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＜Elementary＞ Lesson No.5
大規模な支払い事案の疑義照会 / Investigating a Large Insurance Claim
０．Greetings & Ice-break (2min.)｜挨拶と導入
0-1 Greetings
Let’s practice a short small talk that you can use to greet a business partner and start building a good relationship.
講師との挨拶を兼ねて、ビジネスパートナーと信頼関係を築くための短いスモールトークを練習してみましょう。
[Tips / 会話のヒント]
・Can you hear me clearly?
私の声はクリアに聞こえますか？
・How's your day going so far?
今日はどんな一日でしたか？
・Talk about one small topic (Work, Weather, News, Hometown, Sports event, etc.)
軽い話題について話しましょう（仕事、天気、ニュース、地元、スポーツイベントなど）
0-2 Introduction
In today’s lesson, we’ll learn about the following situation. Have you ever experienced something similar?
本日のレッスンでは以下のようなシチュエーションについて学びます。同様のシチュエーションを経験したことがありますか？
- If you have experience, please tell us what it was like, what was difficult, or what you learned.
経験があれば、どんな内容だったか、難しかったことや学んだことなどを教えて下さい。
- If you don’t have experience, try to imagine yourself handling that situation in English.
What do you think would be challenging?
経験がなければ、英語でその状況に対応しているところを想像してみましょう。どんなことが難しそうですか？
Situation / シチュエーション
Questioning the validity of a high-value insurance claim overseas.
海外での高額な保険金請求に対し、不正の可能性を排除すべく厳格な調査を求める場面です。
1. Read (2 min)｜型を学ぶ
Let's read the following key sentences aloud!
下記の文章や単語を順番に音読しましょう！
1-1 Basic phrases
１．We completed our investigation in...（...で調査を完了した）
２．I believe we should approve...（...を承認すべきと考える）
３．That increase was approved by...（その増額は...によって承認された）
４．We found no medical history that...（...という病歴は見つからなかった）
５．We confirmed with the local bank that...（現地の銀行に...を確認した）
６．I will contact the hospital tomorrow and...（明日病院に連絡して...する）
７．I will also schedule a face-to-face interview with...（...との対面面談も予定する）
1-2 Essential words
１．concern（懸念）
２．verify（検証する）
３．approve（承認する）
４．delay（遅らせる）
５．increase（増額）
６．reasonable（妥当な）
７．confirm（確認する）
８．evidence（証拠）
９．arrange（手配する）
１０．focus（焦点を当てる）
2. Try (3 min)｜ロールプレイ練習
Let’s practice the role-play.
ロールプレイの練習をしましょう！
Situation / シチュエーション（Reference again）
Questioning the validity of a high-value insurance claim overseas.
海外での高額な保険金請求に対し、不正の可能性を排除すべく厳格な調査を求める場面です。
👨💼【Teacher / Head of Claims Investigation】:
Thank you for joining this urgent call. We received a death claim of 5 million USD from our Jakarta office, and I need you to explain why you believe we should pay it immediately.
（緊急の電話会議にご参加いただきありがとうございます。ジャカルタ事務所から500万米ドルの死亡保険金請求を受けましたが、なぜ直ちに支払うべきとお考えか説明していただけますか。）
🧑🎓【Student / Regional Claims Manager】:
I understand your concern. We completed our investigation in 2 weeks, and all documents including the death certificate and medical records were verified by our local legal team. The beneficiary provided complete evidence, so I believe we should approve this claim without further delay.
（ご懸念は理解しています。私たちは2週間で調査を完了し、死亡診断書と医療記録を含むすべての書類は現地の法務チームによって検証されました。受取人は完全な証拠を提出しましたので、これ以上遅らせずにこの請求を承認すべきと考えます。）
👨💼【Teacher / Head of Claims Investigation】:
I reviewed the file myself. The policyholder increased the coverage from 1 million USD to 5 million USD only 3 months before death. Could you explain why this timing does not raise a red flag for you?
