{"id":1477,"title":"Zuno HealthPlus Policy Claim Form A","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_A_V_1_2_3613370694.pdf?updated_at=2025-04-30T10:28:18.982Z","sha256":"6e5845ee6706c542ac1a70f60efdc588c40c1e377eed0b02b48378c3fccafd6c","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by the insured or policyholder to claim health insurance benefits under the Zuno HealthPlus Policy. The insured fills it to provide details of hospitalization, treatment expenses, and other insurance history.","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.","Attach original bills and payment receipts as specified.","If others are selected in options, specify details clearly.","Include STD code with phone numbers.","Read declaration carefully before signing."],"title":"Zuno HealthPlus Policy 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 IRDA and printed in TPA documents","type":"text","label":"Company/ TPA ID No.:","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of the policyholder","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","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","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":"yes-no","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","type":"text","label":"Policy number:","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured in rupees","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 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":"Enter full name of the insurance company","type":"text","label":"Name of the insurance company:","options":[],"required":null,"pdf_field":""},{"help":"Enter policy number","type":"text","label":"Policy No:","options":[],"required":null,"pdf_field":""},{"help":"Enter sum insured in rupees","type":"amount","label":"Sum insured:","options":[],"required":null,"pdf_field":""},{"help":"Enter claimed amount in rupees","type":"amount","label":"Claimed amount:","options":[],"required":null,"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 number of 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 or specify if Other","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","type":"text","label":"City:","options":[],"required":null,"pdf_field":""},{"help":"State of the patient","type":"text","label":"State:","options":[],"required":null,"pdf_field":""},{"help":"Pin code of the patient","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 D – Details of hospitalization","fields":[{"help":"Enter 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 dd-mm-yy format","type":"date","label":"Date of discharge:","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 system of medicine followed","type":"text","label":"System of medicine used for treatment:","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section E – Details of claim","fields":[{"help":"Enter amounts in rupees for each category: pre-hospitalization, hospitalization, post-hospitalization, OPD consultation, ambulance charges, OPD dental, maternity, pre/post natal, home-care treatment, pandemic disease lump sum, vaccination expenses, accidental death benefit, permanent total disability, permanent partial disability, temporary total disability, critical illness lump sum, pre-hospitalization period (days), post-hospitalization period (days)","type":"table","label":"Details of the treatment expenses you’re claiming for","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No; if yes, provide details","type":"yes-no","label":"Claim for domiciliary hospitalization:","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter total claimed amount in rupees","type":"amount","label":"Total:","options":[],"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":""},{"help":"Number of consultation bills enclosed","type":"number","label":"Consultation bills","options":[],"required":null,"pdf_field":""},{"help":"Number of ambulance receipts enclosed","type":"number","label":"Ambulance receipt","options":[],"required":null,"pdf_field":""},{"help":"Number of pathology bills enclosed","type":"number","label":"Pathology bills","options":[],"required":null,"pdf_field":""},{"help":"Number of radiology bills enclosed","type":"number","label":"Radiology bills","options":[],"required":null,"pdf_field":""},{"help":"Number of other bills enclosed","type":"number","label":"Others","options":[],"required":null,"pdf_field":""}],"filled_by":"insured / policyholder"},{"title":"Section G - Details of primary insured’s / policyholder’s bank account","fields":[{"help":"Enter Permanent Account Number as allotted 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 full name of bank and branch","type":"text","label":"Bank name and branch:","options":[],"required":null,"pdf_field":""},{"help":"Enter name of individual/organization to whom cheque/DD should be made 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:","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":"health insurance claims under Zuno HealthPlus Policy","attachments":["Duly signed claim form","Copy of the claim intimation, if any","Original hospital main bill and payment receipt","Original hospital detailed break-up of charges bill","Hospital discharge / death / transfer summary","Hospital bill payment receipt","FIR / MLC if applicable","Disability certificate / fitness certificate if applicable","Operation theatre notes","ECG and / or pathology reports","Doctor's request / referral note for investigation","Investigation reports (including CT/MRI/USG/HPE)","Doctor’s prescriptions and doctor’s notes in home care treatment","Bills for consultation, nursing etc in home care treatment","Original payment receipts of expenses for home care treatment","Pharmacy bills and payment receipts","Epic like Aadhar/PAN/Voter ID/Passport/Driving License: please specify details","Copy of bank passbook / cheque with name printed on leaflet: please specify details","If you’ve chosen worldwide coverage: passport with immigration stamping / boarding pass / travel itinerary as applicable","Self-description of incident / accident and any other additional documents: please specify","Any other document, please specify"],"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/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":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/1477-zuno-healthplus-policy-claim-form-a"}