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 and clarify claim information

1.1. Information relating to the claim is received and entered into the system accurately

1.2. Customer is advised of organisation claims procedures and queries are responded to courteously and accurately

1.3. Completeness of the information is checked

1.4. All information is analysed against legislative requirements and organisation guidelines to decide for or against liability

1.5. Determination is made as to whether the claim is routine and fully covered by the policy

1.6. Claims not completely routine and fully within the policy guidelines are passed on to appropriate staff

1.7. Information which potentially impacts in the future renewal of the policy or renewal terms is communicated promptly to the underwriter or other appropriate staff in keeping with organisational policy

2. Determine acceptability of claim

2.1. Acceptability of claim is determined against policy specifications

2.2. Reinsurance coverage is checked

2.3. Queries on facts or the valid acceptance of the claim are referred to specialists for advice where required

3. Accept or reject claim

3.1. Claim is processed within required timeframes and according to organisation guidelines

3.2. Correct acceptance or rejection decision is made using an effective decision making process within timeframes in accordance with legislation, organisation policy and procedures and codes of practice, as applicable

3.3. Referral procedures are observed where claim amounts are outside claims settlement and/or claims management authorities

3.4. Decision on liability is made in light of the need to withstand scrutiny in subsequent proceedings

4. Process claim

4.1. Claim is registered and processed promptly in accordance with organisation guidelines and procedures

4.2. Where required, payment information is passed on to appropriate staff

4.3. Customer is kept informed of progress of the claim

4.4. All claim information is accurately recorded

5. Document liability decisions

5.1. Liability decisions are clearly communicated to the relevant parties in a manner required by the legislation, operating procedures and codes of practice, as applicable

5.2. Reasons for decisions are communicated promptly to client and other relevant parties

5.3. Decisions are documented in such a way as to demonstrate the basis on which the decision was reached and all the evidence/information that was considered, where appropriate, and filed

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

accountability requirements

IT and communications systems

level at which claims should be referred to senior staff

organisation policy, and procedures

policy coverage, interpretation and application

principles and methods of filing

product knowledge

relevant industry legislation and regulations

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:

accurately process claims across a representative range of products, clients and conditions

apply organisation policy and procedures and comply with legislation and regulations and industry codes of practice.

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 information may include:

identifying data, policy, risk, previous history with the organisation.

Entering claims data may include:

coding according to organisation requirements (entering statistical data).

Systems may be:

computerised, and data recording and updating will be by electronic in the majority of cases.

Organisation procedures may include:

initiation of new claims and processing of fully routine claims

correspondence presentation

security procedures.

Claims checking may include:

manual checklists but in the majority of cases it will be 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

Specialists may include:

organisation specialists or outside service providers such as investigators, lawyers, accountants, medical practitioners, loss assessors.

Referral procedures may involve:

referral to the next authority level.

Registering claims may involve:

entering claims reserve/estimate, observing limits to authority level.

Decision making process may involve:

consultation

fact finding

research.

Files may be:

paper documents or electronic files.

Unit sector

Insurance services

This unit contains employability skills.