{"id":1457,"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_Insurance_Claim_Form_A_V_1_1_c8f4fe3b68.pdf?updated_at=2024-05-07T08:26:43.288Z","sha256":"3ded0d80b96d8c02e120d4b05425b40ea64c99a84357f585d77ffc0736d8cffa","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 all relevant documents as per the checklist.","If claim is for domiciliary hospitalization, provide details in annexure."],"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 the 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 IRDAI and printed in TPA documents","type":"text","label":"Company/ TPA ID No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (Surname, First name, Middle name)","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Include Street, City and Pin Code","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"City of the policyholder's address","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"State of the policyholder's address","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 a valid 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 the full name of the insurance company","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"Enter the policy number","type":"text","label":"Policy number:","options":[],"required":null,"pdf_field":""},{"help":"Enter the total sum insured as per the policy in rupees (do not enter paise values)","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":"Tick Yes or No","type":"choice","label":"Were you previously covered by any other mediclaim / health insurance?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter the full name of the insurance company","type":"text","label":"If yes, company name:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section C – Details of hospitalized insured person / policy holder","fields":[{"help":"Enter the full name of the patient","type":"text","label":"Name:","options":[],"required":null,"pdf_field":""},{"help":"Tick Male, Female or Third gender","type":"choice","label":"Gender:","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter number of years","type":"number","label":"Age: Years","options":[],"required":null,"pdf_field":""},{"help":"Enter number of months","type":"number","label":"Months","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 others, please 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 others, please specify","type":"choice","label":"Occupation:","options":["Service","Self-employed","Homemaker","Student","Retired","Other (Please Specify)"],"required":null,"pdf_field":""},{"help":"Include Street, City and Pin Code","type":"text","label":"Address (if different from above):","options":[],"required":null,"pdf_field":""},{"help":"City of the patient's address","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"State of the patient's address","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Pin code of the patient'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 a valid email address","type":"email","label":"Email ID:","options":[],"required":null,"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:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharged:","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"Time:","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 question","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":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section E – details of claim","fields":[{"help":"Enter amounts in rupees (do not enter paise values) for each category: (i) Pre-hospitalization expenses, (ii) Hospitalization expenses, (iii) Post-hospitalization expenses, (iv) Health-check-up cost, (v) Ambulance charges, (vi) Others (code): specify code and amount, then total","type":"amount","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":"Fill details of bills enclosed with columns: Sl.No., Bill No., Date (DD/MM/YYYY), Issued by, Towards, Amount 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 PAN 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 the bank name in full along with branch","type":"text","label":"Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter the 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":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place:","options":[],"required":null,"pdf_field":""},{"help":"Sign after reading the declaration carefully","type":"signature","label":"Signature of the Insured","options":[],"required":true,"pdf_field":""}],"filled_by":"insured / policyholder"}],"deadlines":[],"applies_to":"","attachments":["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","MLC report & police FIR (if medico legal injury)"],"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 any 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 the bills/receipts for this claim and will not make any supplementary claim except the pre/post hospitalization claim, if any."],"dropped_labels":3},"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/1457-zuno-health-insurance-claim-form-a"}