{"id":1498,"title":"Zuno Empower Health 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_Empower_Health_Claim_Form_B_V_1_79640592fa.pdf?updated_at=2026-03-15T17:07:20.223Z","sha256":"3d67ec90a09cdad5c1f56bc5dd5cdd2b2eed5eb6d1661e9bfbb5a61b79f681e2","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is used by hospitals to submit health insurance claims for patients admitted under the Zuno Empower Health policy.","notes":["This form must be filled in BLOCK letters by the hospital.","Include original pre-authorization request form in lieu of PART A.","Use standard formats for dates and codes as specified.","Enter amounts in rupees without paise.","Use STD codes with phone numbers."],"title":"Zuno Empower Health 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":"a) Name of hospital","options":[],"required":null,"pdf_field":""},{"help":"Enter the hospital ID as allocated by the TPA","type":"text","label":"b) Hospital ID","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"c) Type of Hospital","options":["Network","Non-network"],"required":null,"pdf_field":""},{"help":"Enter the full name of the treating doctor","type":"text","label":"d) Name of treating doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter the educational qualifications of the doctor using abbreviations","type":"text","label":"e) 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":"f) Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"g) Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"j) Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"k) If Maternity, (i) Date of Delivery","options":[],"required":false,"pdf_field":""},{"help":"Provide reason if pre-authorization was not obtained","type":"text","label":"e) If authorization by network hospital not obtained, give reason","options":[],"required":false,"pdf_field":""},{"help":"Tick all that apply; specify others if any","type":"checkbox","label":"f) Facilities available in the hospital","options":["OT","ICU","Others"],"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":"a) Name of Patient","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"b) IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate gender","type":"choice","label":"c) Gender","options":["Male","Female","Third Gender"],"required":null,"pdf_field":""},{"help":"Enter age in years and months","type":"text","label":"d) Age","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"e) Date of Birth","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"f) Date of Admission","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"g) Time","options":[],"required":null,"pdf_field":""},{"help":"Use dd-mm-yyyy format","type":"date","label":"h) Date of Discharge","options":[],"required":null,"pdf_field":""},{"help":"Use hh:mm format","type":"text","label":"i) Time","options":[],"required":null,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"j) Type of Admission","options":["Emergency","Planned","Day Care","Maternity"],"required":null,"pdf_field":""},{"help":"Enter gravida status in standard format","type":"text","label":"m) Gravida Status","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"n) Status at time of discharge","options":[],"required":null,"pdf_field":""},{"help":"Enter amount in rupees without paise","type":"amount","label":"o) Total claim amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section C - Details of ailment diagnosed (primary)","fields":[{"help":"Enter ICD 10 code and description of primary diagnosis","type":"text","label":"a) ICD 10 Code - Primary Diagnosis","options":[],"required":null,"pdf_field":""},{"help":"Enter ICD 10 PCS code and description of first procedure","type":"text","label":"b) 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":""},{"help":"Tick Yes or No","type":"yes-no","label":"c) Pre-authorization obtained","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter pre-authorization number allotted by TPA","type":"text","label":"d) Pre-authorization Number","options":[],"required":false,"pdf_field":""},{"help":"Provide reason for not obtaining pre-authorization","type":"text","label":"e) If authorization by network hospital not obtained, reason","options":[],"required":false,"pdf_field":""},{"help":"Indicate if hospitalization is due to injury","type":"yes-no","label":"f) Hospitalization due to injury - Cause","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate if test was conducted","type":"yes-no","label":"If injury due to substance abuse/alcohol consumption, test conducted to establish this","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if injury is medico legal","type":"yes-no","label":"Medico Legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Indicate if police report was filed","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number issued by police","type":"text","label":"If reported, FIR No.","options":[],"required":false,"pdf_field":""},{"help":"Provide reason for not reporting 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 the documents submitted","type":"checkbox","label":"Claim documents submitted - checklist","options":["Hospital break-up bill","Investigation reports"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section E – Additional hospital details","fields":[{"help":"Enter full postal address including street, city and pin code","type":"text","label":"a) Address","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"b) Phone No.","options":[],"required":null,"pdf_field":""},{"help":"Enter doctor's registration number with state code","type":"text","label":"c) Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Enter hospital's permanent account number","type":"text","label":"d) Hospital PAN","options":[],"required":null,"pdf_field":""},{"help":"Enter number of inpatient beds","type":"number","label":"e) Number of Inpatient beds","options":[],"required":null,"pdf_field":""},{"help":"Tick all that apply; specify others if any","type":"checkbox","label":"f) Facilities available in the hospital","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"}],"deadlines":[],"applies_to":"health insurance claims for hospitalised patients under Zuno Empower Health policy","attachments":["original pre-authorization request form","hospital break-up bill","investigation reports"],"declarations":["The issue of this form is not to be taken as an admission of liability."],"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/1498-zuno-empower-health-claim-form-b-v-1"}