The M.P. Employees' State Insurance (Medical Benefit Services System) Rules, 1959

Published vide Notification No. 469-13775-16, Bhopal dated the 23rd January, 1959, M.P. Rajpatra, Extraordinary, dated 24-1-1959

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In exercise of the powers conferred by clauses (d), (c), (f), (g) and (h) of sub-section (1) of Section 96 of the Employees' State Insurance Act, 1948 (XXXIV of 1948), the State Government hereby makes the following Rules the same having been previously published as required by sub-section (2) of the said section, namely-

Part I

Preliminary

Short title, extent and commencement.- (1) These rules may be called the Madhya Pradesh Employees' State Insurance (Medical Benefit Services System) Rules, 1959.

(2) They shall come into force with effect from the date of their publication in the Madhya Pradesh in the areas in which Chapter V of the Employees' State Insurance Act, 1948 (XXXIV of 1948) is in force.

(3) They shall come into force in other areas on the date or dates from which Chapter V of the Employees' State Insurance Act, 1948 comes into force therein.

Definitions.- In these rules, unless there is anything repugnant in the subject or context-

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

(2) "Administrative Medical Officer" [x x x]

(3) "Drug" includes all medicines for internal or external use of human being 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 an authority specified or notified under Section 3 of the Indian Medical Degrees Act, 1916 (VII of 1916) or specified in the Schedules to the Indian Medical Council Act, 1933 (XXVII of 1933) or a person registered in a medical register of the State of Madhya Pradesh meant for the registration of persons Practising the allopathic 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 later case drugs are maintained and dispensed separately in accordance with those 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 Madhya Pradesh;

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

Part II

Medical Benefit for Insured Persons

Establishment of State Insurance Dispensaries.- The State Government shall establish one or more full time 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; provided that the medical practitioner incharge of the dispensary may be a part-time Insurance Medical Officer so long as the concentration of insured person is less than two thousand.
Provision of Medical benefit where there are no State Insurance Dispensaries.- The State Government shall make arrangements for providing medical treatment to insured persons 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 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.

Medical services provided by employers.- Where an employer is providing medical services not inferior to those provided to insured persons by the Stale Government, the State Government may allow the employer to continue such services for providing medical benefit to insured persons subject to such terms and conditions as may be agreed upon between the State Government, the Corporation and the employer.
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 may 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 under the control of a local body, private institutions or individual.
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 3 to 6 or effect such alteration as may be considered necessary in the location of any dispensary.
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 Form under the Employees' State Insurance (General) Regulations, 1950, or at any subsequent time, indicate the State insurance Dispensary or other medical institution where arrangements for the provision of medical benefits are made to which he desires to be allotted or re-allotted and the State Government shall, so far as practicable and subject to such conditions as may be fixed allot or re-allot such insured person to the dispensary or the institution indicated by him :

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

Failure to indicate dispensary or institution.- (1) An insured person who does not indicate the dispensary to which he desires 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 re-allotted either under sub-rule (1) or under Rule 8, as the case may be, shall be made to the insured person by the State Government.

Procedure for obtaining medical benefit.- An insured person who wishes to claim medical benefit shall bring 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 the case of an emergency, an insured person may claim medical benefit under these rules from any Insurance Medical Officer where he is allotted to him or not :

Provided further that where an insured person is unable to attend the State 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.

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 treatment 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 women;

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

(iv) provision of certificates, fee 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 in 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 the 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 therein and the treatment provided for the patient shall include such specialist and general treatment, including treatment, at confinement where necessary, as may be available in the general ward of the hospital to which the insured person is admitted as well as those special investments which are considered desirable and for which facilities exist at the hospital or at an associated laboratory, Diet free of cost will be provided only in such hospital, where necessary arrangements are in existence.

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

Conditions of service of full time Insurance Medical Officers.- (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-practising allowance as may be determined by the State Government with the consent of the Corporation.

(3) An Insurance Medical Officer shall receive such allowances and at such rates as may be sanctioned from time to time by the Slate Government. An Insurance Medical Officer shall be entitled to leave and leave salary under the leave rules which may, 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 of 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.

Allowances for other Insurance Medical Officer.- 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 allowance as may be fixed by the State Government with the consent of the Corporation.
Staff to be provided at hospitals, dispensaries etc.- Each State Insurance Dispensary shall be in 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 maybe agreed upon between the State Government and the Corporation, appoint two or more Insurance Medical Officers to such State Insurance Dispensary.

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 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.

Rank and precedence of Insurance Medical Officers.- (1) Where more than one Insured Medical Officer have been appointed to a State Insurance Dispensary, the State Government shall specify their rank or precedence.

(2) The Senior Insurance Medical Officer 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 die Insurance Medical Officers appointed thereto.

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 insured 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.

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 Officer attached to State Insurance Dispensaries or to other medical institutions where provision for outpatient 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.
Administrative Control.- All 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 Services, Madhya Pradesh.
Medical records and statistical returns.- The Insurance Medical Officer-in-charge of each State Insurance Dispensary, Hospitals, clinic, mobile dispensary or other medical institution specified for the purpose for each Insurance Medical Officer, as the case may be, shall-

(i) keep such registers, books, and accounts as the State Government or the Administrative Medical Officer 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 and supplied by the Corporation for the purposes 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, Madhya Pradesh] in respect of records, returns and statements in such form and in such manner as the authority making the requisition directs.

Part III

Medical Benefit to Families of the Insured Persons

[21. Medical Benefit to families. - Subject to the provisions of sub-section (2) of Section 46 of the Act, the medical benefit provided to the family of an insured person shall be according to the following scale :

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 dressing that may be considered necessary;

(iv) Domicilary visits, where necessary;

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

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

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

Facilities for the removal, free of charge to hospital where necessary by ambulance or otherwise.

Specialists' consultation and treatment and special investigations of such nature and on such scale as the State Government may specify from time to time.]

General Medical Service.- Where the medical benefit is extended to the family of an insured person under sub-section (2) of Section 46 of the Act, 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 separately for the family of the insured person at an independent State Insurance Dispensary or at other institution established or recognised for the purpose.

Part IV

Miscellaneous

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 consent of the Corporation, specify in this behalf.

(2) Without prejudice to the provisions 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 9 to such officers of the Corporation as it may deem fit.

[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.
Repeal and saving.- The Madhya Pradesh Employees' State Insurance (Medical Benefit) Rules, 1953 and the Madhya Bharat Employees' State Insurance (Medical Benefit Service System) Rules, 1955 are hereby repealed :

Provided that any order made, anything done or any action taken under the rules so repealed shall be deemed to have been made, done or taken under the corresponding provisions of these rules.