Application
This unit describes the skills and knowledge required to process an insurance claim in accordance with organisational guidelines and procedures.
It applies to individuals employed in a range of insurance sectors and may be applied within organisations of various sizes and across a range of customer 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.
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 and clarify claim information | 1.1 Receive and record information relating to claim accurately onto system 1.2 Advise customer of organisational claims procedures and respond to queries courteously and accurately 1.3 Verify completeness of information 1.4 Analyse all information against legislative requirements and organisational guidelines to decide for or against liability 1.5 Determine whether claim is routine and fully covered by policy 1.6 Pass claims not completely routine and within policy guidelines to appropriate staff 1.7 Communicate information which potentially impacts on future renewal of policy or renewal terms promptly to underwriter or other appropriate staff in keeping with organisational policy |
2. Determine acceptability of claim | 2.1 Determine acceptability of claim against policy specifications 2.2 Check reinsurance coverage 2.3 Refer queries on facts or valid acceptance of claim to specialists for advice, where required |
3. Accept or reject claim | 3.1 Process claim within required timeframes and according to organisational guidelines 3.2 Use effective decision-making process to accept or reject claims within timeframes in accordance with legislation, organisational policy and procedures, and codes of practice as applicable 3.3 Observe referral procedures where claim amounts are outside claims settlement and/or claims management authorities 3.4 Make decision on liability in light of need to withstand scrutiny in subsequent proceedings |
4. Process claim | 4.1 Register claim and process promptly in accordance with organisational guidelines and procedures 4.2 Pass payment information on to appropriate staff, where required 4.3 Inform customer of progress of claim 4.4 Record all claim information accurately |
5. Document liability decisions | 5.1 Communicate liability decisions clearly to the relevant parties in a manner required by legislation, operating procedures and codes of practice as applicable 5.2 Communicate reasons for decisions promptly to customer and other relevant parties 5.3 Document decisions to demonstrate basis on which decision was reached and all evidence and/or information that was considered, where appropriate 5.4 File documentation regarding decision according to organisational policy and procedure |
Evidence of Performance
Evidence of the ability to:
accurately process claims across a representative range of products, customers and conditions in accordance with legislation, regulations and organisational policy by:
receiving, recording and clarifying the claim information
making a determination on claim approval
notifying the customer of claim and payment outcomes
documenting and communicating outcomes to relevant parties.
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:
state the accountability requirements of individuals involved with insurance claims and identify the level at which claims should be referred to senior staff
explain the information technology and communications systems used for processing insurance claims
outline key features of organisational policy and procedures, and legislation, regulation and codes of practice relating to processing insurance claims
identify the rationale and principles of filing
identify and describe the organisation’s insurance products available to customers, including any conditions and terms for making claims.
Assessment Conditions
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
an appropriate work environment and conditions.
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, 1.3, 1.4, 1.5, 2.1, 2.2 | Analyses and consolidates information and data from a range of sources against defined criteria and requirements, and checks for accuracy and completeness |
Writing | 1.1, 1.2, 1.6, 1.7, 2.3, 4.1- 4.4, 5.1-5.3 | Accurately records and completes organisational documents and correspondence using clear language and correct spelling, grammar and terminology |
Oral Communication | 1.2, 1.6, 1.7, 2.3, 4.2, 4.3, 5.1, 5.2 | Effectively participates in verbal exchanges using active listening and questioning to convey and clarify information Clearly explains detailed information using language, tone and pace appropriate to audience |
Numeracy | 1.4, 2.1, 3.3 | Performs mathematical calculations to analyse financial data and statistics, and to accurately process claims |
Navigate the world of work | 1.4, 2.1, 3.1, 3.2, 3.3, 4.1, 5.1 | Complies with legal and regulatory requirements and explicit policies and procedures |
Interact with others | 1.2, 1.6, 1.7, 2.3, 4.2, 4.3, 5.1, 5.2 | Identifies and takes steps to follow accepted communication practices and protocols Recognises common cultural and other differences of people in the work context and makes adjustments in addressing the differences |
Get the work done | 1.1, 1.3-1.6, 2.1-2.3, 3.2-3.4, 4.1, 5.3, 5.4 | Plans and implements routine tasks and workload, making limited decisions on sequencing, timing and collaboration, and seeking assistance in setting priorities Makes low-impact decisions within familiar situations, based on a range of predefined or routine solutions Uses digital technologies to access, enter and store information required to complete work tasks |
Sectors
Insurance services