{"id":1491,"title":"Zuno Group Health Insurance Policy Claim Form B","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Group_Health_Insurance_Policy_Claim_form_B_V_2_0_67d7cd394e.pdf","sha256":"fb7c14d95c4fe43baa15b9ce6ac609814f7b6f7e73b38dcee159fabdba98a43f","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for hospitals to fill in details required to claim health insurance under the Zuno Group Health Insurance Policy.","notes":["This form should be filled in by the hospital.","Issuance of this form does not imply acceptance of liability.","Fill all details in BLOCK LETTERS.","Use original bills only.","Use dd-mm-yyyy format for dates and hh:mm format for times.","Attach original pre-authorization request form with Part A.","Use the checklist in Section D to ensure all required documents are submitted."],"title":"Zuno Group Health Insurance Policy Claim Form B","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"Section A : About hospital","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"Name of hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter ID number of hospital as allocated by the TPA","type":"text","label":"Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the right 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 educational qualifications of the treating doctor in short","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter the registration number of the doctor along with the state code as given 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: Some details about the patient","fields":[{"help":"Enter the full name of the patient","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the member","type":"text","label":"Name of the member","options":[],"required":null,"pdf_field":""},{"help":"Enter the name of the department","type":"text","label":"Department","options":[],"required":null,"pdf_field":""},{"help":"Enter employee number","type":"text","label":"Employee No","options":[],"required":null,"pdf_field":""},{"help":"Enter the full name of the policyholder (surname, first name, middle name)","type":"text","label":"Name of the Insured / Policyholder","options":[],"required":null,"pdf_field":""},{"help":"Enter branch location","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"Date of admission","options":[],"required":null,"pdf_field":""},{"help":"Enter time of admission in 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":"Enter time of discharge in hh:mm format","type":"text","label":"Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the right 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-yyyy format","type":"date","label":"If maternity, (i) Date of delivery","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status in standard format","type":"text","label":"(ii) Gravida status","options":[],"required":null,"pdf_field":""},{"help":"Tick the right 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 total claimed amount in rupees (no paise)","type":"amount","label":"Total claim amount","options":[],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"Age","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Gender: Male              Female             Third gender","options":["Male","Female","Third gender"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section C: What was the primary ailment being treated?","fields":[{"help":"Enter ICD 10 Code and description of primary diagnosis","type":"text","label":"ICD 10 Codes Description (i) Primary diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 Code and description of additional diagnosis","type":"text","label":"(ii) Additional diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 Code and description of co-morbidities","type":"text","label":"(iii) Co-morbidities","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 Code and description of co-morbidities","type":"text","label":"(iv) Co-morbidities","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS and description of first procedure","type":"text","label":"ICD 10 Codes Description (i) Procedure 1","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS and description of second procedure","type":"text","label":"(ii) Procedure 2","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS and description of third procedure","type":"text","label":"(iii) Procedure 3","options":[],"required":null,"pdf_field":""},{"help":"Enter details of the procedure","type":"text","label":"(iv) Details of procedure","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If the network hospital has not agreed, please state the reason","options":[],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Hospitalization due to injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the right option","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":null,"pdf_field":""},{"help":"Tick Yes or No; if yes, attach reports","type":"choice","label":"If injury due to substance abuse/alcohol consumption, test conducted to prove this","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"If medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"Reported to police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter FIR number as issued by police authorities","type":"text","label":"If reported, FIR no.","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported, please state the reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section D: Have all the documents you need?","fields":[{"help":"Tick if submitted","type":"checkbox","label":"Signed Claim Form","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":"CT/MR/USG/HPE investigation reports","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":"Doctor’s reference slip for investigation","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"ECG","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","type":"checkbox","label":"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":"Original death summary from hospital where needed","options":[],"required":null,"pdf_field":""},{"help":"Tick if submitted","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 E – Non-network hospital? Please help us with some details.","fields":[{"help":"Enter full postal address including street, city, state, pin code","type":"text","label":"Address of hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter landmark near hospital","type":"text","label":"Landmark","options":[],"required":null,"pdf_field":""},{"help":"Enter city","type":"text","label":"City","options":[],"required":null,"pdf_field":""},{"help":"Enter state","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"Enter pin code","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 registration number as given by Medical Council of India","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 Yes or No","type":"choice","label":"Facilities given in the hospital: (i) OT","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"(ii) ICU","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"(iii) Medical Store","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"(iv) Pathology","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick Yes or No","type":"choice","label":"(v) Radiology","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Specify other facilities if any","type":"text","label":"Other","options":[],"required":false,"pdf_field":""}],"filled_by":"hospital (only 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":true,"pdf_field":""},{"help":"Enter place","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Sign and stamp here","type":"signature","label":"Signature and stamp of authorized signatory","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital authorized signatory"}],"deadlines":[],"applies_to":"group health insurance policy claims","attachments":["original pre-authorization request form with Part A","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","discharge summary","pharmacy bills","operation theatre notes","MLC report & Police FIR","hospital main bill","original death summary from hospital where needed","hospital break-up bill"],"declarations":["The hospital declares that the information given in this Claim Form is true and correct to the best of their knowledge and belief.","If any false or untrue statement is made, or any material fact is suppressed or hidden, the right to claim under this claim shall be taken away."],"dropped_labels":0},"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/1491-zuno-group-health-insurance-policy-claim-form-b"}