This unit applies to 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 customer bases.

ELEMENT

PERFORMANCE CRITERIA

1. Determine terms and conditions of settlement

1.1. Non-routine aspects of the claim are determined and evaluated in light of the policy wording and the general policy of the organisation

1.2. Organisation claims procedures for non-routine/complex claims are followed where required

1.3. Settlement terms are determined according to policy wording, legislation, organisation operating procedures and codes of practice, taking into account the non-routine aspects of the claim

1.4. Type and level of variation to standard claims settlement is identified in order 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. Terms and conditions of settlement offer are promptly advised to client and/or relevant party, according to claims procedures

2.2. Response by client and/or relevant party to terms of settlement offer is considered to assess whether adjustment is required

2.3. Settlement terms are negotiated where required to reach mutual agreement, to meet obligations and to minimise unnecessary loss to the organisation

2.4. Negotiated settlements are supported with suitable documentation that clearly states agreements reached

2.5. Terms of settlement offer are modified as necessary and client and/or relevant party advised promptly

3. Document liability decisions

3.1. Decisions are clearly communicated to the relevant parties in a manner required by the legislation, operating procedures and codes of practice

3.2. Decisions are documented in such a way as to determine the basis on which the decision was reached and all the evidence/information that was considered

3.3. Any aspects of the claim relevant to policy wording and general organisation policy are communicated to relevant personnel

4. Finalise settlement

4.1. Once settlement is reached, final payments are made in the required timeframe

4.2. Settlement release is obtained from client and/or third party, as applicable

4.3. Discharge is obtained to ensure any potential for further liability is eliminated

5. Identify any required changes to policy or procedures

5.1. Circumstances of claim are documented for consideration in portfolio review

5.2. Changes to policy and procedures are instigated to minimise further loss in similar circumstances, if appropriate

6. Report findings and update records

6.1. Actions, procedures and outcomes are documented and recorded promptly and accurately

6.2. Stakeholders are provided with accurate and timely advice regarding the claim settlement

6.3. Finalised claims files are stored and maintained according to organisation policy and legislative requirements and codes of practice, as applicable

Required skills

highly-developed communication skills to:

determine and confirm information, using questioning and active listening as required

relate effectively to customers

liaise with others, share information, listen and understand

use language and concepts appropriate to cultural differences

well-developed numeracy and IT skills to:

interpret charts, graphs and statistical information and calculate settlement offers

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

well-developed literacy skills to read and interpret documentation from a variety of sources and record and consolidate relevant related information

learning skills to maintain knowledge of changes to compliance legislation and requirements

problem solving skills to identify any issues that have the potential to impact on work outcomes and to develop options to resolve these issues when they arise

self-management skills for complying with ethical, legal and procedural requirements research and analysis skills for accessing and interpreting relevant information

organisational skills, including the ability to plan and sequence work

Required knowledge

accountability requirements

application of legal precedents

dispute resolution bodies

level at which claim should be referred to senior staff

organisation business objectives

organisation policy, procedures, guidelines and authorities

regulatory body requirements

relevant legislation and industry compliance requirements

relevant common law, legal systems and procedures

rights of subrogation (the more complex the claim, the more parties may be involved)

roles/responsibilities/jurisdiction of specialists and other authorities

types and categories of insurance policies, industry codes of practice, insurance trends and relevant legislation

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:

interpret and apply organisation policy and procedures and compliance with legislation and regulations and industry codes of practice in identifying non-routine aspects of the claim and effecting an acceptable settlement.

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

setting and reviewing workplace projects and business simulations or scenarios.

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.

Non-routine aspects may include:

disputes in other jurisdictions

special inclusions and exclusions.

Non-routine/complex claims may involve:

claims involving legal procedures, including those that involve working across international boundaries

claims involving long-term settlements

complex claims involving major losses and bodily injury losses

complex technical determinations

high monetary impact

important client base.

Settlement terms may include:

repair, replace or cash settle.

Client and/or relevant parties may include:

broker or agent

claimant or client

consultants

government or statutory authorities

insured

legal or other practitioners

manufacturers

medical

mortgagee

principal

reinsurer

subcontractor

suppliers

third party

trustee.

Adjustment may involve modifications of settlement terms based on:

new facts

negotiating the best terms.

Documentation may include:

legal, government, professional and other documents

meeting notes

minutes

official, general and other correspondence

reasons for recommending certain actions and settlement decisions over others

records of telephone conversations

reference to all data and information considered

reports from others such as loss adjusters, assessors, insurers, medical providers and others

the basis on which the decision was determined.

Stakeholders may include:

claimants

claims managers and specialists

insurance broker

reinsurers

underwriters

other relevant parties.

Unit sector

Insurance services

This unit contains employability skills.