{"id":1494,"title":"Zuno Health Top Up Insurance Claim Form B V.1","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_top_up_insurance_claim_form_B_V_1_b1698ddfda.pdf?updated_at=2026-03-15T17:06:30.644Z","sha256":"fe2feaef0d9fb934de3bfae41e600e38efc4616f9c82c55222ecd8af88983a69","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is for claiming health insurance benefits under the Zuno Health Top Up Insurance policy. It is to be filled by the hospital treating the insured patient.","notes":["Fill all details in BLOCK LETTERS","Attach original pre-authorization request form along with this claim form","Use standard ICD 10 and ICD 10 PCS codes for diagnosis and procedures","Include STD code with telephone numbers","Attach test reports if injury due to substance abuse/alcohol consumption","Use DD MM YYYY format for dates and HH MM format for times","This form should be filled by the hospital","This form is not an admission of liability"],"title":"Zuno Health Top Up Insurance Claim Form B V.1","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 the educational qualifications of the doctor","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter the doctor's registration number with state code as per 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 Patient Admitted","fields":[{"help":"Enter full name of the patient","type":"text","label":"Name of the patient","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of proposer or employee","type":"text","label":"Name of proposer / employee","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of department","type":"text","label":"Department","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Employee No","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of corporate","type":"text","label":"Name of the corporate","options":[],"required":null,"pdf_field":""},{"help":"Enter full name of branch","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":"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"],"required":null,"pdf_field":""},{"help":"Use DD MM YYYY format","type":"date","label":"If maternity, Date of delivery","options":[],"required":null,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida status","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section C: Details of Ailment Diagnosed","fields":[{"help":"Enter details of the procedure","type":"text","label":"Details of procedure","options":[],"required":null,"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 allotted by TPA","type":"text","label":"Pre-authorization No","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If authorization by network hospital not obtained, reason","options":[],"required":null,"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":"Cause of injury","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":null,"pdf_field":""},{"help":"Tick Yes or No and attach reports if Yes","type":"yes-no","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":"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 issued by police","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":"Hospital Information","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 hospital registration number with state code","type":"text","label":"Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Enter Permanent Account Number as per 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 all applicable facilities; specify if Other","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Medical Store","Pathology","Radiology","Other"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Declaration and Signature","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":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"Zuno Health Top Up Insurance claims","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","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":["This form is not an admission of liability","The hospital confirms the accuracy of the information provided","The hospital agrees to provide all necessary documents listed","The hospital confirms that the patient details and treatment information are true and correct"],"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/1494-zuno-health-top-up-insurance-claim-form-b-v-1"}