{"id":1456,"title":"Zuno Health Insurance Claim form - A","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_Claim_Form_A_V_1_2_7873f847fd.pdf?updated_at=2024-09-26T06:01:23.428Z","sha256":"397ebb8a6426cef4bd052532332b92945db580b304bc45f8a05eb31d184947ee","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or policyholder to claim health insurance benefits for hospitalization or related medical expenses.","notes":["Fill the form in BLOCK letters.","Filling and submission of this form does not guarantee claim acceptance.","Use dd-mm-yy format for dates and hh:mm format for times.","Do not enter paise values in amounts, only rupees.","Tick the appropriate options where applicable.","Attach original bills and relevant documents as per checklist."],"title":"Zuno Health Insurance Claim form - A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Details of the primary insured / policyholder","fields":[{"help":"Enter the policy number as allotted by the insurance company","type":"text","label":"Policy No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the social insurance number or certificate number of social health insurance scheme","type":"text","label":"Sl. No ./ Certificate No:","options":[],"required":null,"pdf_field":""},{"help":"Enter the TPA ID No. as allotted by the organization","type":"text","label":"Company/ TPA ID No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Include street, city, state and pin code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"City of the policyholder","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"State of the policyholder","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Pin code of the policyholder's address","type":"number","label":"Pin code:","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section B – Some details of your other/past insurance","fields":[{"help":"Tick Yes or No","type":"choice","label":"Are you currently covered by any other mediclaim/ health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number as allotted by the insurance company","type":"text","label":"Policy number:","options":[],"required":null,"pdf_field":""},{"help":"Enter total sum insured as per the policy in rupees","type":"amount","label":"Sum insured (INR):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Have you been hospitalized in the last four years since the beginning of the policy?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date:","options":[],"required":null,"pdf_field":""},{"help":"Enter diagnosis details","type":"text","label":"Diagnosis:","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"If yes, please specify the details.","options":[],"required":false,"pdf_field":""},{"help":"Enter full name of the insurance company","type":"text","label":"Name of the insurance company:","options":[],"required":false,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No:","options":[],"required":false,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum insured:","options":[],"required":false,"pdf_field":""},{"help":"Enter claimed amount in rupees","type":"amount","label":"Claimed amount:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section C – Details of hospitalized insured person / policy holder","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Gender:","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"number","label":"Age:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of birth:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option; if Other, specify","type":"choice","label":"Relationship with primarily insured:","options":["Self","Spouse","Child","Father","Mother","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Tick the right option; if Other, specify","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker","Student","Retired","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Include street, city, state and pin code","type":"text","label":"Address (if different from above):","options":[],"required":false,"pdf_field":""},{"help":"City of the patient","type":"text","label":"City:","options":[],"required":false,"pdf_field":""},{"help":"State of the patient","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"Pin code of the patient's address","type":"number","label":"Pin code:","options":[],"required":false,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.:","options":[],"required":false,"pdf_field":""},{"help":"Enter email address","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section D – details of hospitalization","fields":[{"help":"Enter the name of hospital in full","type":"text","label":"Name of hospital where admitted:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Room category occupied:","options":["Day care","Single occupancy","Twin sharing","3 or more beds per room"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Hospitalization due to:","options":["Injury","Illness","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time of admission:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharged:","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"If injury, give cause:","options":["Self inflicted","Road traffic accident","Substance abuse /alcohol consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No for each item","type":"checkbox","label":"If medico legal: (i)Yes No (ii) Reported to Police: Yes No (iii) MLC report & police FIR attached: Yes No","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the system of medicine followed in treating the patient","type":"text","label":"System of medicine:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section E – details of