Application
This unit describes the skills and knowledge required to settle insurance claims, including the negotiation of terms, recording of detail, finalisation of payments and filing of documents.
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. Calculate claim entitlement | 1.1 Gather and evaluate information to determine amount of loss suffered by customer 1.2 Determine settlement terms according to policy wording, legislation and codes of practice |
2. Negotiate and communicate settlement terms | 2.1 Advise promptly terms and conditions of settlement to customer and/or third party according to organisational claims procedures, where appropriate 2.2 Consider response by customer and/or third party to terms of settlement offer and assess whether adjustment is required to take into account value of lost or damaged goods 2.3 Undertake negotiation in endeavour to reach mutual agreement on valuation 2.4 Modify terms and conditions of settlement as necessary and advise customer and/or third party promptly |
3. Document liability decisions | 3.1 Clearly communicate claim decisions to relevant parties in manner required by policy wording, legislation, organisational operating procedures and codes of practice 3.2 Document decisions in such a way as to determine basis on which decision was reached and consider all evidence and information, where applicable 3.3 Send claims documentation to reinsurers |
4. Finalise settlement | 4.1 Make or give instructions for payments within the required timeframe once settlement is reached 4.2 Obtain settlement release from customer and/or third party, as applicable 4.3 Refer claim for recovery action if appropriate, and appoint loss recovery agent if applicable 4.4 Initiate recovery action from reinsurers, if applicable 4.5 Store and maintain finalised claims files according to organisational policy, legislative requirements and codes of practice, as applicable |
Evidence of Performance
Evidence of the ability to:
evaluate information and then calculate the claim entitlement
engage in negotiation with the customer to determine agreed settlement
prepare all required documentation and file as appropriate.
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 settlements and identify the level at which settlements should be referred to senior staff
outline key features of organisational policy and procedures required for processing insurance claims
outline key features of relevant legislation, regulation and codes of practice that apply to insurance claims
define the term ‘policy coverage’ and state how it relates to the settlement of insurance 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.
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, 1.2 | Analyses and consolidates information and data from a range of sources, against defined criteria and requirements, and checks for accuracy and completeness |
Writing | 2.1, 2.3, 2.4, 3.1, 3.2, 3.3, 4.1, 4.3, 4.4, 4.5 | Accurately records and completes organisational documents and correspondence using clear language and correct spelling, grammar and terminology |
Oral Communication | 1.1, 2.1, 2.3, 2.4, 3.1, 4.3 | Presents complex information using vocabulary, tone and pace appropriate for the audience and purpose Uses questioning and active listening to clarify and confirm understanding |
Numeracy | 1.1, 1.2, 2.2, 4.1 | Performs mathematical calculations to analyse financial data and statistics, and to accurately process settlement payments |
Navigate the world of work | 1.2, 3.1, 4.5 | Complies with explicit policies and procedures, and legislative and regulatory requirements |
Interact with others | 2.1-2.4, 4.2, 4.3 | Complies with work instructions and contributes to work group discussions using accepted conventions Negotiates with customers, 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, 1.2, 2.2, 2.3, 3.3, 4.1-4.5 | 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 practices Uses digital technologies to access, enter and store information required to complete work tasks |
Sectors
Insurance services