Death Claim Facing Sheet
Date:
Serial No
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1
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Project
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Single Insurance
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2
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Death Claim No
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Serial no- 181/17
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3
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Insurance Letter No
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103110174-3
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4
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Insurance Receiver Name
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Hasi Mia Rafique
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5
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Insurance Receiver Profession
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Firm Work
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6
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Age at the beginning (Prove)
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50 years
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7
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Age at the time of death
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57 years (As per national identity card)
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8
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Insurance amount
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5,00,000/- (Five Lakhs) only
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9
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Description of Lien
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Not necessary
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10
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Amount of paid installments
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07 premium (56,800x7)=3,97,600/-
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11
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Premium cut off
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Not necessary
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12
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Amount of total premium including cut off
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Not necessary
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13
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Amount of expected paid facility
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Not necessary
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14
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Description of due debt
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Not necessary
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15
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Cooperation insurance
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Not necessary
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16
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Planning and Validity
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01/12
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17
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Premium payment system
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Yearly
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18
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FPR issuance date
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19
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Insurance start date
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30/12/2010 AD
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20
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Risk receive date
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30/12/2010 AD
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21
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Final date of premium payment
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30/12/2016 AD
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22
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Next debt date
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30/12/2017 AD
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23
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Validity
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29/01/2018 AD
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24
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Policy situation at the time of death
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Running
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25
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Time of policy automatically running at the time
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Not necessary
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26
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Final paid installment number in one time
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01
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27
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Date of final PR and O/R
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13/03/2017 AD and 13/03/2017 AD
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28
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Date of death
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20/11/2017 AD
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29
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Real reason of death
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Liver serosis
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30
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Related reason of death
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Not necessary
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31
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Duration of running policy
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06 years 10 months 20 days
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32
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Whether claim form is submitted?
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yes
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33
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Whether claim is investigated?
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yes
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34
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Whether post mortem report has been submitted
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No
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35
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Name of nominee
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Momtaz Begum), Age 49 years, relation- wife
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36
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Guardia
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Not necessary
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................... insurance amount taka = 5,00,000/=
Five Lakhs Taka O=nly
Time duration of insurance runing 06 years 10 months
20 days
As is seen observing the received documents that,
insurance receiver last dated 20/11/2017 AD has been got dead. Reason of death
is liver serosis. In that death claim is payable. Wife of insurance receiver
and policy nominee Mrs Momtaz Begum
Page No- 2
Account:
Principle insurance amount taka: 500,000/=
Bonus
taka = 1,11,000/=
Real
paid taka = 611000/=
As
for death claim insurance taka = 6,11,000/= (Six Lakhs Eleven Thousands Taka
Only), the file is presented to the committee to approve for death claim
insurance.
Sd/ Illegible
25/03/2018 AD
SVP (UW and claim dept)
Sd/ Illegible
25/03/2018 AD
CFO
MD Sir
The
time to have running the policy is 06 years 10 months 20 days the reason of
death is liver serosis. As for claimed death insurance taka = 611000/= (Six
Lakhs Eleven Thousands Taka Only) there is presented he file to the committee
of the claim for approval.
Page No- 3
Sd/
Illegible
Final report of death
claim investigation
Name of insurance
receiver: Hasi Mia Rafique
Policy no- 103110174-3
Insurance amount:
500000/=
Serial no- 181/017
Reason of death:
Liver serosis, high blood pressure and diabetics
I am
Md. Abdul Kader, honorable vice president Obolikhon and claim department in
reference no- RLI/ HO/ claim/ 148/ 18 no letter order accordingly I interviewed
nominee Mrs Momtaz Begum as went investigate physically the investigation of
death Hasi Mia Rafique. All of the information that has been found as went to
there physically which are mentioned as follows.
Interview
with Nomine:
I
asked nominee Mrs Momtaz Begum, husband- Hasi Mia Rafique, care of Hazi Sharif
Miahome village + post office- Charan Deep, police station- Boalkhali,
district- Chittagong as meet with questioned about the real reason of death,
age, profession, family history etc of Late Hasi Mia Rafique.
Mrs
Momtaz Begum informed me Late Hasi Mia Rafique was her husband. He was lived in
abroad. He has come from Dubai about two months ago of death. He was made work
of home repair. He is seemed to have no disease. He was very healthy. He was
very smart in his lifestyle. Therefore they cannot understand the way he will
get dead.