claim","fields":[{"help":"Enter amounts in rupees for: (i) Pre-hospitalization expenses, (ii) Hospitalization expenses, (iii) Post-hospitalization expenses, (iv) Health-check-up cost, (v) Ambulance charges, (vi) Others (code), and total","type":"table","label":"Details of the treatment expenses claimed","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Pre-hospitalization period (days):","options":[],"required":null,"pdf_field":""},{"help":"Enter number of days","type":"number","label":"Post-hospitalization period (days):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No. If Yes, provide details in annexure","type":"choice","label":"Claim for domiciliary hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick all documents submitted","type":"checkbox","label":"Claim documents submitted – checklist","options":["Duly signed claim Form","Operation theatre notes","Copy of the claim intimation, if any","ECG","Hospital main bill","Doctor's request for investigation","Hospital break-up bill","Investigation reports (Including CT/MRI / USG / HPE)","Hospital discharge summary","Doctor’s prescriptions","Hospital bill payment receipt","Others","Pharmacy bill"],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section F – details of bills enclosed","fields":[{"help":"List bills with details and amounts in rupees","type":"table","label":"Sl.No., Bill No., Date, Issued by, Towards, Amount (`)","options":[],"required":null,"pdf_field":""},{"help":"Number of hospital main bills enclosed","type":"number","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"Number of pre-hospitalization bills enclosed","type":"number","label":"Pre-hospitalization bills: ___ Nos","options":[],"required":null,"pdf_field":""},{"help":"Number of post-hospitalization bills enclosed","type":"number","label":"Post-hospitalization Bills: ___Nos","options":[],"required":null,"pdf_field":""},{"help":"Number of pharmacy bills enclosed","type":"number","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section G - details of primarily insured’s bank account","fields":[{"help":"Enter Permanent Account Number as allotted by the Income Tax department","type":"text","label":"PAN:","options":[],"required":null,"pdf_field":""},{"help":"Enter bank account number","type":"text","label":"Account No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of the bank in full along with branch","type":"text","label":"Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of the beneficiary the cheque/DD should be made out to","type":"text","label":"Cheque/DD payable details:","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of the bank branch in full","type":"text","label":"IFSC:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section H – declaration by the insured","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""},{"help":"Sign the form","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / policyholder"}],"deadlines":[],"applies_to":"","attachments":["Duly signed claim Form","Operation theatre notes","Copy of the claim intimation, if any","ECG","Hospital main bill","Doctor's request for investigation","Hospital break-up bill","Investigation reports (Including CT/MRI / USG / HPE)","Hospital discharge summary","Doctor’s prescriptions","Hospital bill payment receipt","Others","Pharmacy bill"],"declarations":["The information furnished in this claim form is true and correct to the best of my knowledge and belief.","If any false or untrue statement, suppression or concealment of material fact is made, the right to claim reimbursement shall be forfeited.","I consent and authorize TPA / insurance company to seek necessary medical information/documents from any hospital or medical practitioner who attended the person against whom this claim is made.","I declare that I have included all bills/receipts for this claim and will not make any supplementary claim except pre/post hospitalization claim, if any.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for my claim from the treatment provider."],"dropped_labels":5},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"email","value":"support@hizuno.com","label":"Health claims support email","level":null,"hours":null,"applies_to":"health","source_url":"https://www.hizuno.com/health-insurance/health-claim","quote":"ls, you will need to submit a reimbursement claim. For cashless services at a common network hospital, you can write to\nsupport@hizuno.com\n, call us at 1800 12000, or connect with your TPA as mentioned on your card.\nWhen you’re covered by a health insurance","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 12000","label":"Health claims toll free number","level":null,"hours":null,"applies_to":"health","source_url":"https://www.hizuno.com/health-insurance/health-claim","quote":"imbursement claim. For cashless services at a common network hospital, you can write to\nsupport@hizuno.com\n, call us at 1800 12000, or connect with your TPA as mentioned on your card.\nWhen you’re covered by a health insurance policy and need to be ho","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"022 423 12000","label":"Paid Landline","level":null,"hours":null,"applies_to":"all","source_url":"https://www.hizuno.com/contact-us","quote":"uote\nHome\nContact us\nReach out to us for any Query/ Request or Grievance\nCall us\nToll free - 1800 12000\nPaid Landline -\n022 423 12000\nSenior citizen -\n022 423 12001\nEmail address\nsupport@hizuno.com\nsenior.citizen@hizuno.com\nGrievance Redressal Officer\nM","fetched_at":"2026-10-20"}],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/zuno-general-insurance/1456-zuno-health-insurance-claim-form-a"}