Government scheme
ESIC claims, and where the money actually goes.
This page describes mechanisms, not conduct. We publish no settlement rate for ESIC and no comparison against any other payer — we have not measured one, and a number we cannot show the working for is not worth reading.
ESIC settles against a published rate list, not against what a hospital charges. Most shortfalls come from three places: the rate version applied, whether the referral or authorisation covered what was actually done, and evidence attached after the deadline. This page describes those mechanisms. It publishes no settlement rate for ESIC and no comparison with any other payer.
Entitlement is a period, not a card.
An insured person’s entitlement depends on contribution periods, which means a card in hand is not the same as cover on the day. The check that matters is the one against the current benefit period.
The three that decide most of it
Insured-person entitlement
Cover follows contribution periods and the corresponding benefit period. Checking the card without checking the period is the commonest reason a case that looked covered turns out not to be.
Decided: At registration.
Referral from the ESIC facility
Tie-up hospitals generally receive patients on referral from an ESIC dispensary or hospital. The referral defines the treatment authorised, and a case that drifts beyond it needs to be re-authorised rather than explained.
Decided: Before treatment begins.
Rates under the tie-up
Payment follows the rates in the tie-up agreement, not the hospital tariff. As with any notified-rate payer, the reconciliation belongs at contract load, once per revision.
Decided: At contract load.
What we will not tell you about ESIC
What other sites publish
- A settlement percentage with no method behind it
- Whether ESIC pays slower than other payers
- Which payer to avoid
- A rate schedule reproduced without its source
What is on this page
- How entitlement periods actually work
- What the referral authorises
- Where the tie-up rate governs the bill
- Which checks belong at registration
The check that belongs at the front desk
Almost every expensive ESIC failure is decided at registration: an entitlement period that had lapsed, a referral that named something narrower than what was done, a dependant assumed to be covered. None of these is a billing error and none is fixable at billing. They are front-desk checks, which is the least glamorous and most valuable place to put software in this scheme.
Questions we get asked
Why was an ESIC patient with a valid card not covered?
Entitlement follows contribution and benefit periods rather than possession of a card, so a card in hand does not establish cover on the treatment date. The check that determines payability is against the current benefit period, and it belongs at registration.
Does ESIC pay hospital tariff rates?
Payment follows the rates set in the tie-up agreement rather than the hospital tariff, so the difference between the two is governed by the agreement rather than disputed per claim. Loading the agreed schedule once, and re-loading it on revision, is what keeps the reconciliation manageable.
Where the money actually goes.
Mechanism, not measurement. Neither figure below is a claim about this payer.
- Billed
- Deducted
- Settled
Every step is a named reduction with a clause behind it. None of them is a refusal, and none of them is a surprise once you know which clause applies. This shape is generic to Indian health insurance; it is not a measurement of ESIC.
Illustrative arithmetic. Your own figures will differ.- 58 settled in full
- 27 settled short
- 11 open past 60 days
- 4 written off
The twenty-seven in the middle are the argument. Not refused — paid less than billed, each for a stated reason.
Illustrative arithmetic. Your own figures will differ.A government scheme settles against a list
ESIC does not price a claim. It matches it to a published entry and pays that.
The rate list is the contract
There is no negotiation on a listed item. The only questions are which entry applies and which version of the list was in force on the date of admission.
Accreditation changes the rate
Several schemes pay a differential for accredited facilities. The accreditation status recorded in the empanelment, not the certificate on the wall, is what the claim is priced against.
Referral and authorisation define scope
The sanctioned procedure bounds the claim. A change in theatre recorded afterwards is a representation, judged differently from an enhancement recorded during the stay.
The beneficiary is not the payer
Eligibility, entitlement and ward class come from the beneficiary's card and category. Getting that wrong at admission is unrecoverable at settlement.
What actually decides the number
Four documents. The clinical file is not one of them.
The rate list, and its version
ESIC pays against a published schedule. A claim priced on last year's version is short by the difference, and the difference is not negotiable afterwards. Check which version was in force on the date of admission, not the date of billing.
The referral or authorisation
It states what was sanctioned. A procedure that changed, or a stay that ran longer, needs the change recorded while the patient is still admitted — not explained in a representation afterwards.
The empanelment terms
Accreditation status, the specialities covered and any ward-class entitlement all sit in the empanelment letter. They decide the ceiling before any clinical fact does.
The evidence pack
Discharge summary, investigation reports, implant invoices and the operation notes. A claim can be clinically perfect and still reduce because the invoice for the implant was not attached.
The clock, and where it runs out
Four moments. Three of them are before the money is at stake.
Before admission
Referral or authorisation obtained and on file. A retrospective one rarely repairs a claim.
During the stay
Any change in procedure, ward class or length of stay recorded while the patient is still admitted.
At discharge
The evidence pack completed before the file closes. Chasing a signature a week later is how a claim ages.
After the advice
Read the settlement within days, not weeks. Representation windows are stated in the scheme's own circular and they do not extend because nobody looked.
If the scheme's own process is exhausted
The route is published, and it is the same for every provider.
The scheme's grievance channel
Every scheme runs one, with a stated turnaround. Use it first and in writing — later stages ask what happened at this one.
The nodal or empanelment authority
Above the processing desk sits the office that issued the empanelment. Contract disputes belong there, not with the claims processor.
For a patient, not a provider
A patient facing a shortfall has a separate route, and it is not the hospital's to run for them. Sahayak explains it in plain language and names the official channel.
Questions we are actually asked
Does Drapto publish a rejection rate for ESIC?
No. We have not measured one, and a figure we cannot show the working for is not worth reading. We publish no settlement rate for any payer and no comparison between payers.
Why was the claim approved and still paid less?
Because approval and pricing are separate decisions. A claim can clear on clinical grounds and still reduce on a room-rent proportion, a tariff version, a sub-limit or an unattached document.
A room upgrade cost ₹8,000. Why did the settlement drop by much more?
Under proportionate deduction, exceeding a room-rent limit re-prices the associated heads on the same bill in the same ratio — surgeon, anaesthetist, theatre, investigations. The room is the trigger, not the size of the loss.
Can this be fixed after discharge?
Some of it. Most of it is cheaper to prevent: the room class at admission, the enhancement during the stay, the query inside its window. After discharge the same facts are argued instead of recorded.
The same mechanics, other payers.
- Aditya Birla HealthHow deductions happen
- Bajaj AllianzHow deductions happen
- Care HealthHow deductions happen
- CGHSHow deductions happen
- ECHSHow deductions happen
- HDFC ERGOHow deductions happen
Patients: Sahayak explains a rejection letter in plain language. Hospitals: Decoder separates predictable deductions from contractual ones on a settlement advice.
See these deductions on your own settlements.
Twenty settled claims, advices only, patient details redacted. We read them with you and name the clause behind each reduction.