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Elements and Performance Criteria

1. Establish requirements of legal proceedings for non-routine and complex insurance claim
   • Establish comprehensive terms of reference and instructions applicable to legal proceedings for claim
   • Identify terms of reference and confirm they are within organisational and legislative guidelines, codes of practice and personal authorities, and are documented accordingly
   • Negotiate, confirm and document roles and responsibilities of parties involved in legal proceedings for claim
   • Identify requirements and procedures of legal system involved in claim proceedings
2. Obtain and assess required claims information, and provide to legal team
   • Identify legal team representatives and obtain information requirements
   • Engage with legal team to identify legal data and information sources and discuss applicable options for obtaining requested legal data and information
   • Obtain facts, evidence and information applicable to claims proceedings
   • Research and analyse additional historical and legal data, as required
   • Identify information deficiencies and seek additional information
   • Provide legal data and information to legal team in compliance with organisational policies and procedures, and compliance, ethical and legal requirements
3. Support legal process to manage claim
   • Obtain instructions and receipt of legal advice pertaining to claim
   • Communicate with legal teams and other applicable parties as required and expedite insurance claim resolution
   • Negotiate timelines for provision of required documents to legal team within agreed timeframes
   • Clarify conflicting evidence and information according to organisational and legislative requirements, codes of practice, and other relevant guidelines and ensure settlement payments comply with relevant policies
   • Document all actions, procedures and outcomes in supporting legal team within required timeframes
4. Support legal team with settlement arrangements
   • Participate in mediation and negotiation activities, as required
   • Initiate meeting with instructing legal practitioner to discuss settlement meeting and review settlement documents
   • Check and exchange documentation with required parties
   • Draft letter of confirmation of settlement, and forward to instructing legal practitioner for review and despatch to required parties
5. Report claim outcomes and update records
   • Inform stakeholders of claim outcome according to organisational policies and procedures
   • Document and record actions, procedures and outcomes according to organisational policies and procedures, legislative requirements, and codes of practice
   • Provide stakeholders with advice regarding claim settlement

Performance Evidence

The candidate must demonstrate the ability to complete the tasks outlined in the elements, performance criteria and foundation skills of this unit, including evidence of the ability to:

work with a legal team during the resolution of at least two different insurance claims, where:

at least one claim is a non-routine insurance claim

at least one claim is a complex insurance claim.

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Knowledge Evidence

The candidate must be able to demonstrate knowledge to complete the tasks outlined in the elements, performance criteria and foundation skills of this unit, including knowledge of:

legislative requirements, regulatory guidelines, organisational policies and procedures, and industry sector codes of practice that apply to legal proceedings involving complex insurance claim resolution

key features of claims management process

contract and commercial law principles relevant to insurance claim settlements

roles, responsibilities and jurisdiction of specialists and other authorities applicable to resolving complex insurance claims, including key roles of legal teams and other stakeholders, including medical personnel

data analysis techniques and procedures

loss adjusting principles and practices relevant to complex insurance claims

underwriting guidelines and levels of authority relevant to insurance claim settlements

insurance fundamentals and methods to interpret, comprehend and apply policy wording

international and domestic legal systems relevant to resolving complex insurance claims

fundamentals of mediation and negotiation activities related to complex insurance claims

research methodologies and practices relevant to resolving complex insurance claims

principles of managing matters before court in a cost efficient manner that focuses on beneficial outcomes for own organisation

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

types and categories of insurance policies.

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