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.

It may be applied where it is necessary to work with legal teams in resolving a non-routine/complex insurance claim such as major losses, bodily injury losses and long term settlement.

ELEMENT

PERFORMANCE CRITERIA

1. Establish the requirements of legal proceedings for an insurance claim

1.1. Comprehensive terms of reference or instructions relevant to the legal proceedings for the non-routine and complex claim are established

1.2. Terms of reference are checked to ensure they are within organisation and legislative guidelines, codes of practice and personal authorities and are clearly documented

1.3. Roles and responsibilities of all parties involved in the legal proceedings for the claim are negotiated, confirmed and documented

1.4. Requirements and procedures of legal systems involved in the claim proceedings, including domestic and/or other relevant countries, are clarified

2. Provide relevant claims information to the legal team

2.1. Legal team representatives are identified and information requirements confirmed

2.2. Options for obtaining the legal data/information are discussed and sources of legal data/information are identified

2.3. Facts, evidence and information relevant to claims proceedings, is collected thoroughly, systematically and accurately

2.4. Historical data is researched, as required

2.5. Legal data/information is analysed for relevance

2.6. Information deficiencies are identified and additional information is sought from appropriate sources

2.7. Legal data and information is provided to legal team in compliance with organisation policies and procedures, compliance, ethical and legal requirements and within required timeframes and authorities

3. Support the legal process from a claims/underwriting perspective

3.1. Instructions for and receipt of legal advice pertaining to the claim occurs as required

3.2. Liaison with legal team, doctors or other relevant parties occurs as required to expedite insurance claim resolution

3.3. Documents passed as part of the legal proceedings comply with organisation, regulatory and legislative considerations

3.4. Timelines are negotiated for provision of relevant documents to the legal team and adhered to

3.5. Insurers manage matter before the court in a matter that achieves the best and most expeditious resolution at minimum cost

3.6. All appropriate methods within organisation, legislative, codes of practice or other guidelines are employed to clarify conflicting evidence or information

3.7. All actions, procedures and outcomes in supporting the legal team are documented and recorded promptly

4. Participate in settlement arrangements

4.1. Participation in mediation and negotiation activities occurs, as required

4.2. Meeting is arranged with instructing legal practitioner to discuss settlement meeting and to review settlement documents

4.3. Settlement meeting is attended at prescribed venue

4.4. Documentation is checked to ensure it is correct

4.5. Documentation is exchanged with the appropriate parties

4.6. Letter of confirmation of settlement is drafted, forwarded to instructing legal practitioner for review and despatched to relevant parties

4.7. Relevant documents are registered/lodged/recorded as appropriate

4.8. Stakeholders are informed of outcome

5. Report outcomes and update records

5.1. Actions, procedures and outcomes are documented and recorded promptly and accurately according to organisation policy and legislative requirements and codes of practice, as applicable

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

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:

perform calculations related to achieving required outcomes

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

claims management

contract and commercial law principles

data analysis techniques and procedures

insurance law, relevant legal systems and procedures, relevant acts

IT and communications systems

loss adjusting principles and practice

organisation policy, procedures, underwriting guidelines and authorities

policy coverage, requirements and policy wording

relevant industry compliance requirements, legislation and industry codes of practice

research methodologies and practices

risk prevention/loss minimisation methods and application

roles, responsibilities and jurisdiction of specialists and other authorities

rules of evidence and information gathering and documenting principles

types and categories of insurance policies

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 working with legal teams in all aspects of the managing the legal process associated with a claim and resolving the legal aspects of a claim.

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.

Terms of reference or instructions may include:

date and location of loss, damage or injury

estimate of loss, damage or injury

instructions for scope of information required

insurers reference

legal procedures and timelines associated with the claim

name of insured and initial contact

other parties involved

period of insurance

policy cover

policy number

proposed documents to be passed

type.

Non-routine and 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/bodily injury losses

complex technical determinations

high monetary impact

important client base.

Non-routine aspects may include:

disputes in other jurisdictions

special inclusions and exclusions.

Legal data and information may include:

claimant medical history

claimant medical records and reports

claimant test results

correspondence to a range of medical/hospital professionals on claimant related matters

forms

interview records

legal case reports

legal, government, professional and other documents

letters

meeting notes

minutes

official, general, other correspondence

policy documents (including current and archival policies relevant to the claim)

records of telephone conversations

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

time sheets.

Sources of legal data/information may include:

employer and industry associations

employers

insurance brokers

legal team members

loss adjusters, specialist and other claims staff

medical and like providers

rehabilitation providers

relevant data bases and documentation:

legal

insurance

organisation

risk managers

the community

underwriters

union

work team members.

Historical data may include:

archival policies.

Documentation may include:

legal team reports, correspondence and records

legal, government, professional and other documents

meeting notes

minutes

official, general and other correspondence

reasons for recommending certain actions and 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

others

the basis on which the decision was determined.

Stakeholders may include:

broker or agent

claims managers and specialists

client

government or statutory authorities

insurance broker

insured

principal

reinsurers

third party

trustee

underwriters

other relevant parties.

Unit sector

Insurance services

This unit contains employability skills.