{"id":1518,"title":"Health Insurance Policy Claim Form Part - B TO BE FILLED BY THE HOSPITAL","purpose":"claim","insurer":{"slug":"zurich-kotak-general-insurance","name":"Zurich Kotak General Insurance Company (India) Limited"},"source_pdf":"https://cms.zurichkotak.com/uploads/Health_Insurance_Part_B_Claim_Form_ZK_26_27_v1_09042026_cf6bb9a2c8.pdf","sha256":"5814b664f2c6d98edf6124df3bdb63e974e77734326aa758e64ae11508cc97c0","pages":4,"collected":"2026-10-17","instructions":{"about":"This form is to be filled by the hospital for submitting health insurance claims related to a patient's hospitalization and treatment.","notes":["Use block letters for patient name.","Include original preauthorization request form in lieu of Part A.","Attach reports if test conducted for substance abuse/alcohol consumption.","Use standard formats for dates (dd-mm-yyyy) and times (hh:mm).","Fill section E only if hospital is non-network.","This form is not an admission of liability."],"title":"Health Insurance Policy Claim Form Part - B TO BE FILLED BY THE HOSPITAL","submit":{"to":"","how":"","address":""},"purpose":"claim","sections":[{"title":"DETAILS OF HOSPITAL","fields":[{"help":"Enter the full name of the hospital","type":"text","label":"Name of the 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 Network","options":["Network","Non Network"],"required":null,"pdf_field":""},{"help":"Enter full name of the treating doctor","type":"text","label":"Name of the Treating Doctor","options":[],"required":null,"pdf_field":""},{"help":"Enter abbreviations of educational qualifications","type":"text","label":"Qualification","options":[],"required":null,"pdf_field":""},{"help":"Enter registration number of the doctor along 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 Number","options":[],"required":null,"pdf_field":""},{"help":"Include street, city, state and pin code","type":"text","label":"Address of the Hospital","options":[],"required":null,"pdf_field":""},{"help":"Include STD code with telephone number","type":"phone","label":"Phone No","options":[],"required":null,"pdf_field":""},{"help":"As allocated by the Medical Council of India","type":"text","label":"Registration No. with State Code","options":[],"required":null,"pdf_field":""},{"help":"Enter permanent account number as 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 Yes or No for each facility; specify others if applicable","type":"checkbox","label":"Facilities available in the hospital","options":["OT","ICU","Others"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS OF THE PATIENT ADMITTED","fields":[{"help":"To be filled in block letters","type":"text","label":"Name of the Patient","options":[],"required":null,"pdf_field":""},{"help":"Enter insurance provider registration number","type":"text","label":"IP Registration Number","options":[],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Gender","options":["Male","Female","Others"],"required":null,"pdf_field":""},{"help":"Enter number of 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","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 right option","type":"choice","label":"Type of Admission","options":["Emergency","Planned","Day Care","Maternity","ICU"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"Status at time of discharge","options":["Discharge to home","Discharge to another hospital","Deceased"],"required":null,"pdf_field":""},{"help":"Indicate total claimed amount in rupees (do not enter paise values)","type":"amount","label":"Total claimed amount","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DETAILS OF AILMENT DIAGNOSED (PRIMARY)","fields":[{"help":"Enter details of the procedure","type":"text","label":"Details of Procedure","options":[],"required":null,"pdf_field":""},{"help":"Indicate whether pre-authorization obtained","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 Number","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not obtaining pre-authorization","type":"text","label":"If Authorization by Network Hospital not obtained, give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"HOSPITALISATION DUE TO INJURY","fields":[{"help":"Tick Yes or No","type":"yes-no","label":"Hospitalisation due to Injury","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Tick the right option","type":"choice","label":"If Yes, give cause","options":["Self-inflicted","Road Traffic Accident","Substance abuse/alcohol consumption"],"required":null,"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":null,"pdf_field":""},{"help":"Indicate whether injury is medico legal","type":"yes-no","label":"If Medico legal","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Indicate whether police report was filed","type":"yes-no","label":"Reported to Police","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Enter first information report number as issued by police authorities","type":"text","label":"FIR No","options":[],"required":null,"pdf_field":""},{"help":"Enter reason for not reporting to police","type":"text","label":"If not reported to police