Momtaz
Begum told last dated 05/11/2017 AD her husband suddenly as was got fallen he
has been taken to Chittagong National Hospital. As the doctor prescribed
medicine he has been taken to home started to feed medicine.
Page No- 4
10/11
days he was in good. Again dated 16/11/2017 AD as started to have have caught
he has been taken to that medical and made admitted there. One day later of the
admission there is told about liver serosis and as his situation was serious he
has been taken to ICU. Four days later as was in in ICU dated 20/11/2017 AD at
around 6.30 AM he has got dead. At the time of death he was about 57/ 58 years
old. At the time of death he has left his wife, three sons, three daughters as
well.
Interviews
with Honorable Imam: He has made prayed the funeral prater name Mr Moulana
Muhammad Ishaque Ansari with him in my interview Late Hasi Mia Rafique as asked
related to it he told let it see I am the Friday Imam of that mosque. He has
made prayed one day in a week. In addition I am a freedom fighter and I am
Arabic professor of Charan Deep Islamia Fazil Madrasha. I am used to have busily
always. I used to go to speak in different places. As a result Late Hasi Mia
Rafique is used to meet with me very little. Before death after coming from
abroad he has been meet with me 2/3 times. Whatever the problem was I don’t
know. But it is true he is dead. He has been got dead in Chittagong National
Hospital on dated 20/11/2017 AD. I have been made prayer of the funnel prayer.
At the time of death he has left his wife, three daughters and three sons. Late
Hasi Mia is about 60 years old.
Trying
to meet with Chairman: In the 07 no Charan Deep Union Parishad office as went
there Samsul Alam Chairman was not found there. As is konws that as because
conflicts within the parties Chairman is not about to come in the office
therefore, secretary of the Parishad as was not presented local member Md.
Saddam Hossen has been seen the death certificate and made it attested. Mr
Saddam Hossen told Late Hasi Mia Rafique is my neighbour. I have heard anything
that he was angry. Suddenly I have heard he has been made admitted in the
medical. So far I know he has been got dead dated 20/11/2017 AD in Chittagong
National Hospital. I have heard from the people of the family he was suffering
in liver serosis
Page No- 5
Sd/ Illegible
26/02/2018
AD
He
has become dead.
Interview
with Doctor: Death Certificate as verified the truth Chittagong National Hospital
as went there Medical Officer Dr. Shimur as talked with me Dr. Shimu told- he
has gone out becoming admitted for the first time. He has made EBL twice. He
has not been kept in medical for the first time. Advice has been made of
discharge certificate.
Whatever
the disease was of the Mr Hasi Mia principally as asked of Dr. Shimu told- he
was in disease liver serosis. He was diabets and high blood pressure . Why he
has been made EBL or what is EBL? As asked the types of question he told he was
bleeding in his liver. And if EBL is made bleeding in liver is stopped. In that
situation EBL has been done.
Dr.
Shimu told Late Hasi Mia on dated 05/112017 AD as admitting there was to date
14/11/2017 AD. His relatives has been taken him out on dated 14/11/2017 AD.
Again he has been admitted on dated 16/11/2017 AD. As his situation
diteriorated he was there in ICU fro some days. On dated 20/11/2017 AD he has
been passed away. Medical officer Dr. Shimu told- you may see record as is
going to the room of manager and he has meet with gastorioloigist Dr Mohammad
Jashim Uddin.
As
went to the room of manager as is seen the death certificate as is seen the
record told to me yes all are truth. Telling that he has made sealed the
attested.
Gastoriologist
Dr. Mohammad Jashim Udfdin as went to meet befor in his chamber I had to sit
there about one hour there. In that time one gentle man told as was working in
the chamber – he has been suffered a lot. Before get admitted he used to have
one after another day.
Page No- 6
As
is got the opportunity to enter Dr
Jashim Uddin told- there were many problems to him. He has been went out once
got admitted there forcedly. If he would not have gone out it may not happen.
As like medical officer he aslo told – Late Hasi Mia dated 05/11/2017 AD as
becoming admitted on dated 14/11/2017 AD then went out. Again on dated
16/11/2017 AD he has got admitted and on dated 20/11/2017 AD he got dead.