（私自身でファイルを確認しました。契約者は死亡のわずか3か月前に補償額を100万米ドルから500万米ドルに増額しています。なぜこのタイミングが警告にならないとお考えですか。）
🧑🎓【Student / Regional Claims Manager】:
That increase was approved by our underwriting team after a full health check. The policyholder was 45 years old and worked as a business owner, so higher coverage was reasonable for his financial situation. We found no medical history that would indicate fraud at that time.
（その増額は、完全な健康診断の後に引受チームによって承認されました。契約者は45歳で事業主として働いていたため、より高い補償額は彼の財務状況にとって妥当でした。当時、不正を示す病歴は見つかりませんでした。）
👨💼【Teacher / Head of Claims Investigation】:
I also noticed the beneficiary is not a family member but a business partner. Did you check the relationship between them and confirm there was no financial pressure or unusual transactions before the death?
（受取人が家族ではなくビジネスパートナーであることにも気づきました。彼らの関係を確認し、死亡前に金銭的圧力や異常な取引がなかったことを確認しましたか。）
🧑🎓【Student / Regional Claims Manager】:
Yes, we did. We confirmed with the local bank that the business partner had a legitimate joint venture with the policyholder for 8 years. There were no unusual money transfers or debts recorded in the past 12 months. Our legal team found no evidence of wrongdoing.
（はい、確認しました。現地の銀行に確認したところ、ビジネスパートナーは契約者と8年間正当な合弁事業を行っていました。過去12か月間に異常な送金や負債の記録はありませんでした。法務チームは不正行為の証拠を見つけませんでした。）
👨💼【Teacher / Head of Claims Investigation】:
I appreciate your thorough work, but I still have concerns. The cause of death was listed as sudden heart failure with no prior symptoms. I need you to arrange a second independent medical review and interview the attending doctor directly. Can you handle that within 10 business days?
（徹底した作業には感謝しますが、まだ懸念があります。死因は事前の症状がない突然の心不全とされています。第二の独立した医学的審査を手配し、担当医に直接面談していただく必要があります。10営業日以内に対応できますか。）
🧑🎓【Student / Regional Claims Manager】:
Understood. I will contact the hospital tomorrow and arrange an independent review by a cardiologist who was not involved in the original case. I will also schedule a face-to-face interview with the attending doctor and share a detailed report with you by the end of next week. If any new evidence appears, we will escalate immediately.
（承知しました。明日病院に連絡し、元の症例に関与していなかった心臓専門医による独立した審査を手配します。担当医との対面面談も予定し、来週末までに詳細な報告書を共有します。新たな証拠が現れた場合は、直ちにエスカレーションします。）
👨💼【Teacher / Head of Claims Investigation】:
Good. I want you to focus on any inconsistencies in the medical timeline and check if the doctor followed standard procedures. Until we receive that report, we will put this claim on hold. Please keep me updated every 3 days.
（良いでしょう。医療の時系列における矛盾に焦点を当て、医師が標準的な手順に従ったかを確認してください。その報告を受け取るまで、この請求は保留にします。3日ごとに状況を報告してください。）
3. Use (4 min)｜ロールプレイ & 実践（空欄補完）
Let's perform the role-play and fill in the blanks by translating the Japanese into English!
空欄の日本語を英語に訳しながら、ロールプレイを実践してみましょう！
Situation / シチュエーション（Reference again）
Questioning the validity of a high-value insurance claim overseas.
海外での高額な保険金請求に対し、不正の可能性を排除すべく厳格な調査を求める場面です。
👨💼【Teacher / Head of Claims Investigation】:
Thank you for joining this urgent call. We received a death claim of 5 million USD from our Jakarta office, and I need you to explain why you believe we should pay it immediately.
🧑🎓【Student / Regional Claims Manager】:
I understand your ［懸念］. We completed our investigation in 2 weeks, and all documents including the death certificate and medical records were ［検証する］d by our local legal team. The beneficiary provided complete ［証拠］, so I believe we should ［承認する］ this claim without further ［遅らせる］.
