 the 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.

Download ESI Medical Reimbursement Claim Form in PDF Format

ESI Reimbursement Form Download | ESIC Medical Reimbursement Claim form

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Required Documents 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 the 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 the claim amount.
  6. Bank passbook xerox copy of an insured person.

How to Fill ESIC Medical Reimbursement Claim Form

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.

35 thoughts on “ESIC Medical Reimbursement Form PDF [Download]”

  1. Sir mughe esic medical reimbursement claim from chayiye sir aur mughe esic ka email id chahiye sir jis par esic ka claim from send kar saku is ke liye aap sada abhari rahugaa.

  2. Hello sir,
    On 5/11/2021 dated we all in a road accident ,my husband get more injured on brain with bleeding so immediately our local hospital means (oil) hospital refered to another hospital for further treatment we all are injured no time to inform at esic because it took place around 8o’clock but next day inform to esic center. I have face some problems due to reambursment of medical bill because this private hospital is not tie up with esic. Is it possible or how can I get information from you.

  3. नमस्ते महोदय,

    मेरे बेटे को डेंगू हुआ था। और ईएसआईसी अस्पताल उसके घर से बहुत दूर है। और मैंने निजी अस्पताल से उसका इलाज कराया अब बाद में ईएसआईसी कार्यालय में दावा करना संभव है ???

  4. Hii sir meri delivery emergency private hospital main hui hai muje ESIC dispensary dr ne form 18 diya hai muje reimbursement process kya hai pls details muje mil sakta hai kya reimbursement medical

  5. Respected sir
    Mai apna esi 2014 se contribute karva rahi health na theak hone ko vajah se mujhe job chodni padhi…bt ab meri job continue ho chuki hai…bt mera 1 saal ka contribution ni ja paya to kya koi haal hai jisse mai apna claim le saku…mai multiple sclerosis ki patient hun mera bht zyada kharcha ho raha treatment par

  6. Hi sir,
    On emergency i have admitted my mother due to heart attack in private hospital . After two days i visited the esic hospital , they have referred the other hospital for cardiac it possible to claim the bill for the hospital i have admiited in private hospital.
    Please help me

  7. one of our female employee gave birth to her child in a private hospital. Can she claim her medical bill from esic. if yes ,then what is the procedure ? is there any time limit to claim that? is she eligible to get cash benefit from esic during her maternity leave ? tell me the procedure.

  8. Hi,

    Please help me to understand the process to claim hospital bills.
    my brother had poison, immediately we joined private hospital and informed to ESI medical officer nearby my location. Almost we spent 3.5L for treatment/medicine during hospitalization period, what form we need to fill and what are the supported documents required for this process. Please do needful on this…


  9. Hi,
    My employer is telling me that there is no protocol like this that they can give the parent eligibility certificate. My company is refusing to give the eligibility certificate. Please reply me what should I do. It’s an emergency and my father has been admitted in the hospital. Please help me

    • Hi Swagatika Mishra,
      There is no protocol like that, whenever you and your family need ESIC treatment, then the employer has to help you.

  10. Hi sir,
    Due to some emergency I delivered a baby in a nearby private hospital. They gave emergency certificate along with remaining bills. I want to claim for medical reimbursement . Is it possible? I contacted my dispensary and they are saying there is no medical reimbursement for emergency maternity. Is dat true? Plz help me.

      • I actually work in Bangalore. Contributed for 1 year to esic. Came to hometown in Andhra Pradesh. There I submitted my esic -105 form to local dispensary. As I mentioned earlier mine was an emergency case so got admitted in nearby multispeciality hospital. After my delivery I went to dispensary n informed same to them. That doctor signed n gave me form-18 to submit. So can I avail medical reimbursement now? As I informed esi dispensary.

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

  12. 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.

  13. 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….

  14. 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???

    • 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.


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