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Follow the links below to find material targeted to the unit's elements, performance criteria, required skills and knowledge

Elements and Performance Criteria

1. Analyse claim to determine validity
   • 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
2. Evaluate impact of claim
   • 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
3. Determine settlement options
   • Identify settlement options within policy obligations, organisational and legislative requirements
   • Seek advice on settlement options from appropriate person if required
4. Manage support arrangements to resolve claim
   • 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
5. Identify any required changes to policy or procedures
   • Document circumstances of claim for consideration in portfolio review
   • Instigate changes to policy and procedures to minimise further loss in similar circumstances, if appropriate
6. Report findings and update records
   • 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

Performance Evidence

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.

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Knowledge Evidence

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.

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