Assessor Resource

FNSISV510
Manage non-routine and complex claims

Assessment tool

Version 1.0
Issue Date: April 2024


This unit describes the skills and knowledge required to manage non-routine and complex insurance claims, including non-standard issues, determination of the business impact and managing all aspects of the claims resolution process.

It applies to individuals working in job roles involving specialist knowledge and functions where skills are needed to manage non-routine and complex insurance claims such as major losses, bodily injury losses, long-term settlement and claims involving legal procedures across international boundaries.

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. Analyse claim to determine validity

1.1 Assess validity of claim against organisational and policy acceptance criteria for relevant type and category of policy

1.2 Confirm information as accurate, comprehensive and authentic

1.3 Seek inclusive validity from specialists for advice where required

1.4 Notify reinsurer of any claim immediately

2. Evaluate impact of claim

2.1 Analyse data relating to extent of loss, damage or injury, and seek and review claim estimates

2.2 Compare claim to expected payment projections for product type and determine business impact

2.3 Determine strategies to minimise negative impact of any non-routine or complex claim within requirements to meet policy obligations

2.4 Determine necessity for urgent action to protect organisational interests

3. Determine settlement options

3.1 Identify settlement options within policy obligations, organisational and legislative requirements

3.2 Seek advice on settlement options from appropriate person if required

4. Manage support arrangements to resolve claim

4.1 Liaise with relevant parties to identify and meet support requirements such as partnering with external experts to ensure clients’ needs are met

4.2 Manage any legal processes from non-routine or complex claims perspective, including international legal system requirements, if applicable

4.3 Employ mediation skills to resolve issues or disputes associated with significant claim, as required

5. Identify any required changes to policy or procedures

5.1 Document circumstances of claim for consideration in portfolio review

5.2 Instigate changes to policy and procedures to minimise further loss in similar circumstances, if appropriate

6. Report findings and update records

6.1 Document actions, procedures and outcomes and record promptly and accurately

6.2 Provide stakeholders with accurate and timely advice regarding claim proceedings

6.3 Store and maintain finalised claims files according to organisational policy, legislative requirements and codes of practice, as applicable

Evidence of the ability to:

accurately interpret the claims data to:

determine if validation is required

quantify the impact on the organisation

identify strategies to minimise impact

examine the data and identify options for settlement

communicate effectively with colleagues and clients to effectively negotiate an acceptable outcome to mutual benefit

manage reporting requirements and documentation required to finalise a claim.

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:

outline organisational policy, procedures, claims guidelines and levels of authority relevant to non-routine and complex claims

describe the organisation’s business objectives and alignments with managing non-routine and complex claims

identify and explain key features of relevant legislation, regulatory guidelines and industry sector codes of practice as they apply to:

insurance contracts

privacy

insurance claims

describe the roles, responsibilities and jurisdiction of specialists and other authorities who may contribute to resolving complex insurance claims

outline types and categories of insurance policies and their trends that may be affected by complex claims

identify payment projections for the product types to compare against expected claims payments.

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.

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. Analyse claim to determine validity

1.1 Assess validity of claim against organisational and policy acceptance criteria for relevant type and category of policy

1.2 Confirm information as accurate, comprehensive and authentic

1.3 Seek inclusive validity from specialists for advice where required

1.4 Notify reinsurer of any claim immediately

2. Evaluate impact of claim

2.1 Analyse data relating to extent of loss, damage or injury, and seek and review claim estimates

2.2 Compare claim to expected payment projections for product type and determine business impact

2.3 Determine strategies to minimise negative impact of any non-routine or complex claim within requirements to meet policy obligations

2.4 Determine necessity for urgent action to protect organisational interests

3. Determine settlement options

3.1 Identify settlement options within policy obligations, organisational and legislative requirements

3.2 Seek advice on settlement options from appropriate person if required

4. Manage support arrangements to resolve claim

4.1 Liaise with relevant parties to identify and meet support requirements such as partnering with external experts to ensure clients’ needs are met

4.2 Manage any legal processes from non-routine or complex claims perspective, including international legal system requirements, if applicable

4.3 Employ mediation skills to resolve issues or disputes associated with significant claim, as required

5. Identify any required changes to policy or procedures

5.1 Document circumstances of claim for consideration in portfolio review

5.2 Instigate changes to policy and procedures to minimise further loss in similar circumstances, if appropriate

6. Report findings and update records

6.1 Document actions, procedures and outcomes and record promptly and accurately

6.2 Provide stakeholders with accurate and timely advice regarding claim proceedings

6.3 Store and maintain finalised claims files according to organisational policy, legislative requirements and codes of practice, as applicable

Evidence of the ability to:

accurately interpret the claims data to:

determine if validation is required

quantify the impact on the organisation

identify strategies to minimise impact

examine the data and identify options for settlement

communicate effectively with colleagues and clients to effectively negotiate an acceptable outcome to mutual benefit

manage reporting requirements and documentation required to finalise a claim.

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:

outline organisational policy, procedures, claims guidelines and levels of authority relevant to non-routine and complex claims

describe the organisation’s business objectives and alignments with managing non-routine and complex claims

identify and explain key features of relevant legislation, regulatory guidelines and industry sector codes of practice as they apply to:

insurance contracts

privacy

insurance claims

describe the roles, responsibilities and jurisdiction of specialists and other authorities who may contribute to resolving complex insurance claims

outline types and categories of insurance policies and their trends that may be affected by complex claims

identify payment projections for the product types to compare against expected claims payments.

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.

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
Assess validity of claim against organisational and policy acceptance criteria for relevant type and category of policy 
Confirm information as accurate, comprehensive and authentic 
Seek inclusive validity from specialists for advice where required 
Notify reinsurer of any claim immediately 
Analyse data relating to extent of loss, damage or injury, and seek and review claim estimates 
Compare claim to expected payment projections for product type and determine business impact 
Determine strategies to minimise negative impact of any non-routine or complex claim within requirements to meet policy obligations 
Determine necessity for urgent action to protect organisational interests 
Identify settlement options within policy obligations, organisational and legislative requirements 
Seek advice on settlement options from appropriate person if required 
Liaise with relevant parties to identify and meet support requirements such as partnering with external experts to ensure clients’ needs are met 
Manage any legal processes from non-routine or complex claims perspective, including international legal system requirements, if applicable 
Employ mediation skills to resolve issues or disputes associated with significant claim, as required 
Document circumstances of claim for consideration in portfolio review 
Instigate changes to policy and procedures to minimise further loss in similar circumstances, if appropriate 
Document actions, procedures and outcomes and record promptly and accurately 
Provide stakeholders with accurate and timely advice regarding claim proceedings 
Store and maintain finalised claims files according to organisational policy, legislative requirements and codes of practice, as applicable 

Forms

Assessment Cover Sheet

FNSISV510 - Manage non-routine and complex claims
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

Feedback to student

 

 

 

 

 

 

 

 

Assessor name:

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Date:

Assessment Record Sheet

FNSISV510 - Manage non-routine and complex 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: