Assessor Resource

FNSISV307
Follow organisation procedures to process claim

Assessment tool

Version 1.0
Issue Date: May 2024


This unit describes the skills and knowledge required to process an insurance claim in accordance with organisational guidelines and procedures.

It applies to individuals employed in a range of insurance sectors and may be applied within organisations of various sizes and across a range of customer bases.

Work functions in the occupational areas where this unit may be used are subject to regulatory requirements. Refer to the FNS Implementation Guide Companion Volume or the relevant regulator for specific guidance on requirements.

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


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.

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Receive and clarify claim information

1.1 Receive and record information relating to claim accurately onto system

1.2 Advise customer of organisational claims procedures and respond to queries courteously and accurately

1.3 Verify completeness of information

1.4 Analyse all information against legislative requirements and organisational guidelines to decide for or against liability

1.5 Determine whether claim is routine and fully covered by policy

1.6 Pass claims not completely routine and within policy guidelines to appropriate staff

1.7 Communicate information which potentially impacts on future renewal of policy or renewal terms promptly to underwriter or other appropriate staff in keeping with organisational policy

2. Determine acceptability of claim

2.1 Determine acceptability of claim against policy specifications

2.2 Check reinsurance coverage

2.3 Refer queries on facts or valid acceptance of claim to specialists for advice, where required

3. Accept or reject claim

3.1 Process claim within required timeframes and according to organisational guidelines

3.2 Use effective decision-making process to accept or reject claims within timeframes in accordance with legislation, organisational policy and procedures, and codes of practice as applicable

3.3 Observe referral procedures where claim amounts are outside claims settlement and/or claims management authorities

3.4 Make decision on liability in light of need to withstand scrutiny in subsequent proceedings

4. Process claim

4.1 Register claim and process promptly in accordance with organisational guidelines and procedures

4.2 Pass payment information on to appropriate staff, where required

4.3 Inform customer of progress of claim

4.4 Record all claim information accurately

5. Document liability decisions

5.1 Communicate liability decisions clearly to the relevant parties in a manner required by legislation, operating procedures and codes of practice as applicable

5.2 Communicate reasons for decisions promptly to customer and other relevant parties

5.3 Document decisions to demonstrate basis on which decision was reached and all evidence and/or information that was considered, where appropriate

5.4 File documentation regarding decision according to organisational policy and procedure

Evidence of the ability to:

accurately process claims across a representative range of products, customers and conditions in accordance with legislation, regulations and organisational policy by:

receiving, recording and clarifying the claim information

making a determination on claim approval

notifying the customer of claim and payment outcomes

documenting and communicating outcomes to relevant parties.

Note: If a specific volume or frequency is not stated, then evidence must be provided at least once.

To complete the unit requirements safely and effectively, the individual must:

state the accountability requirements of individuals involved with insurance claims and identify the level at which claims should be referred to senior staff

explain the information technology and communications systems used for processing insurance claims

outline key features of organisational policy and procedures, and legislation, regulation and codes of practice relating to processing insurance claims

identify the rationale and principles of filing

identify and describe the organisation’s insurance products available to customers, including any conditions and terms for making claims.

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the insurance services field of work and include access to:

organisational records

organisational policy, procedures, legislation and regulations as they relate to contracts of insurance

a range of common technology and software

an appropriate work environment and conditions.

Assessors must satisfy NVR/AQTF assessor requirements.

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.

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Receive and clarify claim information

1.1 Receive and record information relating to claim accurately onto system

1.2 Advise customer of organisational claims procedures and respond to queries courteously and accurately

1.3 Verify completeness of information

1.4 Analyse all information against legislative requirements and organisational guidelines to decide for or against liability

1.5 Determine whether claim is routine and fully covered by policy

1.6 Pass claims not completely routine and within policy guidelines to appropriate staff

1.7 Communicate information which potentially impacts on future renewal of policy or renewal terms promptly to underwriter or other appropriate staff in keeping with organisational policy