Doctor
Jashim Uddin to he had liver serosis, high blood pressure and diabetes. He has
been done EBL twice. Injection, normal saline, injection ciporokism including
many other injections has been given. 7 bags blood have been given. Later
doctor has given seal with discharge certificate of the doctor.
There
has been seen some mismatched with the information of nominee with information
given from national hospital. Nominee told Late Hasi Mia on dated 05/11/2017 AD
in the morning as has been taken to the hospital then has been taken to the
home again. As per prescription medicine has been taken and has become well.
10/ 11 days as were in good on dated 16/11/2017 AD again has got admitted in
the hospital. But there has been told from the hospital there has been admitted
from dated from 05/11/2017 AD to 14/11/2017 AD as was admitted in the medical.
On dated 14/11/2017 AD he went out. Again on dated 16/11/2017 AD as becoming
got admitted on dated 20/11/2017 AD he has got dead.
So
as pre received information this is to certify that Late Hasi Mia Rafique in
profession was a driver. In abroad he used to have drive in Dubai after coming
to the home two months later last dated 20/11/2017 AD has got in dead suffering
in liver serosis, high blood pressure in national hospital, Chittagong at
around 6.30 M. At the time as was in the medical there has been given 7 bags of
bloods and different injections. 2 times EBL
Page No- 7
Sd/
Illegible
16/02/2018
AD
There
has been given. He was in ICU about four days. At the time of death he was
about 57 years old (as per passport). The dead body of the dead person is
buried in family grave. At the time of death in addition to wife he has left
three sons and three daughters.
So
the death claim to take in consideration there is have next steps.
Sincerely
Sd/
Illegible
15/02/2018
AD
Md.
Abdul Kader
E.O
(Writting and deed department)
Bahaddar
Hat Service Sale
Chittagong
(Seal)
Date: 15/02/2018 AD
Page No- 8
Interview of Nominee
I am
Momtaz Begum is informing with very regretfully that, Late Hasi Mia Rafique was
my husband. He was in profession of driving as was in abroad in Dubai. He was
in abroad for long time he had been have in abroad. Two months before the death
he has comes from abroad. There was repair work of the home. He was well man no
one will believe he has any disease, as because if anyone sees no one will
believe it. He was in very very handsome body. I have not heard any time any
disease in him. As he was in abroad he has not told he has any disease. But he
used to tell he regularly checks up his body. Last dated 05/11/2017 AD as was
repair work was ongoing of our home suddenly he was caughing as was about sense
less he has been taken to national hospital. As there has been gven some
consultant he has been taken to home with prescription and medicine. The
situation was developing. Later on dated 16/11/2017 AD in the morning as coughing
as like before as made admitted again in national hospital 4 days later he has
got dead. After the admission he was in ICU. Doctors told he has liver serosis.
If he becomes well from ICU he would have done EBL. As I have no any conscious
guardian the real reason is unknown. My son and daughter two were in the
hospital. They were unable to know what the problem was. Because there has not
told anything from the hospital. The doctors and nurses told you do not think
anything. We are looking. You manage money. There will come much money in the
ICU. I do not know any literature so I do not understand anything. Finally on
dated 20/11/2017 AD in the morning he has got dead. After the death after funeral
prayer he has been buried in family grave. At the time of death he was about
57/ 58 years old. At the time of death he has left wife, three sons, and three
daughters. I wish the mercy of his departed soul.
Signature of the
nominee
Sd/ Illegible
Mob: 01885401739
Sd/ Illegible
(Seal)
Page No- 9
I am
Saddam Hossen Hossen so far I know he last dated 20/11/2017 AD has got dead in
national hospital. Late Hasi Mia is my neighbor. I have seen him well as he
returned from the abroad. He was used to have work in the home. No one was
about to believe as is seen him that he is in illness. Because he is in good
health he as was coughing too much become sense less therefore he has been gort
admitted in national hospital. And in a level on dated 20/11/2017 AD he has got
dead in the hospital. At the time of death he was over 55 years old. As I heard
from the family he was suffering from disease of liver serosis therefore has
got dead. At the time of death he has left three sons, three daughters and
wife. I wish mercy of his departed soul. And I recommended paying the death
claim to the Rupali Life Insurance Company Limited.
1.
