Application
This unit describes the skills and knowledge required to analyse and evaluate claims within a medical indemnity context. It encompasses collecting, analysing and using appropriate evidence and criteria to determine cause and apportion liability.
It applies to individuals who use specialised legal and medical knowledge to make judgements within their level of responsibility. They work independently and in teams and take responsibility for assessing claims within a structured organisational framework.
No licensing, legislative or certification requirements apply to this unit at the time of publication.
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. Receive and organise information relating to medical indemnity claim | 1.1 Organise and collate information relating to the claim into a coherent file 1.2 Enter relevant claim details in organisational systems 1.3 Identify any information deficiencies and seek specific additional information from appropriate sources including medical experts 1.4 Maintain confidentiality of information according to legislative requirements, industry principles and organisational requirements |
2. Research claim and validate medical indemnity claim information | 2.1 Determine type of medical indemnity claim and the key parties involved 2.2 Assess sufficiency and thoroughness of information supplied including expert medical evidence 2.3 Determine if case needs to be referred to other personnel according to organisational delegation rules for cases with unresolved complexity, abnormalities, classification uncertainties or insufficient information 2.4 Review claim information to determine legitimacy of claim including validity and coverage of insurance policy 2.5 Review, segment and prioritise claims for assessment of liability |
3. Assess medical indemnity claim to determine cause, liability and quantum | 3.1 Undertake thorough and systematic review and assessment of facts, expert medical evidence and information relevant to circumstances of the claim 3.2 Consult with technical and/or claims advisers to clarify information and seek advice as required 3.3 Follow organisational procedures and use analysis tools to assess evidence in determining cause and liability 3.4 Apportion liability and determine quantum fairly and impartially within limits of delegated authority according to regulatory and organisational guidelines |
4. Document decisions and determine quantum of claim settlement | 4.1 Record outcome of analysis documenting all relevant information used to support the decision-making process 4.2 Use organisational tools and systems to determine quantum including claim settlement amount and note any additional considerations or exceptions 4.3 Update organisational systems accurately with required information in a timely manner |
Evidence of Performance
Evidence of the ability to:
Collate, analyse and research medical indemnity claims information
Assess claim to determine causation, apportion liability and determine quantum for medical indemnity claims.
Document decisions and update records.
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:
identify and explain key features of relevant regulatory requirements and industry codes of practice relating to medical indemnity claims
describe the types and key features of medical indemnity insurance policy coverage and terms and conditions
outline risk management in the medical indemnity context
outline organisational procedures for medical indemnity claims evaluation including the use of case law
explain organisational systems and administrative requirements for data entry and filing including coding requirements
describe the organisation's methodology for determining causation and apportioning liability
outline requirements of health practitioners in providing expert medical evidence including qualifications and experience
list and describe key legal terminology used in the medical indemnity sector
provide a brief overview of the principles of cost estimating in claims assessments
describe analysis tools used to assess medical indemnity claims and to calculate losses or damages
describe organisational arrangements for delegations of authority.
Assessment Conditions
Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the personal injury management field of work and include access to :
office equipment, technology, software and consumables
organisational records, policies and procedures.
Assessors of this unit must satisfy the requirements for assessors in applicable vocational education and training legislation, frameworks and/or standards.
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, 2.1-2.5, 3.1 | Gathers, analyses and interprets simple to complex information from a range of sources and identifies relevant information and actions |
Writing | 1.2, 4.1 | Produces texts of varying complexity using appropriate language, grammar and logical sequence to convey and record information accurately and effectively |
Oral Communication | 1.3, 3.2 | Uses clear, specific language and correct medical and legal terminology to convey and clarify information and achieve required outcomes |
Numeracy | 3.4, 4.2 | Uses mathematical operations to perform calculations |
Navigate the world of work | 1.4, 3.3 | Recognises and follows legislative requirements, explicit and implicit protocols, policies and procedures and meets expectations associated with own role |
Interact with others | 1.3, 3.2 | Selects and uses appropriate communication conventions and protocols to liaise with others |
Get the work done | 1.1-1.4, 2.1-2.5, 3.1-3.4, 4.1-4.3 | Organises, sequences and prioritises tasks and own workload for efficiency and effective outcomes Investigates and uses intuition taking into consideration a range of variables and previous cases Addresses less predictable problems and initiates standard procedures in response, applying problem-solving processes in determining a solution Uses a range of digitally based technologies to access, extract and manage relevant information to achieve required outcomes |
Sectors
Personal injury management