{"id":1487,"title":"Zuno HealthPlus Policy claim form B V-1.1","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_f5d05a2128.pdf?updated_at=2026-03-15T17:02:44.393Z","sha256":"518112bdbbcb01e403eb7888d9f7748c681036acbd899e11181567ea93f51991","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by hospitals to submit health insurance claims under the Zuno HealthPlus Policy for inpatient treatment. It is filled by the hospital treating the patient.","notes":["Fill the form in BLOCK letters.","Submission of this form does not guarantee claim acceptance.","Include the original pre-authorization request form in lieu of PART A."],"title":"Zuno HealthPlus Policy claim form B V-1.1","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Hospital and Doctor Details","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 the doctor's educational qualifications (abbreviations allowed)","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter the medical council registration number with state code","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":"Patient and Admission Details","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","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-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 for time of admission","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 for time of discharge","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, date of delivery","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Hospitalization Due to Injury Details","fields":[{"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":"Cause","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption","Others"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"If injury was due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"yes-no","label":"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 as issued by police","type":"text","label":"If reported, 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":"Details of Ailment Diagnosed","fields":[{"help":"Enter ICD 10 code and description of primary diagnosis","type":"text","label":"ICD 10 Code - Primary Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of first procedure","type":"text","label":"ICD 10 PCS - Procedure 1","options":[],"required":false,"pdf_field":""},{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Pre-authorization Details","fields":[{"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 was not obtained, reason","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Amount and Status","fields":[{"help":"Tick the appropriate status","type":"choice","label":"Status at time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter total claimed amount in rupees (no paisa)","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Claim Documents Submitted - Checklist","fields":[{"help":"Tick the documents being submitted","type":"checkbox","label":"Claim documents submitted - check list","options":["Copy of the pre-authorization approval letter","Hospital break-up bill"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Details in Case of Non-Network Hospital","fields":[{"help":"Enter full postal address including street, city and pin code","type":"text","label":"Address","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 of doctor with state code","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent account number as given by Income Tax department","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 applicable facilities; if others, please mention","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration by the Hospital","fields":[{"help":"Read declaration carefully, then enter date (DD-MM-YYYY), place and sign with hospital stamp","type":"signature","label":"Declaration by the hospital","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Zuno HealthPlus Policy inpatient claims","attachments":["Copy of the pre-authorization approval letter","Hospital break-up bill"],"declarations":["The hospital declares that the information provided is true and correct to the best of their knowledge."],"dropped_labels":5},"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/1487-zuno-healthplus-policy-claim-form-b-v-1-1"}