Application
This unit describes the skills and knowledge required to manage non-routine and complex insurance claims, including non-standard issues, determination of the business impact and managing all aspects of the claims resolution process.
It applies to individuals working in job roles involving specialist knowledge and functions where skills are needed to manage non-routine and complex insurance claims such as major losses, bodily injury losses, long-term settlement and claims involving legal procedures across international boundaries.
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. Analyse claim to determine validity | 1.1 Assess validity of claim against organisational and policy acceptance criteria for relevant type and category of policy 1.2 Confirm information as accurate, comprehensive and authentic 1.3 Seek inclusive validity from specialists for advice where required 1.4 Notify reinsurer of any claim immediately |
2. Evaluate impact of claim | 2.1 Analyse data relating to extent of loss, damage or injury, and seek and review claim estimates 2.2 Compare claim to expected payment projections for product type and determine business impact 2.3 Determine strategies to minimise negative impact of any non-routine or complex claim within requirements to meet policy obligations 2.4 Determine necessity for urgent action to protect organisational interests |
3. Determine settlement options | 3.1 Identify settlement options within policy obligations, organisational and legislative requirements 3.2 Seek advice on settlement options from appropriate person if required |
4. Manage support arrangements to resolve claim | 4.1 Liaise with relevant parties to identify and meet support requirements such as partnering with external experts to ensure clients’ needs are met 4.2 Manage any legal processes from non-routine or complex claims perspective, including international legal system requirements, if applicable 4.3 Employ mediation skills to resolve issues or disputes associated with significant claim, as required |
5. Identify any required changes to policy or procedures | 5.1 Document circumstances of claim for consideration in portfolio review 5.2 Instigate changes to policy and procedures to minimise further loss in similar circumstances, if appropriate |
6. Report findings and update records | 6.1 Document actions, procedures and outcomes and record promptly and accurately 6.2 Provide stakeholders with accurate and timely advice regarding claim proceedings 6.3 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:
accurately interpret the claims data to:
determine if validation is required
quantify the impact on the organisation
identify strategies to minimise impact
examine the data and identify options for settlement
communicate effectively with colleagues and clients to effectively negotiate an acceptable outcome to mutual benefit
manage reporting requirements and documentation required to finalise a claim.
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:
outline organisational policy, procedures, claims guidelines and levels of authority relevant to non-routine and complex claims
describe the organisation’s business objectives and alignments with managing non-routine and complex claims
identify and explain key features of relevant legislation, regulatory guidelines and industry sector codes of practice as they apply to:
insurance contracts
privacy
insurance claims
describe the roles, responsibilities and jurisdiction of specialists and other authorities who may contribute to resolving complex insurance claims
outline types and categories of insurance policies and their trends that may be affected by complex claims
identify payment projections for the product types to compare against expected claims payments.
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, 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 | 1.3, 1.4, 3.2, 4.1, 5.1, 5.2, 6.1, 6.2 | Accurately records and completes organisational documents and correspondence using clear language and correct spelling, grammar and terminology Records outcomes of discussions and makes changes to policy documentation using industry relevant terminology |
Oral Communication | 1.3, 1.4, 3.2, 4.1, 4.3, 6.2 | Uses active listening and questioning to convey and clarify information and to confirm understanding Presents complex information in formal situations using clear and convincing language, tone and pace appropriate for the audience and purpose |
Numeracy | 2.1, 2.2 | Performs mathematical calculations to analyse financial information, costs and values to accurately process claims |
Navigate the world of work | 1.1, 3.1, 4.2, 6.3 | Follows policies, procedures and legislative requirements and identifies organisational implications of new legislation or regulation Modifies organisational policy and procedures to comply with legislative requirements or organisational goals |
Interact with others | 1.3, 1.4, 4.1, 4.3, 6.2 | Selects and uses appropriate conventions and protocols when communicating with clients and co-workers in a range of work contexts Implements strategies for a diverse range of colleagues and clients to build rapport and foster strong relationships Recognises the diversity in people and manages this diversity to improve workplace relations and practices |
Get the work done | 1.1, 1.2, 1.3, 2.2, 2.3, 2.4, 3.1, 4.1, 4.2, 5.2, 6.3 | Accepts responsibility for planning and sequencing complex tasks and workload, negotiating key aspects with others and taking into account capabilities, efficiencies and effectiveness Makes critical decisions quickly and intuitively in complex situations, taking into consideration a range of variables including the outcomes of previous decisions Responds intuitively to problems requiring immediate resolution, drawing on past experiences to focus on the cause Uses digital technologies to access, enter and store information required to complete work tasks |
Sectors
Insurance services