This unit applies to job roles involving insurance claims in a range of insurance sectors and may be applied within organisations of various sizes and across a range of customer bases.

ELEMENT

PERFORMANCE CRITERIA

1. Receive notification of claim

1.1. Customer is advised of claims procedure

1.2. Customer is given comprehensive information on the organisation claims procedure, how to make a claim, and any forms required for claim are sent to customer

1.3. Customer queries are answered clearly and accurately

2. Receive claim

2.1. New claims advice is checked to verify correct policy detail

2.2. Claims records are checked to ensure that the claim has not been registered previously

3. Record/register claim

3.1. Claims data is accurately entered and claims are registered in accordance with organisation procedures and level of authority

3.2. Where necessary government authorities are notified in the correct format

4. Estimate a claims reserve, including reinsurance as appropriate

4.1. A preliminary reserve/estimate is calculated, where appropriate, according to organisation reserving policy

4.2. For a routine claim, a determination may be made on acceptance or referral of claim in accordance with organisation policy and procedures

4.3. Need for internal or external service providers is identified, if appropriate

4.4. Policy is checked for reinsurance details, if applicable

4.5. Reinsurers are advised of potential claim, if applicable, by raising reinsurance advice

4.6. Potential impact of the claim on the premium is reported as required

5. Create claim files or add information to existing files

5.1. Correspondence is filed in correct claims files and allocated to relevant claims operatives

5.2. All missing information, abnormalities or classification uncertainties are referred according to organisation policy

5.3. An appropriate date is entered into diary system, where necessary

5.4. All information is completed accurately and clearly, and in accordance with legislative and organisation requirements

5.5. Completed documentation is filed or referred for processing if appropriate

Required skills

communication skills to:

determine and confirm information, using questioning and active listening as required

relate to customers

liaise with others, share information, listen and understand

use language and concepts appropriate to cultural differences

numeracy and IT skills to:

perform calculations related to achieving required outcomes

use computer applications (word processing, spreadsheet, database, specific purpose computer systems) to assist in achieving required outcomes

access and update records electronically

access web-based information services

literacy skills to read and interpret documentation from a variety of sources and record and consolidate relevant related information

research and analysis skills for accessing and interpreting relevant information

organisational skills, including the ability to plan and sequence work

Required knowledge

IT and communications systems

organisation and industry sector policy wording

principles and methods of filing

product knowledge, including any conditions and terms of reinsurance

relevant legislation and regulations, organisation policy and procedures, underwriting guidelines and authorities

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:

fully comply with organisation operating procedures, legislative requirements and industry codes of practice

use accuracy and attention to detail and thorough checking of data.

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 organisation records

access to organisation policies and procedures.

Method of assessment

A range of assessment methods should be used to assess practical skills and knowledge. The following examples, in combination, 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.

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.

Claims checking involves:

manual checklists or through data entry validation on computer systems and may include:

previous payment to claimant

claim has been sent to the wrong insurer

liability has not been accepted.

Entering claims data may include:

coding according to organisation requirements (entering statistical data).

Registering claims may involve:

entering claims reserve/estimate

identifying interested parties

identifying reinsurance involvement

linking to relative policy

observing limits to authority level

recording in system.

Organisation procedures may include:

correspondence presentation

initiation of new claims and processing of claims

security procedures.

Authorities may include:

a written policy and procedures manuals that define the level of authority to make decisions on claims within the organisation

guidelines/procedures relating to injury management and use of service providers.

Systems may be:

computerised, with record updating by electronic or manual data recording.

Service providers may include

accountants

assessors

auditors

engineers

investigators

medical advisers

private investigators

surveyors

others as required.

If reinsurance is identified:

check specific treaty and/or facultative coverage for catastrophic claims and allocate internal category code.

Reinsurance advice may include:

notifying the reinsurer of potential claim (if appropriate) by raising a credit/debit note.

Legislative and organisational requirements may include:

Health and Other Services (Compensation) Act

industrial relations legislation

Privacy Act

social security legislation

State and Territory workers compensation Acts and regulations

taxation legislation.

Unit sector

Insurance services

This unit contains employability skills.