Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

FNSISV511 Mapping and Delivery Guide
Settle non-routine and complex claims

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency FNSISV511 - Settle non-routine and complex claims
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to settle non-routine and complex insurance claims, including the identification of non-standard issues, accessing all required information to allow a decision to be made, negotiation and finalisation of claims.It applies to individuals working in job roles involving specialist knowledge and functions in a range of insurance sectors and may be applied within organisations of various sizes and across a range of client bases.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.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

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.
Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: Determine terms and conditions of settlement
  • Determine and evaluate non-routine aspects of claim in light of policy wording and general policy of organisation
  • Follow organisational claims procedures for non-routine and complex claims, where required
  • Determine settlement terms according to policy wording, legislation, organisational operating procedures and codes of practice, taking into account non-routine aspects of claim and parties involved
  • Identify type and level of variation to standard claims settlement to establish type of negotiation or mediation that may be required and to ensure logical, persuasive and technically correct claims interpretations can be applied
       
Element: Negotiate and communicate settlement terms
  • Advise promptly client and/or relevant party terms and conditions of settlement offer according to claims procedures
  • Consider response by client and/or relevant party to terms of settlement offer to assess whether adjustment is required
  • Negotiate settlement terms, where required, to reach mutual agreement, meet obligations and minimise unnecessary loss to organisation
  • Support negotiated settlements with suitable documentation that clearly states agreements reached
  • Modify terms of settlement offer as necessary and advise client and/or relevant party promptly
       
Element: Document liability decisions
  • Clearly communicate decisions to relevant parties in manner required by legislation, operating procedures and codes of practice
  • Document decisions in such a way as to determine basis on which decision was reached and all evidence and information that was considered
  • Communicate to relevant personnel any aspects of claim relevant to policy wording and general organisational policy
       
Element: Finalise settlement
  • Make final payments in required timeframe once settlement is reached
  • Obtain settlement release from client and/or third party, as applicable
  • Obtain discharge to ensure any potential for further liability is eliminated
       
Element: 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
       
Element: Report findings and update records
  • Document actions, procedures and outcomes and record promptly and accurately
  • Provide stakeholders with accurate and timely advice regarding claim settlement
  • Store and maintain finalised claims files according to organisational policy, legislative requirements and codes of practice, as applicable
       


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. Determine terms and conditions of settlement

1.1 Determine and evaluate non-routine aspects of claim in light of policy wording and general policy of organisation

1.2 Follow organisational claims procedures for non-routine and complex claims, where required

1.3 Determine settlement terms according to policy wording, legislation, organisational operating procedures and codes of practice, taking into account non-routine aspects of claim and parties involved

1.4 Identify type and level of variation to standard claims settlement to establish type of negotiation or mediation that may be required and to ensure logical, persuasive and technically correct claims interpretations can be applied

2. Negotiate and communicate settlement terms

2.1 Advise promptly client and/or relevant party terms and conditions of settlement offer according to claims procedures

2.2 Consider response by client and/or relevant party to terms of settlement offer to assess whether adjustment is required

2.3 Negotiate settlement terms, where required, to reach mutual agreement, meet obligations and minimise unnecessary loss to organisation

2.4 Support negotiated settlements with suitable documentation that clearly states agreements reached

2.5 Modify terms of settlement offer as necessary and advise client and/or relevant party promptly

3. Document liability decisions

3.1 Clearly communicate decisions to relevant parties in manner required by legislation, operating procedures and codes of practice

3.2 Document decisions in such a way as to determine basis on which decision was reached and all evidence and information that was considered

3.3 Communicate to relevant personnel any aspects of claim relevant to policy wording and general organisational policy

4. Finalise settlement

4.1 Make final payments in required timeframe once settlement is reached

4.2 Obtain settlement release from client and/or third party, as applicable

4.3 Obtain discharge to ensure any potential for further liability is eliminated

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 settlement

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:

recognise claims that are non-routine and complex

determine settlement terms by evaluating available data and through negotiation

document future revised terms of claim based on review of non-routine claims and communicate to relevant people

manage financial transactions and settlement documentation

modify or report on potential changes to organisational policy and procedures to protect the organisation from future losses

document and file all activities for future reference.