👨💼【Teacher / Head of Claims Investigation】:
I reviewed the file myself. The policyholder increased the coverage from 1 million USD to 5 million USD only 3 months before death. Could you explain why this timing does not raise a red flag for you?
🧑🎓【Student / Regional Claims Manager】:
That ［増額］ was ［承認する］d by our underwriting team after a full health check. The policyholder was 45 years old and worked as a business owner, so higher coverage was ［妥当な］ for his financial situation. We found no medical history that would indicate fraud at that time.
👨💼【Teacher / Head of Claims Investigation】:
I also noticed the beneficiary is not a family member but a business partner. Did you check the relationship between them and confirm there was no financial pressure or unusual transactions before the death?
🧑🎓【Student / Regional Claims Manager】:
Yes, we did. We ［確認する］ed with the local bank that the business partner had a legitimate joint venture with the policyholder for 8 years. There were no unusual money transfers or debts recorded in the past 12 months. Our legal team found no ［証拠］ of wrongdoing.
👨💼【Teacher / Head of Claims Investigation】:
I appreciate your thorough work, but I still have concerns. The cause of death was listed as sudden heart failure with no prior symptoms. I need you to arrange a second independent medical review and interview the attending doctor directly. Can you handle that within 10 business days?
🧑🎓【Student / Regional Claims Manager】:
Understood. I will contact the hospital tomorrow and ［手配する］ an independent review by a cardiologist who was not involved in the original case. I will also schedule a face-to-face interview with the attending doctor and share a detailed report with you by the end of next week. If any new ［証拠］ appears, we will escalate immediately.
👨💼【Teacher / Head of Claims Investigation】:
Good. I want you to focus on any inconsistencies in the medical timeline and check if the doctor followed standard procedures. Until we receive that report, we will put this claim on hold. Please keep me updated every 3 days.
4. Challenge (7 min)｜応用実践
Let's perform the role-play and fill in the blanks by translating the Japanese into English!
空欄の日本語を英語に訳しながら、ロールプレイを実践してみましょう！
*Let's practice this part repeatedly until we can speak it smoothly.
このパートはスムーズにスピーキングできるようになるまで繰り返し練習しましょう。
Situation / シチュエーション（Reference again）
Questioning the validity of a high-value insurance claim overseas.
海外での高額な保険金請求に対し、不正の可能性を排除すべく厳格な調査を求める場面です。
👨💼【Teacher / Head of Claims Investigation】:
Thank you for joining this urgent call. We received a death claim of 5 million USD from our Jakarta office, and I need you to explain why you believe we should pay it immediately.
🧑🎓【Student / Regional Claims Manager】:
I understand your concern. ［私たちは2週間で調査を完了し、死亡診断書と医療記録を含むすべての書類は現地の法務チームによって検証されました。］ The beneficiary provided complete evidence, so I believe we should approve this claim without further delay.
👨💼【Teacher / Head of Claims Investigation】:
I reviewed the file myself. The policyholder increased the coverage from 1 million USD to 5 million USD only 3 months before death. Could you explain why this timing does not raise a red flag for you?
🧑🎓【Student / Regional Claims Manager】:
［その増額は、完全な健康診断の後に引受チームによって承認されました。］ The policyholder was 45 years old and worked as a business owner, so higher coverage was reasonable for his financial situation. ［当時、不正を示す病歴は見つかりませんでした。］
👨💼【Teacher / Head of Claims Investigation】:
I also noticed the beneficiary is not a family member but a business partner. Did you check the relationship between them and confirm there was no financial pressure or unusual transactions before the death?
🧑🎓【Student / Regional Claims Manager】:
Yes, we did. ［現地の銀行に確認したところ、ビジネスパートナーは契約者と8年間正当な合弁事業を行っていました。］ There were no unusual money transfers or debts recorded in the past 12 months. Our legal team found no evidence of wrongdoing.
