Application
This unit describes the skills and knowledge required to handle the receipt, initial assessment and processing of claims made under risk-based life insurance policies.
It applies to those engaged in claims management functions of life insurance organisations.
No licensing, legislative or certification requirements apply to this unit at the time of publication.
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
Elements describe the essential outcomes. | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Receive claim form | 1.1 Receive claim form and compile necessary documentation 1.2 Review policy details to ensure valid cover is in force 1.3 Establish that claimant is authorised to deal with policy 1.4 Check that documentation is correct and complete 1.5 Determine authority level required to evaluate claim and refer application to appropriate authority as necessary |
2. Evaluate claim information | 2.1 Identify and review evidence against payment criteria 2.2 Check and confirm whether terms and conditions of policy have been met 2.3 Identify whether policy exclusions apply 2.4 Seek additional specialist advice as appropriate 2.5 Recognise where information suggests unresolved complexity and seek further information as appropriate |
3. Establish liability for payment | 3.1 Determine whether claim can be admitted in accordance with procedures and within authority limits 3.2 Make payment recommendation in accordance with procedures 3.3 Communicate outcomes to all relevant parties in accordance with procedures 3.4 Update records and file documentation in accordance with procedures and regulatory requirements |
Evidence of Performance
Evidence of the ability to:
check and evaluate claims to identify exclusions and possible unresolved complexities
make payment recommendations in accordance with relevant procedures and regulatory requirements
effectively communicate outcomes to relevant parties and update records accurately.
Note: If a specific volume or frequency is not stated, then evidence must be provided at least once.
Evidence of Knowledge
To complete the unit requirements safely and effectively, the individual must:
outline life insurance administrative requirements and organisational procedures relating to life insurance claims evaluation and processing
explain life insurance policy payment criteria
outline life insurance policy terms and conditions
explain organisational systems for data entry and filing
describe product information
outline relevant regulatory requirements relating to life insurance claims evaluation.
Assessment Conditions
Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the life insurance field of work and include access to:
office equipment, technology, software and consumables
organisational records, policy and procedures.
Assessors must satisfy NVR/AQTF assessor requirements.
Foundation Skills
This section describes language, literacy, numeracy and employment skills incorporated in the performance criteria that are required for competent performance.
Skill | Performance Criteria | Description |
Reading | 1.1-1.5, 2.1-2.3, 2.5, 3.1 | Gathers, analyses and interprets simple to complex information from a range of sources and identifies relevant information and actions |
Writing | 2.4, 3.3, 3.4 | Produces texts of varying complexity using appropriate language, grammar and logical sequence to convey and record information accurately and effectively |
Oral Communication | 2.4, 3.3 | Uses clear, specific language and correct terminology to convey information and achieve required outcomes |
Numeracy | 2.1, 3.2 | Uses mathematical equations to perform calculations |
Navigate the world of work | 1.5, 3.1-3.4 | Recognises and follows legislative requirements, explicit and implicit protocols, policies and procedures, and meets expectations associated with own role |
Interact with others | 2.4, 2.5, 3.3 | Selects and uses appropriate communication conventions and protocols to liaise with others Adjusts personal communication style in response to the values, beliefs and cultural expectations of others |
Get the work done | 1.1-1.5, 2.1-2.3, 3.1-3.4 | Takes responsibility for planning, sequencing and prioritising tasks and own workload for efficiency and effectiveness Makes decisions regarding claim validity based on implementation of standard procedures and/or evaluation against set criteria Uses the main features and functions of digital tools to complete work tasks |
Sectors
Life insurance