Assessor Resource

FNSILF504A
Manage complex life insurance claims

Assessment tool

Version 1.0
Issue Date: May 2024


This unit applies to those involved in complex non-standard claims management within the life insurance sector.

This unit describes the performance outcomes, skills and knowledge required to manage people, information systems and other resources needed to assess life insurance claims of a complex nature.

You may want to include more information here about the target group and the purpose of the assessments (eg formative, summative, recognition)

Prerequisites

Not applicable.

Employability Skills

This unit contains employability skills.



Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

The evidence guide provides advice on assessment and must be read in conjunction with the performance criteria, required skills and knowledge, range statement and the Assessment Guidelines for the Training Package.

Overview of assessment

Critical aspects for assessment and evidence required to demonstrate competency in this unit

Evidence of the ability to:

apply highly developed analytical and administrative skills to complex claims assessment

maintain and apply a thorough understanding of all aspects of claims procedures and administrative requirements

perform tasks in accordance with relevant procedures and regulatory requirements.

Context of and specific resources for assessment

Assessment must ensure:

competency is demonstrated in the context of the work environment and conditions specified in the range statement either in a relevant workplace or a closely simulated work environment

access to and the use of a range of common office equipment, technology, software and consumables

access to records

access to organisational policies and procedures.

Method of assessment

A range of assessment methods should be used to assess practical skills and knowledge. The following examples are appropriate for this unit:

evaluating an integrated activity, which combines the elements of competency for the unit, or a cluster of related units of competency

observing processes and procedures in workplaces

verbal or written questioning on underpinning knowledge and skills

evaluating samples of work

accessing and validating third party reports

setting and reviewing workplace projects and business simulations or scenarios.

Guidance information for assessment

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assingnment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

Required skills

communication skills to:

gather and check information

liaise and share information with others

communicate appropriately with people from diverse backgrounds

IT skills to:

use computer applications (word processing, spreadsheet, database, specific purpose computer systems)

access and update records electronically

access web-based information services

numeracy skills to interpret numeric data and relevant statistics and make payment calculations

organisational skills to efficiently plan and sequence work

problem solving skills to address errors in life insurance documentation

reading skills to:

read and understand relevant procedures

read and understand life insurance policies

read and interpret life insurance claims and supporting documentation

research and analysis skills to:

identify and interpret relevant information

analyse information and data

maintain currency of products and services knowledge

writing skills to:

accurately record information

prepare professional letters and emails.

Required knowledge

the ability to apply and explain as relevant to the management of complex life insurance claims:

dispute resolution policy and procedures

industry practice and ethical standards in claims risk management

life insurance administrative requirements

life insurance policy payment criteria

life insurance policy terms and conditions

organisational procedures

procedures for processing complex prudential claims

product information

relevant regulatory requirements.

The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.

Life insurance policy may include:

disability income

endowment

term life (including terminal illness and Total and Permanent Disablement (TPD))

trauma

whole of life.

Valid must include:

policy exists

policy is current

claimant is legally authorised to act on the policy.

Documentation may include:

claim forms

records of death

records of disablement

other medical records

statutory declarations and other such records.

Complex claims may be claims that involve:

legal procedures, including those that involve working across international boundaries

long-term settlements

complex medical conditions

complex technical determinations

high monetary impact

an important client base.

Procedures may include:

organisational complaints handling processes

organisational customer service charter

organisational guidelines

organisational policy

organisational privacy and confidentiality guidelines

organisational procedures.

Payment criteria may include:

death (including terminal illness)

invalidity (permanent or temporary disability)

trauma.

Policy exclusions may include:

pre-existing illnesses

medical conditions

high risk activities.

Further information may include:

medical evidence

financial evidence

interview records

surveillance records.

Specialists may include:

advisers

investigators

medical and related practitioners

solicitors

forensic accountants.

Ethical and regulatory requirements may include:

corporations legislation

life insurance legislation

privacy legislation

Australian Securities and Investments Commission (ASIC) regulatory guides

industry Codes of Practice

professional Codes of Practice.

Appropriate stakeholders may include:

internal parties:

administrators

investigation agencies

medical officers

trustees

client and associated parties:

assignees

beneficiaries

executors

lawyers

life insured

next of kin

policy owners.

Consequences may include:

loss or reduction of future life insurance cover

termination of the present contract

inability to claim again for the same event under the present contract.

Policy discharge may include:

acceptance by client of amount of settlement

acceptance by client of timing of settlement

acceptance by client of terms of settlement.

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
Receive and acknowledge claim notification 
Review details of the life insurance policy to ensure valid cover is in force 
Establish that the claimant is authorised to deal with the policy 
Compile necessary documentation 
Check that documentation is correct and complete and address any gaps in accordance with procedures 
Assess the organisational authority level required to process the claim and refer it to an appropriately authorised individual as necessary 
Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures 
Identify and review evidence against payment criteria in accordance with procedures 
Review all information relevant to the circumstances of loss/damage/injury to establish a chain of events 
Identify potential fraud indicators 
Identify whether policy exclusions apply 
Recognise the need for further information and collect as appropriate 
Identify the need to appoint specialists to undertake claims assessment 
Engage and brief appointed specialists as required 
Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements 
3.4 Interpret and utilise specialists' reports 
Identify whether the terms and conditions of the policy have been verifiably met 
Assess liability in accordance with the terms and conditions of the policy 
Where the claim is not admitted, communicate the decision to appropriate stakeholders 
Where the claim is admitted, calculate 
Advise client of the consequences of proceeding with the payment 
Obtain policy discharge, as appropriate 
Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements 
Update all appropriate records in accordance with procedures 
Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements 
Initiate reinsurance recovery, if appropriate 

Forms

Assessment Cover Sheet

FNSILF504A - Manage complex life insurance claims
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

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Result: Competent Not yet competent

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Assessor name:

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Assessment Record Sheet

FNSILF504A - Manage complex life insurance claims

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: