{"id":1458,"title":"Zuno Group Health Insurance Policy Claim form - A","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Group_Health_Claim_Form_A_V_1_1_d0cf690bb7.pdf?updated_at=2024-09-26T06:01:24.702Z","sha256":"aff36aca61fdb62055cd995af4be150ee2bd5970ffc75cfdb8c0e84cfa287146","pages":5,"collected":"2026-10-17","instructions":{"about":"This form is for the insured person to claim health insurance benefits under the Zuno Group Health Insurance Policy.","notes":["Fill all details in BLOCK LETTERS.","This form should be filled in by the insured person.","This form is not an admission of liability.","Use dd-mm-yy format for dates and hh:mm format for times.","Do not enter paise values in amount fields.","Tick the appropriate options where applicable.","Attach original bills and documents as per checklist.","Use the guidance notes on page 4 for correct formats and details."],"title":"Zuno Group Health Insurance Policy Claim form - A","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Some details about your policy","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":"Serial 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":"","type":"email","label":"Email ID:","options":[],"required":null,"pdf_field":""},{"help":"Name of the corporate employer","type":"text","label":"Name of corporate:","options":[],"required":null,"pdf_field":""},{"help":"Employee number","type":"text","label":"Employee No:","options":[],"required":null,"pdf_field":""},{"help":"Branch location of the corporate","type":"text","label":"Branch location:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section B – Share your past/other insurance information","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Are you currently covered by any other mediclaim / health insurance:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Name of the insurance company in full","type":"text","label":"If Yes, company name:","options":[],"required":null,"pdf_field":""},{"help":"Policy number as allotted by the insurance company","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured in rupees (do not enter paise values)","type":"amount","label":"Sum insured (INR):","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Have you been hospitalized in the last four years since the start 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":"Provide details of the other insurance policy","type":"text","label":"If yes, please specify the details.","options":[],"required":null,"pdf_field":""},{"help":"Name of the other insurance company","type":"text","label":"Name of the insurance company:","options":[],"required":null,"pdf_field":""},{"help":"Policy number of the other insurance","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Sum insured under the other policy in rupees","type":"amount","label":"Sum insured:","options":[],"required":null,"pdf_field":""},{"help":"Amount claimed under the other policy in rupees","type":"amount","label":"Claimed amount:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section C – A bit about the person hospitalized","fields":[{"help":"Full name of the patient hospitalized","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 and Pin Code","type":"text","label":"Address (if different from above):","options":[],"required":false,"pdf_field":""},{"help":"City of patient's address if different","type":"text","label":"City:","options":[],"required":false,"pdf_field":""},{"help":"State of patient's address if different","type":"text","label":"State:","options":[],"required":false,"pdf_field":""},{"help":"Pin code of patient's address if different","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":"","type":"email","label":"Email ID:","options":[],"required":false,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section D – details of hospitalization","fields":[{"help":"Enter name of hospital in full","type":"text","label":"Name of hospital admitted:","options":[],"required":null,"pdf_field":""},{"help":"Full address of hospital","type":"text","label":"Address:","options":[],"required":null,"pdf_field":""},{"help":"Nearby landmark of hospital","type":"text","label":"Landmark:","options":[],"required":false,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Room category opted for:","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 sub-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 person"},{"title":"Section E - details of claim","fields":[{"help":"Tick Yes or No; if Yes, provide details in annexure","type":"yes-no","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","ECG","Copy of the claim intimation, if any","Doctor's request for investigation","Hospital main bill","Investigation reports (Including CT/MRI / USG / HPE)","Hospital break-up bill","Doctor’s prescriptions","Hospital release in short","Hospital Bill Payment Receipt","Pharmacy Bill","Operation Theatre Notes"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section F – Details of bills enclosed","fields":[{"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:","options":[],"required":null,"pdf_field":""},{"help":"Number of post-hospitalization bills enclosed","type":"number","label":"Post-hospitalization Bills:","options":[],"required":null,"pdf_field":""},{"help":"Number of pharmacy bills enclosed","type":"number","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section G - In case it’s an accident","fields":[{"help":"Tick if claim is for death","type":"checkbox","label":"Death","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claim is for permanent partial disability","type":"checkbox","label":"Permanent partial disability","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claim is for permanent total disability","type":"checkbox","label":"Permanent total disability","options":["Yes"],"required":null,"pdf_field":""},{"help":"Tick if claim is for temporary total disability","type":"checkbox","label":"Temporary total disability","options":["Yes"],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section H - Tell us more about the accident","fields":[{"help":"Use dd-mm-yy format and HH:MM for time","type":"date","label":"Date and time of accident:","options":[],"required":null,"pdf_field":""},{"help":"Mention the place of accident","type":"text","label":"Place of accident:","options":[],"required":null,"pdf_field":""},{"help":"Mention the cause of accident","type":"text","label":"Cause of accident:","options":[],"required":null,"pdf_field":""},{"help":"Provide details if applicable","type":"text","label":"Temporary total disability:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section I - The insured’s or nominee’s bank account details","fields":[{"help":"Enter Permanent Account Number as given by 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 bank name in full along with branch","type":"text","label":"Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of 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 code:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section J - Details of out-patient cover","fields":[{"help":"Use dd-mm-yy format","type":"date","label":"Treatment start date:","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Treatment end date:","options":[],"required":null,"pdf_field":""},{"help":"Enter name and contact details","type":"text","label":"Name and contact details of treating doctor:","options":[],"required":null,"pdf_field":""},{"help":"Enter name and address","type":"text","label":"Name and address of clinic / hospital:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of disease or ICD code","type":"text","label":"Nature of illness / disease:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees (do not enter paise values)","type":"amount","label":"Consultation fees:","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees (do not enter paise values)","type":"amount","label":"Pharmacy / investigations etc:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured person"},{"title":"Section K – Declaration by the insured / nominee","fields":[{"help":"Enter date in dd-mm-yy format","type":"date","label":"Date:","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place:","options":[],"required":true,"pdf_field":""}],"filled_by":"insured person or nominee"}],"deadlines":[],"applies_to":"Zuno Group Health Insurance Policy claims","attachments":["Duly signed claim Form","ECG","Copy of the claim intimation, if any","Doctor's request for investigation","Hospital main bill","Investigation reports (Including CT/MRI / USG / HPE)","Hospital break-up bill","Doctor’s prescriptions","Hospital release in short","Hospital Bill Payment Receipt","Pharmacy Bill","Operation Theatre Notes"],"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 / medical practitioner who has attended on the person against whom this claim is made.","I declare that I have included all the bills / receipts for the purpose of this claim and will not make any other claim except the pre / post hospitalization claim, if any.","I authorize Zuno General Insurance / Zuno authorized TPA to collect relevant medical documents for my claim from the provider where I have taken treatment."],"dropped_labels":7},"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/1458-zuno-group-health-insurance-policy-claim-form-a"}