give reason","options":[],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"CLAIM DOCUMENTS SUBMITTED - CHECK LIST","fields":[{"help":"","type":"checkbox","label":"Copy of photo ID card of patient verified by hospital","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Operation Theatre notes","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital main bill","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital Discharge summary","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Hospital break-up bill","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"ECG","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"MLC report & Police FIR","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Original death summary from hospital where applicable","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Pharmacy bills","options":["Yes"],"required":null,"pdf_field":""},{"help":"Specify any other documents submitted","type":"text","label":"Any other, please specify","options":[],"required":false,"pdf_field":""},{"help":"","type":"checkbox","label":"Copy of the Pre-authorization approval letter","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Claim Form duly signed","options":["Yes"],"required":null,"pdf_field":""},{"help":"Include original pre-authorization request form in lieu of Part A","type":"checkbox","label":"Original Pre-authorization request","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Investigation reports","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"CT/MR/USG/HPE investigation reports","options":["Yes"],"required":null,"pdf_field":""},{"help":"","type":"checkbox","label":"Doctor’s reference slip for investigation","options":["Yes"],"required":null,"pdf_field":""}],"filled_by":"hospital"},{"title":"DECLARATION BY THE HOSPITAL","fields":[{"help":"Use dd-mm-yyyy format","type":"date","label":"Date","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Place","options":[],"required":null,"pdf_field":""},{"help":"Sign and stamp the form","type":"signature","label":"Signature and Seal of the Hospital Authority","options":[],"required":true,"pdf_field":""}],"filled_by":"hospital authority"}],"deadlines":[],"applies_to":"","attachments":["Original preauthorization request form","Copy of photo ID card of patient verified by hospital","Operation Theatre notes","Hospital main bill","Hospital Discharge summary","Hospital break-up bill","ECG","MLC report & Police FIR","Original death summary from hospital where applicable","Pharmacy bills","Copy of the Pre-authorization approval letter","Claim Form duly signed","Investigation reports","CT/MR/USG/HPE investigation reports","Doctor’s reference slip for investigation"],"declarations":["The hospital declares that the information furnished in this claim form is true and correct to the best of their 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":8},"pdf_fields":null,"fillable_pdf":false,"send_to":[{"purpose":"claim","channel":"address","value":"Family Health Plan Insurance TPA Limited, Srinilaya – Cyber Spazio, Suite # 101,102,109&110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad : 500034, Telangana , India","label":"Health claims department address","level":null,"hours":null,"applies_to":"health","source_url":"https://www.zurichkotak.com/services/claims","quote":"g address as early as possible, but no later than 30 days from the date of discharge.\nHealth claims department address:\nFamily Health Plan Insurance TPA Limited, Srinilaya – Cyber Spazio, Suite # 101,102,109&110, Ground Floor,Road No. 2, Banjara Hills, Hyderabad : 500034, Telangana , India\nIs there any time period for filing pre and post hospital claims?\nThe pre-hospitalisation claim documents duly complete","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"email","value":"care@zurichkotak.com","label":"Email Address","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"in\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be used for calls. This is chat only number.\nAccessibility\nZoom in page\nZoom out page\nIncrea","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"1800 2120","label":"Toll Free Number","level":null,"hours":null,"applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"age claims\nCustomer support\nGrievance redressal\nLogin\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be used for calls. This is cha","fetched_at":"2026-10-20"},{"purpose":"claim","channel":"phone","value":"+91-22-69417220","label":"Toll Number (INDIA And Overseas)","level":null,"hours":"IST 8 am to 8 pm","applies_to":"all","source_url":"https://www.zurichkotak.com/services/claims","quote":"Download policy\nManage policy\nManage claims\nCustomer support\nGrievance redressal\nLogin\nToll Number (INDIA And Overseas)\n+91-22-69417220\nToll Free Number\n1800 2120\nWhatsApp Number\n7998879988\nEmail Address\ncare@zurichkotak.com\nOur WhatsApp number cannot be","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/zurich-kotak-general-insurance/1518-health-insurance-policy-claim-form-part-b-to-be-filled-by-the-hospital"}