{"id":1505,"title":"Zuno Health Assure Insurance Claim Form B","purpose":"claim","insurer":{"slug":"zuno-general-insurance","name":"Zuno General Insurance Ltd"},"source_pdf":"https://cms.hizuno.com/uploads/Zuno_Health_Assure_Insurance_Claim_Form_B_7c85b434ea.pdf?updated_at=2026-03-15T17:08:08.872Z","sha256":"d65f3ab2f3f68d0b41e16a8868a0102adde49907db2e36cbb807d30c7dd3cb36","pages":3,"collected":"2026-10-17","instructions":{"about":"This form is used by hospitals to submit health insurance claims for inpatient treatment under the Zuno Health Assure Insurance policy.","notes":["Fill the form in BLOCK letters.","Issue of this form is not an admission of liability.","Include the original pre-authorization request form in lieu of PART A.","Use dd-mm-yyyy format for dates and hh:mm format for times.","Attach original bills and reports as specified.","Section E is to be filled only if hospital is non-network."],"title":"Zuno Health Assure Insurance Claim Form B","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 (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":"Section B – Details of the patient admitted","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","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 if applicable","type":"date","label":"If maternity, (i) Date of delivery","options":[],"required":false,"pdf_field":""},{"help":"Enter gravida status if maternity","type":"text","label":"Gravida status","options":[],"required":false,"pdf_field":""},{"help":"Tick the appropriate option","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Enter amount in rupees (no paise)","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"Section C – Details of ailment diagnosed (primary)","fields":[{"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":"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":false,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If authorization by network hospital not obtained, give reason","options":[],"required":false,"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":"If Yes, give cause","options":["Self-inflicted","Road traffic accident","Substance abuse/alcohol consumption"],"required":false,"pdf_field":""},{"help":"Tick yes or no; if yes, attach reports","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":"Tick yes or no","type":"yes-no","label":"If medico legal","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Tick yes or no","type":"yes-no","label":"Reported to police","options":["Yes","No"],"required":false,"pdf_field":""},{"help":"Enter FIR number if reported","type":"text","label":"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":"Section D – Claim documents submitted – checklist","fields":[{"help":"","type":"checkbox","label":"Claim form duly signed","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Original pre-authorization request","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of the Pre-authorization approval letter","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital discharge summary","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Operation theatre notes","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital main bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital break-up bill","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Investigation reports","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"CT/MR/USG/HPE investigation reports","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Doctor’s reference slip for investigation","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"ECG","options":[],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Pharmacy bills","options":[],"required":null,"pdf_field":""},{"help":"Attach if applicable","type":"checkbox","label":"MLC report & police FIR","options":[],"required":false,"pdf_field":""},{"help":"Attach if applicable","type":"checkbox","label":"Original death summary from hospital where applicable","options":[],"required":false,"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 – Additional details in case of non-network hospital","fields":[{"help":"Enter full postal address including street, city, state, and pin code","type":"text","label":"Address of hospital","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 with state code","type":"text","label":"Registration No. with state code","options":[],"required":null,"pdf_field":""},{"help":"Enter Permanent Account Number allotted 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; specify if other","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Other"],"required":null,"pdf_field":""}],"filled_by":"hospital (if non-network)"},{"title":"Section F – Declaration by the hospital","fields":[{"help":"Enter date in dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":true,"pdf_field":""},{"help":"Enter place of signing","type":"text","label":"Place","options":[],"required":true,"pdf_field":""},{"help":"Hospital authority must sign and stamp","type":"signature","label":"Signature & Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital authority"}],"deadlines":[],"applies_to":"health insurance inpatient claims","attachments":["Original pre-authorization request form","Pre-authorization approval letter copy","Photo ID card copy of patient verified by hospital","Hospital discharge summary","Operation theatre notes","Hospital main bill","Hospital break-up bill","Investigation reports","CT/MR/USG/HPE investigation reports","Doctor’s reference slip for investigation","ECG","Pharmacy bills","MLC report & police FIR (if applicable)","Original death summary from hospital (if applicable)","Test reports for substance abuse/alcohol consumption (if applicable)"],"declarations":["The information furnished in this Claim Form is true and correct to the best of our knowledge and belief.","If any false or untrue statement, suppression or concealment of any material fact is made, the right to claim under this claim shall be forfeited."],"dropped_labels":6},"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/1505-zuno-health-assure-insurance-claim-form-b"}