Elements and Performance Criteria
- Receive and organise information relating to medical indemnity claim
- Organise and collate information relating to the claim into a coherent file
- Enter relevant claim details in organisational systems
- Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts
- Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements
- Research claim and validate medical indemnity claim information
- Determine type of medical indemnity claim and the key parties involved
- Assess sufficiency and thoroughness of information supplied including expert medical evidence
- Determine if case needs to be referred to other personnel according to organisational delegation rules for cases with unresolved complexity, abnormalities, classification uncertainties or insufficient information
- Review claim information to determine legitimacy of claim including validity and coverage of insurance policy
- Review, segment and prioritise claims for assessment of liability
- Assess medical indemnity claim to determine cause, liability and quantum
- Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim
- Consult with technical and/or claims advisers to clarify information and seek advice as required
- Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability
- Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines
- Document decisions and determine quantum of claim settlement
- Record outcome of analysis documenting all relevant information used to support the decision-making process
- Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions
- Update organisational systems accurately with required information in a timely manner