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 the key features of organisational policy, procedures, insurance guidelines, levels of authority and accountabilities relevant to non-routine and complex claims

describe the application of legal precedents

identify dispute resolution bodies

state the level and conditions at which claim should be referred to senior staff

explain organisational business objectives relative to non-routine and complex claims

outline the key features of relevant legislation, regulatory guidelines and industry sector compliance requirements and codes of practice as they apply to:

insurance contracts

insurance claims

consumer protection

define the rights of subrogation (the more complex the claim, the more parties may be involved)

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

discuss the types and categories of insurance policies and insurance trends in non-routine and complex claims.

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, 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. Determine terms and conditions of settlement

1.1 Determine and evaluate non-routine aspects of claim in light of policy wording and general policy of organisation

1.2 Follow organisational claims procedures for non-routine and complex claims, where required

1.3 Determine settlement terms according to policy wording, legislation, organisational operating procedures and codes of practice, taking into account non-routine aspects of claim and parties involved

1.4 Identify type and level of variation to standard claims settlement to establish type of negotiation or mediation that may be required and to ensure logical, persuasive and technically correct claims interpretations can be applied

2. Negotiate and communicate settlement terms

2.1 Advise promptly client and/or relevant party terms and conditions of settlement offer according to claims procedures

2.2 Consider response by client and/or relevant party to terms of settlement offer to assess whether adjustment is required

2.3 Negotiate settlement terms, where required, to reach mutual agreement, meet obligations and minimise unnecessary loss to organisation

2.4 Support negotiated settlements with suitable documentation that clearly states agreements reached

2.5 Modify terms of settlement offer as necessary and advise client and/or relevant party promptly

3. Document liability decisions

3.1 Clearly communicate decisions to relevant parties in manner required by legislation, operating procedures and codes of practice

3.2 Document decisions in such a way as to determine basis on which decision was reached and all evidence and information that was considered

3.3 Communicate to relevant personnel any aspects of claim relevant to policy wording and general organisational policy

4. Finalise settlement

4.1 Make final payments in required timeframe once settlement is reached

4.2 Obtain settlement release from client and/or third party, as applicable

4.3 Obtain discharge to ensure any potential for further liability is eliminated

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 settlement

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

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
Determine and evaluate non-routine aspects of claim in light of policy wording and general policy of organisation 
Follow organisational claims procedures for non-routine and complex claims, where required 
Determine settlement terms according to policy wording, legislation, organisational operating procedures and codes of practice, taking into account non-routine aspects of claim and parties involved 
Identify type and level of variation to standard claims settlement to establish type of negotiation or mediation that may be required and to ensure logical, persuasive and technically correct claims interpretations can be applied 
Advise promptly client and/or relevant party terms and conditions of settlement offer according to claims procedures 
Consider response by client and/or relevant party to terms of settlement offer to assess whether adjustment is required 
Negotiate settlement terms, where required, to reach mutual agreement, meet obligations and minimise unnecessary loss to organisation 
Support negotiated settlements with suitable documentation that clearly states agreements reached 
Modify terms of settlement offer as necessary and advise client and/or relevant party promptly 
Clearly communicate decisions to relevant parties in manner required by legislation, operating procedures and codes of practice 
Document decisions in such a way as to determine basis on which decision was reached and all evidence and information that was considered 
Communicate to relevant personnel any aspects of claim relevant to policy wording and general organisational policy 
Make final payments in required timeframe once settlement is reached 
Obtain settlement release from client and/or third party, as applicable 
Obtain discharge to ensure any potential for further liability is eliminated 
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 settlement 
Store and maintain finalised claims files according to organisational policy, legislative requirements and codes of practice, as applicable 

Forms

Assessment Cover Sheet

FNSISV511 - Settle non-routine and complex claims
Assessment task 1: [title]

Student name:

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I declare that the assessment tasks submitted for this unit are my own work.

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Assessment Record Sheet

FNSISV511 - Settle non-routine and complex claims

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Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

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Overall assessment result: Competent Not yet competent

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