Application
This unit describes the skills and knowledge required to support legal proceedings to resolve a non-routine, complex claim and encompasses establishment of terms of reference for working with a legal team, the provision of timely, accurate information to support the legal proceedings for the claim, and participation in the settlement of a non-routine, complex claim that involves legal resolution.
It applies to individuals working in job roles involving specialist knowledge and functions where it may be necessary to work with legal teams in resolving non-routine, complex insurance claims such as major losses, bodily injury losses and long-term settlement.
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. Establish requirements of legal proceedings for insurance claim | 1.1 Establish comprehensive terms of reference or instructions relevant to legal proceedings for non-routine and complex claim 1.2 Check terms of reference to ensure they are within organisational and legislative guidelines, codes of practice and personal authorities, and are clearly documented 1.3 Negotiate, confirm and document roles and responsibilities of all parties involved in legal proceedings for claim 1.4 Clarify requirements and procedures of legal systems involved in claim proceedings, including domestic and/or other relevant countries |
2. Provide relevant claims information to legal team | 2.1 Identify legal team representatives and confirm information requirements 2.2 Discuss options for obtaining legal data and information, and identify sources of legal data and information 2.3 Collect facts, evidence and information relevant to claims proceedings thoroughly, systematically and accurately 2.4 Research historical data, as required 2.5 Analyse legal data and information for relevance 2.6 Identify information deficiencies and seek additional information from appropriate sources 2.7 Provide legal data and information to legal team in compliance with organisational policy and procedures, compliance, ethical and legal requirements and within required timeframes and authorities |
3. Support legal process from claims perspective | 3.1 Ensure instructions for and receipt of legal advice pertaining to claim occurs as required 3.2 Liaise with legal team, doctors or other relevant parties as required to expedite insurance claim resolution 3.3 Ensure documents passed as part of legal proceedings comply with organisational, regulatory and legislative considerations 3.4 Negotiate timelines for provision of relevant documents to legal team and ensure they are adhered to 3.5 Ensure insurers manage matters before court in a manner that achieves best and most expeditious resolution and at minimum cost 3.6 Employ all appropriate methods within organisational, legislative, codes of practice or other guidelines to clarify conflicting evidence or information 3.7 Document all actions, procedures and outcomes in supporting legal team and record promptly |
4. Participate in settlement arrangements | 4.1 Participate in mediation and negotiation activities as required 4.2 Arrange meeting with instructing legal practitioner to discuss settlement meeting and review settlement documents 4.3 Attend settlement meeting at prescribed venue 4.4 Check documentation to ensure it is correct 4.5 Exchange documentation with appropriate parties 4.6 Draft letter of confirmation of settlement, forward to instructing legal practitioner for review and despatch to relevant parties 4.7 Register, lodge and record relevant documents as appropriate 4.8 Inform stakeholders of outcome |
5. Report outcomes and update records | 5.1 Document and record actions, procedures and outcomes promptly and accurately according to organisational policy, legislative requirements and codes of practice, as applicable 5.2 Provide stakeholders with accurate and timely advice regarding the claim settlement |
Evidence of Performance
Evidence of the ability to:
formulate terms of reference and establish a legal team to undertake legal proceedings
establish a portfolio of evidence and information on which the legal team can act
liaise and negotiate requirements and scheduling with the personnel associated with legal proceedings
contribute to the resolution process through mediation and negotiation
prepare documentation as required for the legal proceedings and following the resolution
interpret and apply organisational policy and procedures, and comply with legislation, regulations and industry codes of practice related to the resolution of complex claims
oversee and coordinate the legal process associated with 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:
explain the process of claims management
outline contract and commercial law principles relevant to claims settlements
describe and apply data analysis techniques and procedures
identify and describe key features of relevant legislation, regulatory guidelines and industry sector codes of practice as they apply to legal proceedings
explain loss adjusting principles and practice relevant to complex claims
outline organisational policy, procedures, underwriting guidelines and levels of authority
explain the importance of wording of insurance policies in keeping with organisational or insurance sector principles
outline research methodologies and practices relevant to resolving complex claims
outline risk prevention and loss minimisation methods and application
describe the roles, responsibilities and jurisdiction of specialists and other authorities
outline the principles of rules of evidence and information gathering, and the importance of accurate documentation for legal proceedings
describe types and categories of insurance policies
describe the key roles of legal teams and other stakeholders in assisting in resolving 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 | 1.2, 1.4, 2.1, 2.3-2.6, 3.6, 4.4 | Critically analyses complex documentation from a variety of sources and consolidates information relating to specific criteria to determine requirements |
Writing | 1.1, 1.3, 1.4, 2.6, 3.7, 4.1, 4.6, 4.7, 4.8, 5.1, 5.2 | Records outcomes of discussions and makes changes to policy documentation using industry relevant terminology Writes, edits and proofreads documents to ensure clarity of meaning, and accuracy and consistency of information Accurately records and completes organisational documents and correspondence using clear language and correct spelling, grammar and terminology |
Oral Communication | 1.3, 2.2, 2.6, 3.2, 3.4, 4.1, 4.3, 4.6, 4.8, 5.2 | 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 | 2.4, 3.5 | Performs mathematical calculations to analyse costs |
Navigate the world of work | 1.2, 2.7, 3.3, 3.6, 5.1 | Takes full responsibility for following policies, procedures and legislative requirements and identifies organisational implications of new legislation or regulation Identifies and resolves key business issues, processes and practices that may have legal implications |
Interact with others | 1.3, 2.2, 2.6, 2.7, 3.2, 3.4, 4.1, 4.3, 4.6, 4.8, 5.2 | Collaborates with others, sharing information to build strong organisational outcomes Recognises the diversity in people and manages this diversity to improve relations and practices Manages conflict in the workplace through the recognition of contributing factors and by implementing strategies to resolve it |
Get the work done | 1.1, 1.3, 1.4, 2.1, 2.3, 2.5, 2.7, 3.1, 3.3, 3.6, 4.2, 4.3, 4.5-4.7, 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 Monitors progress of plans and schedules, and reviews and changes them to meet new demands and priorities Responds intuitively to problems requiring immediate resolution, drawing on past experiences to focus on the cause of a problem rather than the symptom Investigates new and innovative ideas as a means to improve work practices and processes through consultation, formal and analytical thinking Uses digital technologies to access, enter, check and store information required to complete work tasks |
Sectors
Insurance services