This unit applies to those involved in complex non-standard claims management within the life insurance sector.
Not applicable.
1. Confirm validity of the claim | 1.1 Receive and acknowledge claim notification 1.2 Review details of the life insurance policy to ensure valid cover is in force 1.3 Establish that the claimant is authorised to deal with the policy 1.4 Compile necessary documentation 1.5 Check that documentation is correct and complete and address any gaps in accordance with procedures 1.6 Assess the organisational authority level required to process the claim and refer it to an appropriately authorised individual as necessary |
2. Conduct complex claim assessment | 2.1 Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures 2.2 Identify and review evidence against payment criteria in accordance with procedures 2.3 Review all information relevant to the circumstances of loss/damage/injury to establish a chain of events 2.4 Identify potential fraud indicators 2.5 Identify whether policy exclusions apply 2.6 Recognise the need for further information and collect as appropriate |
3. Appoint specialists to assist in complex claims assessment as required | 3.1 Identify the need to appoint specialists to undertake claims assessment 3.2 Engage and brief appointed specialists as required 3.3 Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements 3.4 Interpret and utilise specialists' reports |
4. Assess and report on liability | 4.1 Identify whether the terms and conditions of the policy have been verifiably met 4.2 Assess liability in accordance with the terms and conditions of the policy 4.3 Where the claim is not admitted, communicate the decision to appropriate stakeholders 4.4 Where the claim is admitted, calculate |
5. Finalise claim payments | 5.1 Advise client of the consequences of proceeding with the payment 5.2 Obtain policy discharge, as appropriate 5.3 Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements 5.4 Update all appropriate records in accordance with procedures 5.5 Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements 5.6 Initiate reinsurance recovery, if appropriate |
Required skills
communication skills to:
gather and check information
liaise and share information with others
communicate appropriately with people from diverse backgrounds
IT skills to:
use computer applications (word processing, spreadsheet, database, specific purpose computer systems)
access and update records electronically
access web-based information services
numeracy skills to interpret numeric data and relevant statistics and make payment calculations
organisational skills to efficiently plan and sequence work
problem solving skills to address errors in life insurance documentation
reading skills to:
read and understand relevant procedures
read and understand life insurance policies
read and interpret life insurance claims and supporting documentation
research and analysis skills to:
identify and interpret relevant information
analyse information and data
maintain currency of products and services knowledge
writing skills to:
accurately record information
prepare professional letters and emails.
Required knowledge
the ability to apply and explain as relevant to the management of complex life insurance claims:
dispute resolution policy and procedures
industry practice and ethical standards in claims risk management
life insurance administrative requirements
life insurance policy payment criteria
life insurance policy terms and conditions
organisational procedures
procedures for processing complex prudential claims
product information
relevant regulatory requirements.
The evidence guide provides advice on assessment and must be read in conjunction with the performance criteria, required skills and knowledge, range statement and the Assessment Guidelines for the Training Package.
Overview of assessment | |
Critical aspects for assessment and evidence required to demonstrate competency in this unit | Evidence of the ability to: apply highly developed analytical and administrative skills to complex claims assessment maintain and apply a thorough understanding of all aspects of claims procedures and administrative requirements perform tasks in accordance with relevant procedures and regulatory requirements. |
Context of and specific resources for assessment | Assessment must ensure: competency is demonstrated in the context of the work environment and conditions specified in the range statement either in a relevant workplace or a closely simulated work environment access to and the use of a range of common office equipment, technology, software and consumables access to records access to organisational policies and procedures. |
Method of assessment | A range of assessment methods should be used to assess practical skills and knowledge. The following examples are appropriate for this unit: evaluating an integrated activity, which combines the elements of competency for the unit, or a cluster of related units of competency observing processes and procedures in workplaces verbal or written questioning on underpinning knowledge and skills evaluating samples of work accessing and validating third party reports setting and reviewing workplace projects and business simulations or scenarios. |
Guidance information for assessment |
The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.
Life insurance policy may include: | disability income endowment term life (including terminal illness and Total and Permanent Disablement (TPD)) trauma whole of life. |
Valid must include: | policy exists policy is current claimant is legally authorised to act on the policy. |
Documentation may include: | claim forms records of death records of disablement other medical records statutory declarations and other such records. |
Complex claims may be claims that involve: | legal procedures, including those that involve working across international boundaries long-term settlements complex medical conditions complex technical determinations high monetary impact an important client base. |
Procedures may include: | organisational complaints handling processes organisational customer service charter organisational guidelines organisational policy organisational privacy and confidentiality guidelines organisational procedures. |
Payment criteria may include: | death (including terminal illness) invalidity (permanent or temporary disability) trauma. |
Policy exclusions may include: | pre-existing illnesses medical conditions high risk activities. |
Further information may include: | medical evidence financial evidence interview records surveillance records. |
Specialists may include: | advisers investigators medical and related practitioners solicitors forensic accountants. |
Ethical and regulatory requirements may include: | corporations legislation life insurance legislation privacy legislation Australian Securities and Investments Commission (ASIC) regulatory guides industry Codes of Practice professional Codes of Practice. |
Appropriate stakeholders may include: | internal parties: administrators investigation agencies medical officers trustees client and associated parties: assignees beneficiaries executors lawyers life insured next of kin policy owners. |
Consequences may include: | loss or reduction of future life insurance cover termination of the present contract inability to claim again for the same event under the present contract. |
Policy discharge may include: | acceptance by client of amount of settlement acceptance by client of timing of settlement acceptance by client of terms of settlement. |
Life insurance
This unit contains employability skills.
No licensing, legislative, regulatory or certification requirements apply to this unit at the time of publication.