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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. Establish requirements of legal proceedings for insurance claim
   • Establish comprehensive terms of reference or instructions relevant to legal proceedings for non-routine and complex claim
   • Check terms of reference to ensure they are within organisational and legislative guidelines, codes of practice and personal authorities, and are clearly documented
   • Negotiate, confirm and document roles and responsibilities of all parties involved in legal proceedings for claim
   • Clarify requirements and procedures of legal systems involved in claim proceedings, including domestic and/or other relevant countries
2. Provide relevant claims information to legal team
   • Identify legal team representatives and confirm information requirements
   • Discuss options for obtaining legal data and information, and identify sources of legal data and information
   • Collect facts, evidence and information relevant to claims proceedings thoroughly, systematically and accurately
   • Research historical data, as required
   • Analyse legal data and information for relevance
   • Identify information deficiencies and seek additional information from appropriate sources
   • Provide legal data and information to legal team in compliance with organisational policy and procedures, compliance, ethical and legal requirements and within required timeframes and authorities
3. Support legal process from claims perspective
   • Ensure instructions for and receipt of legal advice pertaining to claim occurs as required
   • Liaise with legal team, doctors or other relevant parties as required to expedite insurance claim resolution
   • Ensure documents passed as part of legal proceedings comply with organisational, regulatory and legislative considerations
   • Negotiate timelines for provision of relevant documents to legal team and ensure they are adhered to
   • Ensure insurers manage matters before court in a manner that achieves best and most expeditious resolution and at minimum cost
   • Employ all appropriate methods within organisational, legislative, codes of practice or other guidelines to clarify conflicting evidence or information
   • Document all actions, procedures and outcomes in supporting legal team and record promptly
4. Participate in settlement arrangements
   • Participate in mediation and negotiation activities as required
   • Arrange meeting with instructing legal practitioner to discuss settlement meeting and review settlement documents
   • Attend settlement meeting at prescribed venue
   • Check documentation to ensure it is correct
   • Exchange documentation with appropriate parties
   • Draft letter of confirmation of settlement, forward to instructing legal practitioner for review and despatch to relevant parties
   • Register, lodge and record relevant documents as appropriate
   • Inform stakeholders of outcome
5. Report outcomes and update records
   • Document and record actions, procedures and outcomes promptly and accurately according to organisational policy, legislative requirements and codes of practice, as applicable
   • Provide stakeholders with accurate and timely advice regarding the claim settlement

Performance Evidence

Evidence of the ability to:

formulate terms of reference and establish a legal team to undertake legal proceedings

establish a portfolio of evidence and information on which the legal team can act

liaise and negotiate requirements and scheduling with the personnel associated with legal proceedings

contribute to the resolution process through mediation and negotiation

prepare documentation as required for the legal proceedings and following the resolution

interpret and apply organisational policy and procedures, and comply with legislation, regulations and industry codes of practice related to the resolution of complex claims

oversee and coordinate the legal process associated with 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:

explain the process of claims management

outline contract and commercial law principles relevant to claims settlements

describe and apply data analysis techniques and procedures

identify and describe key features of relevant legislation, regulatory guidelines and industry sector codes of practice as they apply to legal proceedings

explain loss adjusting principles and practice relevant to complex claims

outline organisational policy, procedures, underwriting guidelines and levels of authority

explain the importance of wording of insurance policies in keeping with organisational or insurance sector principles

outline research methodologies and practices relevant to resolving complex claims

outline risk prevention and loss minimisation methods and application

describe the roles, responsibilities and jurisdiction of specialists and other authorities

outline the principles of rules of evidence and information gathering, and the importance of accurate documentation for legal proceedings

describe types and categories of insurance policies

describe the key roles of legal teams and other stakeholders in assisting in resolving complex claims.

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