Application
This unit describes the skills and knowledge required to settle non-routine and complex insurance claims, including the identification of non-standard issues, accessing all required information to allow a decision to be made, negotiation and finalisation of claims.
It applies to individuals working in job roles involving specialist knowledge and functions in a range of insurance sectors and may be applied within organisations of various sizes and across a range of client 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. Determine terms and conditions of settlement | 1.1 Determine and evaluate non-routine aspects of claim in light of policy wording and general policy of organisation 1.2 Follow organisational claims procedures for non-routine and complex claims, where required 1.3 Determine settlement terms according to policy wording, legislation, organisational operating procedures and codes of practice, taking into account non-routine aspects of claim and parties involved 1.4 Identify type and level of variation to standard claims settlement to establish type of negotiation or mediation that may be required and to ensure logical, persuasive and technically correct claims interpretations can be applied |
2. Negotiate and communicate settlement terms | 2.1 Advise promptly client and/or relevant party terms and conditions of settlement offer according to claims procedures 2.2 Consider response by client and/or relevant party to terms of settlement offer to assess whether adjustment is required 2.3 Negotiate settlement terms, where required, to reach mutual agreement, meet obligations and minimise unnecessary loss to organisation 2.4 Support negotiated settlements with suitable documentation that clearly states agreements reached 2.5 Modify terms of settlement offer as necessary and advise client and/or relevant party promptly |
3. Document liability decisions | 3.1 Clearly communicate decisions to relevant parties in manner required by legislation, operating procedures and codes of practice 3.2 Document decisions in such a way as to determine basis on which decision was reached and all evidence and information that was considered 3.3 Communicate to relevant personnel any aspects of claim relevant to policy wording and general organisational policy |
4. Finalise settlement | 4.1 Make final payments in required timeframe once settlement is reached 4.2 Obtain settlement release from client and/or third party, as applicable 4.3 Obtain discharge to ensure any potential for further liability is eliminated |
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 settlement 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:
recognise claims that are non-routine and complex
determine settlement terms by evaluating available data and through negotiation
document future revised terms of claim based on review of non-routine claims and communicate to relevant people
manage financial transactions and settlement documentation
modify or report on potential changes to organisational policy and procedures to protect the organisation from future losses
document and file all activities for future reference.
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 the key features of organisational policy, procedures, insurance guidelines, levels of authority and accountabilities relevant to non-routine and complex claims
describe the application of legal precedents
identify dispute resolution bodies
state the level and conditions at which claim should be referred to senior staff
explain organisational business objectives relative to non-routine and complex claims
outline the key features of relevant legislation, regulatory guidelines and industry sector compliance requirements and codes of practice as they apply to:
insurance contracts
insurance claims
consumer protection
define the rights of subrogation (the more complex the claim, the more parties may be involved)
identify the roles, responsibilities and jurisdiction of specialists and other authorities
discuss the types and categories of insurance policies and insurance trends in non-routine and complex 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, 1.3, 1.4, 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 | 2.1, 2.3, 2.4, 2.5, 3.1, 3.2, 3.3, 5.1, 6.1, 6.2 | Accurately records information and prepares correspondence and documentation using clear language and organisational formats and protocols Records outcomes of discussions and makes changes to policy documentation using industry relevant terminology |
Oral Communication | 2.1, 2.2, 2.3, 2.5, 3.1, 3.3, 4.2, 6.2 | Uses active listening and questioning to convey and clarify information Presents complex information in formal situations using clear and convincing language, tone and pace appropriate for the audience and purpose |
Numeracy | 1.3, 1.4, 4.1 | Interprets charts, graphs and statistical information and calculates settlement offers |
Navigate the world of work | 1.1, 1.2, 1.3, 2.1, 3.1, 5.2, 6.3 | Takes full responsibility for following policies, procedures and legislative requirements and identifies organisational implications of new legislation or regulation Seeks to improve policies and procedures to better meet organisational goals |
Interact with others | 2.1, 2.2, 2.3, 2.5, 3.1, 3.3, 6.2 | Implements strategies for a diverse range of colleagues and clients to build rapport and foster strong relationships Manages conflict through the recognition of contributing factors and by implementing strategies to resolve disputes |
Get the work done | 1.1, 1.3, 1.4, 2.3, 3.1, 4.1, 4.2, 4.3, 5.2 | Accepts responsibility for planning and sequencing complex tasks and workload, negotiating key aspects with others and taking into account capabilities, efficiencies and effectiveness Responds intuitively to problems requiring immediate resolution, drawing on past experiences to focus on the cause of the problem Investigates new and innovative ideas as a means to continuously improve policies and processes through consultation and formal and analytical thinking Uses digital technologies to access, enter, check and store information required to complete work tasks |
Sectors
Insurance services