{"id":1475,"title":"Zuno HealthPlus Policy Claim form - B","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_Plus_Policy_claim_form_B_V_1_1_1eacac1336.pdf?updated_at=2025-04-30T10:28:19.003Z","sha256":"80c980176c514ece82275107d99f2497f19f21192ea4ee2187f59f7dba37a0f8","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is for hospitals to fill in details related to a patient's hospitalization and treatment to support a health insurance claim under the Zuno HealthPlus Policy.","notes":["Fill the form in BLOCK letters.","Filling and submission of this form does not guarantee claim acceptance.","Include original pre-authorization request form in lieu of PART A.","Use DD-MM-YYYY format for dates and HH-MM format for times.","Do not enter paisa values in amount fields.","Attach reports if test for substance abuse/alcohol consumption was conducted.","Section E is to be filled only if hospital is non-network."],"title":"Zuno HealthPlus Policy 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","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 registration number of the doctor with state code as given by 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 full name of the patient","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration No.","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"Gender","options":["Male","Female","Third gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"Date of birth","options":[],"required":null,"pdf_field":""},{"help":"Use DD-MM-YYYY 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-YYYY format","type":"date","label":"Date of discharge","options":[],"required":null,"pdf_field":""},{"help":"Use HH-MM format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Type of admission","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Use DD-MM-YYYY format","type":"date","label":"If maternity, (i) date of delivery","options":[],"required":false,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"(ii) Gravida status","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter amount in rupees (do not enter paisa values)","type":"amount","label":"Total claim 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 if obtained","type":"text","label":"Pre-authorization No","options":[],"required":false,"pdf_field":""},{"help":"Enter reason if pre-authorization not obtained by network hospital","type":"text","label":"If authorization by network hospital was not obtained, 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, mention the cause","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number if reported","type":"text","label":"If reported, FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Enter reason if not reported 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":"Tick if submitted","type":"checkbox","label":"Claim form duly signed","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Original pre-authorization request","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of the pre-authorization approval letter","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital discharge summary","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Operation theatre notes","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"MLC report & police FIR","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Hospital break-up bill","options":[],"required":null,"pdf_field":""},{"help":"Tick if applicable and submitted","type":"checkbox","label":"Original death summary from hospital where needed","options":[],"required":false,"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 E – Details in case of non-network hospital","fields":[{"help":"Include street, city, state and pin code","type":"text","label":"Address of hospital","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 permanent account 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":""},{"help":"Tick the appropriate options; specify others if any","type":"choice","label":"Facilities available in the hospital","options":["OT: Yes","OT: No","ICU: Yes","ICU: No","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital (if non-network)"},{"title":"Section F – Declaration by the hospital","fields":[{"help":"Enter date in DD-MM-YYYY format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign and stamp the form","type":"signature","label":"Signature & Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance claims under Zuno HealthPlus Policy","attachments":["original pre-authorization request form","original pre-authorization approval letter copy","photo ID card of patient verified by hospital copy","investigation reports","CT/MR/USG/HPE investigation reports","doctor’s reference slip for investigation","ECG","hospital discharge summary","pharmacy bills","operation theatre notes","MLC report & police FIR","hospital main bill","hospital break-up bill","original death summary from hospital where needed","reports for substance abuse/alcohol consumption test if conducted"],"declarations":["The information given in this claim form is true and correct to the best of our knowledge and belief.","If any false or untrue statement is made, or any material fact is knowingly hidden, the right to claim will be cancelled."],"dropped_labels":9},"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/1475-zuno-healthplus-policy-claim-form-b"}