Application
This unit describes the skills and knowledge required to support legal proceedings to resolve non-routine and complex insurance claims. It involves establishing terms of reference for working with a legal team, providing timely and accurate information to support the legal proceedings for the claim, and participating in the settlement of a non-routine, complex claim that involves legal resolution.
The unit applies to those who work with legal teams to resolve 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. Users are advised to check with the relevant state and territory regulatory authorities to confirm those requirements.
Elements and Performance Criteria
1. Establish requirements of legal proceedings for non-routine and complex insurance claim | 1.1 Establish comprehensive terms of reference and instructions applicable to legal proceedings for claim 1.2 Identify terms of reference and confirm they are within organisational and legislative guidelines, codes of practice and personal authorities, and are documented accordingly 1.3 Negotiate, confirm and document roles and responsibilities of parties involved in legal proceedings for claim 1.4 Identify requirements and procedures of legal system involved in claim proceedings |
2. Obtain and assess required claims information, and provide to legal team | 2.1 Identify legal team representatives and obtain information requirements 2.2 Engage with legal team to identify legal data and information sources and discuss applicable options for obtaining requested legal data and information 2.3 Obtain facts, evidence and information applicable to claims proceedings 2.4 Research and analyse additional historical and legal data, as required 2.5 Identify information deficiencies and seek additional information 2.6 Provide legal data and information to legal team in compliance with organisational policies and procedures, and compliance, ethical and legal requirements |
3. Support legal process to manage claim | 3.1 Obtain instructions and receipt of legal advice pertaining to claim 3.2 Communicate with legal teams and other applicable parties as required and expedite insurance claim resolution 3.3 Negotiate timelines for provision of required documents to legal team within agreed timeframes 3.4 Clarify conflicting evidence and information according to organisational and legislative requirements, codes of practice, and other relevant guidelines and ensure settlement payments comply with relevant policies 3.5 Document all actions, procedures and outcomes in supporting legal team within required timeframes |
4. Support legal team with settlement arrangements | 4.1 Participate in mediation and negotiation activities, as required 4.2 Initiate meeting with instructing legal practitioner to discuss settlement meeting and review settlement documents 4.3 Check and exchange documentation with required parties 4.4 Draft letter of confirmation of settlement, and forward to instructing legal practitioner for review and despatch to required parties |
5. Report claim outcomes and update records | 5.1 Inform stakeholders of claim outcome according to organisational policies and procedures 5.2 Document and record actions, procedures and outcomes according to organisational policies and procedures, legislative requirements, and codes of practice 5.3 Provide stakeholders with advice regarding claim settlement |
Evidence of Performance
The candidate must demonstrate the ability to complete the tasks outlined in the elements, performance criteria and foundation skills of this unit, including evidence of the ability to:
work with a legal team during the resolution of at least two different insurance claims, where:
at least one claim is a non-routine insurance claim
at least one claim is a complex insurance claim.
Evidence of Knowledge
The candidate must be able to demonstrate knowledge to complete the tasks outlined in the elements, performance criteria and foundation skills of this unit, including knowledge of:
legislative requirements, regulatory guidelines, organisational policies and procedures, and industry sector codes of practice that apply to legal proceedings involving complex insurance claim resolution
key features of claims management process
contract and commercial law principles relevant to insurance claim settlements
roles, responsibilities and jurisdiction of specialists and other authorities applicable to resolving complex insurance claims, including key roles of legal teams and other stakeholders, including medical personnel
data analysis techniques and procedures
loss adjusting principles and practices relevant to complex insurance claims
underwriting guidelines and levels of authority relevant to insurance claim settlements
insurance fundamentals and methods to interpret, comprehend and apply policy wording
international and domestic legal systems relevant to resolving complex insurance claims
fundamentals of mediation and negotiation activities related to complex insurance claims
research methodologies and practices relevant to resolving complex insurance claims
principles of managing matters before court in a cost efficient manner that focuses on beneficial outcomes for own organisation
principles of rules of evidence and information gathering, including importance of accurate documentation for legal proceedings
types and categories of insurance policies.
Assessment Conditions
Skills in this unit must be demonstrated in a workplace or simulated environment where the conditions are typical of those in a working environment in this industry.
This includes access to:
organisational records
organisational policies, procedures, legislation and regulations as they relate to contracts of insurance
common technology and software required to resolve insurance claims.
Assessors of this unit must satisfy the requirements for assessors in applicable vocational education and training legislation, frameworks and/or standards.
Foundation Skills
Numeracy | Performs mathematical calculations to analyse costs |
Oral communication | Uses active listening and questioning techniques to convey and clarify information and confirm understanding Presents complex information in formal situations using clear and convincing language, tone and pace suitable to audience and purpose |
Reading | Critically analyses complex documentation from a variety of sources |
Writing | Records outcomes of discussions and changes to policy documentation using industry-required terminology Writes, edits and proofreads documents to ensure clarity of meaning and consistency of information |
Initiative and enterprise | Investigates new and innovative ideas to improve work practices and processes through consultation, formal and analytical thinking |
Planning and organising | Monitors progress of plans and schedules, and reviews and changes them to meet new demands and priorities |
Problem solving | Responds to problems requiring immediate resolution, drawing on past experiences to focus on the cause rather than the symptom |
Self-management | Identifies organisational implications of new legislation and regulations Identifies and resolves key business issues, processes and practices that may have legal implications Accepts responsibility for planning and sequencing complex tasks and workload, negotiating key aspects with others and taking into account capabilities, efficiencies and effectiveness |
Teamwork | Collaborates with others, sharing information to build strong organisational outcomes Manages conflict in the workplace by identifying contributing factors and implementing strategies to resolve conflict |
Technology | Uses digital technologies to access, enter, check and store information |
Sectors
Insurance services