Md. Saddam Hossen
U.P Member, 7 no ward
7 no Charan Deep Union Parishad
Boalkhali,
Chittagong
Sd/ Illegible
01878752755
(Seal)
As
far I know late Hasi Mia has got dead in national hospital. As I heard he was
got admitted in the national hospital becoming affected in liver serosis. Last
dated 20/11/2017 AD in the morning he has got dead. I have made prayed of his
funnel prayer. He has been buried in the family grave. I have not heard any
disease in him before death. He lived in abroad. At the time of death he was
about 60 years old. At the time of death he has left wife, three sons, and
three daughters. I wish mercy in his departed soul.
Moulana
Muhammad Ishaque Ansari
Hazrat
Nuz Shah (Rah) Jame Mosque
Charan
Deep, Boalkhali, Chittagong
Sd/ Illgeible
(Seal)
Sd/ Illegible
01817206606
Page No- 10
Interview of Local
Important People
We
are the signature provider bellow is informing on that, Late Hasi Mia Rafique
Gang last dated 20/11/2017 AD has got dead in national hospital. We have not
heard any disease in him before deathLate Hasi Mia Raque was lived in abroad.
We have seen him good as he came from abroad. We have not imagined that he will
die in that way. He was making work of home. Suddenly on dated 20/11/2017 AD as
we have heard his death we went for burying himself. Late Hasi Mia was very
good man. There were no any conflicts with him in the society. He was not
involved in any activities against the society or country. Late Hasi Mia dead
body was buried in family grave of them. At the time of death he was about 55
years old. We wish mercy in his life. And we are recommending paying the death
claim to the authority of Rupali Life Insurance Limited.
2.
Md. Jahed
Father- Late Ismail Ahmed
C/ O- Hazi Islmail Ahmed Moulana Bari
Village- Charan Deep
Post Office- Charan Deep
Police Station- Boalkhali, Chittagong
3.
Md. Saiful
Father- Azizul Haque
C/ O- Late Thanda Mia Moulana Bari
Village+ Post Office- Charan Deep
Police
Station- Boalkhali, Chittagong
Sd/ Illegible
01817701888
Sd/ Illegible
01871322685
Sd/ Illegible
11/02//2018 AD
(Seal)
Page No-
11
(Monogram)
National Hospital Chattagram (Pvt) Ltd
Discharge
Certificate
AN: (Bar Code)
|
HN: (Bar
Code)
|
Patient Name: Mr. Hasi Meah
Father/ Husband: Late Fazu Meah
Age: 60Y 0M 0D
Gender: Male
Consultant: Dr. Md. Jashim Uddin, FCPS (Med), MD
(Gastro)
|
DOA:
05-11-2017 11:00:11 AM
DOD:
14-11-2017 05:12:34 PM
Bed: (717
AC) 717 AC CABIN
|
Diagnosis: CLD with OV with portal HTN with DM with
anaemia (corrected) with EBL (2nd & 3rd session) with
hypoalbuminaemia with hypokalaemia.
Major Medicine Used During Treatment:
Inj. Normal Saline, Inj. Cefuroxime, Inj.
Metronidazole, Inj. Konakion, Inj. Panpro, 7 unit BT done.
Treatment
& Advice during discharge: (DOR)
1.
Food- Diabetes
2.
Cap. Cef – 3 DS (400mg)
1+0+1+1-7 days
3.
Tab. Filmet (400 mg)
1+1+1-5 days
4.
Syp. Kt
2 spoon in a day 2 times- 7 days
5.
Tab. Panpro (20 mg)
1+0+1 (Half an hour before eat) – 1 month
6.
Cap. Traxyl (500 mg)
1+1+1-3 days
7.
Tab. Emistat (8 mg)
1+1+1 (In empty belly – bomi if bomi may happen)
Advice:
There will have to feed
regularly as per instruction.
Dr. Md Jashim Uddin sir
Chamber will have to be contacted with report examining S. Electrolyte after 7
days.
Sd/ Illegible
SMO/ Medical Director
National Hospital Chattagram
(Pvt) Ltd
Sd/ Illegible
Dr. Shimu
Medical Officer
National Hospital Chattagram (Pvt) Ltd
Prepared by:
Md Abu Taher Jewel
14/15, Mehdibag, Chittagong, Bangladesh, Phone:
623713, 6237914, 627914, 2855128-29, Email: nationalhospitalctg@yahoo.com
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