{"id":1473,"title":"Zuno Health Assure Insurance Claim Form B","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_Assure_Insurance_Claim_Form_B_V_1_0_db2783c16d.pdf?updated_at=2025-03-29T10:01:22.117Z","sha256":"22f26ee17087a189bdd63fc846526a90251961589cca45b8a3fd32a3deb3abe8","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by hospitals to provide details for health insurance claims under the Zuno Health Assure Insurance policy. It is filled primarily by the hospital and includes patient, treatment, and claim details.","notes":["Form must be filled in BLOCK letters by the hospital.","Issue of this form is not an admission of liability.","Original pre-authorization request form must be included in lieu of Part A.","Use dd-mm-yy format for dates and hh:mm format for times.","Use standard formats for ICD 10 codes and medical details.","Attach original documents as per checklist.","Section E to be filled only if hospital is non-network."],"title":"Zuno Health Assure Insurance Claim Form B","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A – Details of hospital","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"Name of hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital ID as allocated by the TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of hospital: Network  Non-network (If non-network, fill section E)","options":["Network","Non-network"],"required":null,"pdf_field":""},{"help":"Enter the full name of the treating doctor","type":"text","label":"Name of treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter the doctor's educational qualifications (abbreviations allowed)","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter the registration number with state code as allocated by the medical council of India","type":"text","label":"Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section B – Details of the patient admitted","fields":[{"help":"Enter the full name of the patient","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"Enter the insurance provider registration number","type":"text","label":"IP registration No.","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender: Male Female Third 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":"Use dd-mm-yy format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format for time of admission","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format for time of discharge","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of admission: Emergency Planned Day Care Maternity","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yy format","type":"date","label":"If maternity, (i) Date of delivery","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Status at time of discharge: Discharge to home Discharge to another hospital Deceased","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter amount in rupees (no paise)","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section C – Details of ailment diagnosed (primary)","fields":[{"help":"Enter details of the procedure","type":"text","label":"Details of procedure","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number as allotted by TPA","type":"text","label":"Pre-authorization No.","options":[],"required":false,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the appropriate cause","type":"choice","label":"If Yes, give cause: Self-inflicted Road traffic accident Substance abuse/alcohol consumption","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick yes or no; if yes, attach reports","type":"yes-no","label":"If injury due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"If medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number if reported","type":"text","label":"FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported, give reason","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section D – Claim documents submitted – checklist","fields":[{"help":"","type":"checkbox","label":"Claim form duly signed","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Original pre-authorization request","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"CT/MR/USG/HPE investigation reports","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of the Pre-authorization approval letter","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Doctor’s reference slip for investigation","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"ECG","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital discharge summary","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Operation theatre notes","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"MLC report & police FIR","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Original death summary from hospital where applicable","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital break-up bill","options":[],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Any other, please specify","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section I - The insured’s or nominee’s bank account details","fields":[{"help":"Enter PAN number","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 and branch","type":"text","label":"Bank name and branch","options":[],"required":null,"pdf_field":""},{"help":"Enter details for cheque or demand draft payable","type":"text","label":"Cheque / DD payable details","options":[],"required":null,"pdf_field":""},{"help":"Enter IFSC code of the bank branch","type":"text","label":"IFSC code","options":[],"required":null,"pdf_field":""}],"filled_by":"insured or nominee"},{"title":"Section E – Additional details in case of non-network hospital","fields":[{"help":"Enter full postal address including city, state and pin code","type":"text","label":"Address of hospital: City, State, 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 registration number with state code","type":"text","label":"Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital PAN number","type":"text","label":"Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"Number of inpatient beds","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital (if non-network)"},{"title":"Section F – Declaration by the hospital","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":"Signature and seal of hospital authority","type":"signature","label":"Signature & Seal of the Hospital Authority","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"","attachments":["Original pre-authorization request form","Investigation reports","CT/MR/USG/HPE investigation reports","Copy of the Pre-authorization approval letter","Doctor’s reference slip for investigation","Copy of photo ID card of patient verified by hospital","ECG","Hospital discharge summary","Pharmacy bills","Operation theatre notes","MLC report & police FIR","Hospital main bill","Original death summary from hospital where applicable","Hospital break-up bill","Reports for substance abuse/alcohol consumption test if conducted"],"declarations":["The hospital declares that the information furnished is true and correct to the best of their knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim shall be forfeited."],"dropped_labels":8},"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/1473-zuno-health-assure-insurance-claim-form-b"}