👨💼【Teacher / Head of Claims Investigation】:
I appreciate your thorough work, but I still have concerns. The cause of death was listed as sudden heart failure with no prior symptoms. I need you to arrange a second independent medical review and interview the attending doctor directly. Can you handle that within 10 business days?
🧑🎓【Student / Regional Claims Manager】:
Understood. I will contact the hospital tomorrow and arrange an independent review by a cardiologist who was not involved in the original case. I will also schedule a face-to-face interview with the attending doctor and share a detailed report with you by the end of next week. If any new evidence appears, we will escalate immediately.
👨💼【Teacher / Head of Claims Investigation】:
Good. I want you to focus on any inconsistencies in the medical timeline and check if the doctor followed standard procedures. Until we receive that report, we will put this claim on hold. Please keep me updated every 3 days.
\ If you have some extra capacity, give it a try（余力があればやってみましょう）/
5. Real-world application (5 min)｜実務応用
Let's speak freely with the phrases and flow we learned today. If you can, imagine your real job—it makes practice more effective.
本日学習した単語やフレーズ、会話の流れを思い出しながら、自由に話してみましょう。可能であれば、自身の実務を想像しながら話すと効果的です。
Situation / シチュエーション
A high-value death claim of 5 million USD was submitted from an overseas office, and headquarters suspects possible fraud.
The regional manager believes the evidence is sufficient, but headquarters requests a second investigation before approval.
海外拠点から500万米ドルの高額な死亡保険金請求が提出され、本社は不正の可能性を疑っている。
地域マネージャーは証拠が十分と考えているが、本社は承認前に再調査を要求している。
👨💼【Teacher / Head of Claims Investigation】:
I reviewed your investigation report, but I still have concerns about the timing and the beneficiary relationship. Could you explain your position and outline the next steps you will take?
（あなたの調査報告書を確認しましたが、タイミングと受取人の関係についてまだ懸念があります。あなたの立場を説明し、次に取る手順を概説していただけますか。）
🧑🎓【Student / Your Role】:
(Free Speaking based on today's lesson)
Hints / ヒント
１．Explain the completed investigation process（完了した調査プロセスを説明する）
２．Describe the verification of documents and evidence（書類と証拠の検証を述べる）
３．Confirm the legitimacy of relationships and transactions（関係と取引の正当性を確認する）
４．Arrange additional independent review and reporting（追加の独立した審査と報告を手配する）
※This is not a role-play. Please speak until you finish your thoughts.
このパートはロールプレイ形式ではありません。最後まで通して話してみましょう。
6. Wrap-up (2 min) ｜レッスンの振り返り
Let's review today's lesson with your teacher!
今日のレッスンについて講師と振り返ってみましょう！
6-1 Comments from student
・Good points / 良かったところ・上手くできたところ
・Things to work on / 今後強化したいところ
6-2 Feedback from teacher
・Good points / 良かった点
・Things to work on / 今後の強化ポイント
・What to review / 復習ポイント
*6-3 Questions from student (if any)
Japanese translation（日本語訳）
1. Read (2min)（型を学ぶ）｜基本フレーズ
2. Try (4min)（ロールプレイ練習）｜型を使った練習
Let’s practice the role-play.
ロールプレイの練習をしましょう！
3. Use (7min)｜応用
Let’s perform the role-play and filling in the missing English!
英語を補完しながら、ロールプレイを実践してみましょう！
4. Challenge (7min)｜実践
Let’s perform the role-play and filling in the missing English!
英語を補完しながら、ロールプレイを実践してみましょう！
5. Wrap-up (3min) – レッスンの振り返り
"Let’s review today’s lesson with your teacher!”
「今日のレッスンについて講師と振り返ってみましょう！」
5-1. Comments from Student
- Good points / 良かったところ・上手くできたところ
- Things to work on / 今後強化したいところ
5-2. Feedback from Teacher
- Good points / 良かった点
- Things to work on / 今後の強化ポイント
- What to review / 復習ポイント
5-3. Question from Students (If any)
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