1. Receive a claim against a group life policy

1.1 Ensure that correct channels of lodgement have been followed

1.2 Identify the relevant policy and the type of cover

1.3 Evaluate evidence of the member’s identity

2. Review the member’s group history and eligibility for cover

2.1 Identify whether cover was granted within the policy’s automatic acceptance provisions or if it was individually underwritten

2.2 Establish whether the member was at work on the commencement date of the present insurance

2.3 Verify that premium contributions are current and correct

3. Manage relationships and information collection

3.1 Identify important contact points and intermediaries, understanding each one’s role and responsibilities

3.2 Identify communication channels most appropriate to each relationship

3.3 Manage an information collection and communication strategy

3.4 Where communication problems arise, refer the case to a suitably authorised team member

4. Assess the claim

4.1 Review claim submission to establish the circumstances of the member’s claimed condition

4.2 Identify the appropriate policy wordings to establish assessment criteria

4.3 Evaluate evidence to determine whether the assessment criteria are met

4.4 Where cover was provided by means other than automatic acceptance, assess whether the client complied with all additional disclosure requirements

4.5 Decide whether a benefit is payable

4.6 For disability claims, consider the opportunity for rehabilitation

5. Pay group life insurance benefits

5.1 Determine entitlements as per relevant policy conditions, within authority levels and obtain sign-off where required

5.2 Identify the parties authorised to receive the benefits paid by the insurer

5.3 Communicate decisions to relevant parties, in accordance with procedures and regulatory requirements

5.4 In the case of death benefits, evaluate dependent relationships and beneficiary nominations if necessary

5.5 In the case of salary continuance claims, set in place ongoing assessment processes and ensure benefit is appropriately taxed prior to payment

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 group life insurance 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 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

Type of cover may include:

death

total & permanent disablement (TPD)

salary continuance (income protection)

trauma

consumer credit.

At work definitions need to consider:

policy wording

relevant Financial Services Council guidance notes and standards.

Commencement date of the present insurancemay be:

for individuals whose group membership pre-existed the present insurance contract, the date that the policy commenced with the present insurer (i.e. the takeover date)

for individuals who joined the group since the policy has been held with the present insurer, the date that the member took out cover or was granted automatic cover (i.e. the risk commencement date).

Contact points and intermediaries may include:

the member

policy beneficiaries

the member’s employer

superannuation fund trustees

superannuation fund administrators

medical professionals

solicitors

donee of power of attorney

financial adviser

insurance broker

internal divisions of the insurer.

Claimed condition may be:

death

disability.

Assessment criteria may include:

death or survivorship

existence of medical condition

severity of medical condition

financial assessments

medical disclosure assessments.

Evidence may include:

legal certification (e.g. birth certificates, death certificates)

statements from:

the member

the member’s employer

potential beneficiaries

medical attendant

medical records

functional capacity tests

employment records

accounting/taxation records.

Relevant policy conditions may include:

benefit offsets

definitions of partial disability

ancillary benefits, such as

rehabilitation expenses

trauma benefits.

Procedures may include:

organisational complaints handling processes

organisational customer service charter

organisational guidelines

organisational policy

organisational privacy and confidentiality guidelines

organisational procedures.

Regulatory requirements may include:

corporations legislation

life insurance legislation

privacy legislation

superannuation legislation

Australian Securities and Investments Commission (ASIC) regulatory guides

Financial Services Council guidance notes and standards.