2. Determine acceptability of claim

2.1 Determine acceptability of claim against policy specifications

2.2 Check reinsurance coverage

2.3 Refer queries on facts or valid acceptance of claim to specialists for advice, where required

3. Accept or reject claim

3.1 Process claim within required timeframes and according to organisational guidelines

3.2 Use effective decision-making process to accept or reject claims within timeframes in accordance with legislation, organisational policy and procedures, and codes of practice as applicable

3.3 Observe referral procedures where claim amounts are outside claims settlement and/or claims management authorities

3.4 Make decision on liability in light of need to withstand scrutiny in subsequent proceedings

4. Process claim

4.1 Register claim and process promptly in accordance with organisational guidelines and procedures

4.2 Pass payment information on to appropriate staff, where required

4.3 Inform customer of progress of claim

4.4 Record all claim information accurately

5. Document liability decisions

5.1 Communicate liability decisions clearly to the relevant parties in a manner required by legislation, operating procedures and codes of practice as applicable

5.2 Communicate reasons for decisions promptly to customer and other relevant parties

5.3 Document decisions to demonstrate basis on which decision was reached and all evidence and/or information that was considered, where appropriate

5.4 File documentation regarding decision according to organisational policy and procedure

Evidence of the ability to:

accurately process claims across a representative range of products, customers and conditions in accordance with legislation, regulations and organisational policy by:

receiving, recording and clarifying the claim information

making a determination on claim approval

notifying the customer of claim and payment outcomes

documenting and communicating outcomes to relevant parties.

Note: If a specific volume or frequency is not stated, then evidence must be provided at least once.

To complete the unit requirements safely and effectively, the individual must:

state the accountability requirements of individuals involved with insurance claims and identify the level at which claims should be referred to senior staff

explain the information technology and communications systems used for processing insurance claims

outline key features of organisational policy and procedures, and legislation, regulation and codes of practice relating to processing insurance claims

identify the rationale and principles of filing

identify and describe the organisation’s insurance products available to customers, including any conditions and terms for making claims.

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the insurance services field of work and include access to:

organisational records

organisational policy, procedures, legislation and regulations as they relate to contracts of insurance

a range of common technology and software

an appropriate work environment and conditions.

Assessors must satisfy NVR/AQTF assessor requirements.
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 record information relating to claim accurately onto system 
Advise customer of organisational claims procedures and respond to queries courteously and accurately 
Verify completeness of information 
Analyse all information against legislative requirements and organisational guidelines to decide for or against liability 
Determine whether claim is routine and fully covered by policy 
Pass claims not completely routine and within policy guidelines to appropriate staff 
Communicate information which potentially impacts on future renewal of policy or renewal terms promptly to underwriter or other appropriate staff in keeping with organisational policy 
Determine acceptability of claim against policy specifications 
Check reinsurance coverage 
Refer queries on facts or valid acceptance of claim to specialists for advice, where required 
Process claim within required timeframes and according to organisational guidelines 
Use effective decision-making process to accept or reject claims within timeframes in accordance with legislation, organisational policy and procedures, and codes of practice as applicable 
Observe referral procedures where claim amounts are outside claims settlement and/or claims management authorities 
Make decision on liability in light of need to withstand scrutiny in subsequent proceedings 
Register claim and process promptly in accordance with organisational guidelines and procedures 
Pass payment information on to appropriate staff, where required 
Inform customer of progress of claim 
Record all claim information accurately 
Communicate liability decisions clearly to the relevant parties in a manner required by legislation, operating procedures and codes of practice as applicable 
Communicate reasons for decisions promptly to customer and other relevant parties 
Document decisions to demonstrate basis on which decision was reached and all evidence and/or information that was considered, where appropriate 
File documentation regarding decision according to organisational policy and procedure 

Forms

Assessment Cover Sheet

FNSISV307 - Follow organisation procedures to process claim
Assessment task 1: [title]

Student name:

Student ID:

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

Student signature:

Result: Competent Not yet competent

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Assessor name:

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Date:

Assessment Record Sheet

FNSISV307 - Follow organisation procedures to process claim

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: