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Evidence Guide: FNSILF504 - Manage complex life insurance claims

Student: __________________________________________________

Signature: _________________________________________________

Tips for gathering evidence to demonstrate your skills

The important thing to remember when gathering evidence is that the more evidence the better - that is, the more evidence you gather to demonstrate your skills, the more confident an assessor can be that you have learned the skills not just at one point in time, but are continuing to apply and develop those skills (as opposed to just learning for the test!). Furthermore, one piece of evidence that you collect will not usualy demonstrate all the required criteria for a unit of competency, whereas multiple overlapping pieces of evidence will usually do the trick!

From the Wiki University

 

FNSILF504 - Manage complex life insurance claims

What evidence can you provide to prove your understanding of each of the following citeria?

Confirm validity of claim

  1. Receive and acknowledge claim notification
  2. Review details of life insurance policy to ensure valid cover is in force
  3. Establish that claimant is authorised to deal with policy
  4. Compile necessary documentation
  5. Check that documentation is correct and complete, and address any gaps in accordance with procedures
  6. Assess organisational authority level required to process claim and refer it to an appropriately authorised individual as necessary
Receive and acknowledge claim notification

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review details of life insurance policy to ensure valid cover is in force

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Establish that claimant is authorised to deal with policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Compile necessary documentation

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Check that documentation is correct and complete, and address any gaps in accordance with procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess organisational authority level required to process claim and refer it to an appropriately authorised individual as necessary

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Conduct complex claim assessment

  1. Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures
  2. Identify and review evidence against payment criteria in accordance with procedures
  3. Review all information relevant to circumstances of loss, damage or injury to establish chain of events
  4. Identify potential fraud indicators
  5. Identify whether policy exclusions apply
  6. Recognise need for further information and collect as appropriate
Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify and review evidence against payment criteria in accordance with procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Review all information relevant to circumstances of loss, damage or injury to establish chain of events

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify potential fraud indicators

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Identify whether policy exclusions apply

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Recognise need for further information and collect as appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Appoint specialists to assist in complex claims assessment as required

  1. Identify need to appoint specialists to undertake claims assessment
  2. Engage and brief appointed specialists as required
  3. Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements
  4. 3.4 Interpret and utilise specialists' reports
Identify need to appoint specialists to undertake claims assessment

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Engage and brief appointed specialists as required

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

3.4 Interpret and utilise specialists' reports

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess and report on liability

  1. Identify whether terms and conditions of policy have been verifiably met
  2. Assess liability in accordance with terms and conditions of policy
  3. Where claim is not admitted, communicate decision to appropriate stakeholders
  4. Where claim is admitted, calculate payments due
Identify whether terms and conditions of policy have been verifiably met

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assess liability in accordance with terms and conditions of policy

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Where claim is not admitted, communicate decision to appropriate stakeholders

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Where claim is admitted, calculate payments due

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Finalise claim payments

  1. Advise client of consequences of proceeding with payment
  2. Obtain policy discharge, as appropriate
  3. Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements
  4. Update all appropriate records in accordance with procedures
  5. Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements
  6. Initiate reinsurance recovery, if appropriate
Advise client of consequences of proceeding with payment

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Obtain policy discharge, as appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Update all appropriate records in accordance with procedures

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Initiate reinsurance recovery, if appropriate

Completed
Date:

Teacher:		 Evidence:

 

 

 

 

 

 

 

Assessed

Teacher: ___________________________________ Date: _________

Signature: ________________________________________________

Comments:

 

 

 

 

 

 

 

 

Instructions to Assessors

Evidence Guide

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Confirm validity of claim

1.1 Receive and acknowledge claim notification

1.2 Review details of life insurance policy to ensure valid cover is in force

1.3 Establish that claimant is authorised to deal with policy

1.4 Compile necessary documentation

1.5 Check that documentation is correct and complete, and address any gaps in accordance with procedures

1.6 Assess organisational authority level required to process claim and refer it to an appropriately authorised individual as necessary

2. Conduct complex claim assessment

2.1 Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures

2.2 Identify and review evidence against payment criteria in accordance with procedures

2.3 Review all information relevant to circumstances of loss, damage or injury to establish chain of events

2.4 Identify potential fraud indicators

2.5 Identify whether policy exclusions apply

2.6 Recognise need for further information and collect as appropriate

3. Appoint specialists to assist in complex claims assessment as required

3.1 Identify need to appoint specialists to undertake claims assessment

3.2 Engage and brief appointed specialists as required

3.3 Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements

3.4 Interpret and utilise specialists' reports

4. Assess and report on liability

4.1 Identify whether terms and conditions of policy have been verifiably met

4.2 Assess liability in accordance with terms and conditions of policy

4.3 Where claim is not admitted, communicate decision to appropriate stakeholders

4.4 Where claim is admitted, calculate payments due

5. Finalise claim payments

5.1 Advise client of consequences of proceeding with payment

5.2 Obtain policy discharge, as appropriate

5.3 Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements

5.4 Update all appropriate records in accordance with procedures

5.5 Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements

5.6 Initiate reinsurance recovery, if appropriate

Required Skills and Knowledge

ELEMENT

PERFORMANCE CRITERIA

Elements describe the essential outcomes.

Performance criteria describe the performance needed to demonstrate achievement of the element.

1. Confirm validity of claim

1.1 Receive and acknowledge claim notification

1.2 Review details of life insurance policy to ensure valid cover is in force

1.3 Establish that claimant is authorised to deal with policy

1.4 Compile necessary documentation

1.5 Check that documentation is correct and complete, and address any gaps in accordance with procedures

1.6 Assess organisational authority level required to process claim and refer it to an appropriately authorised individual as necessary

2. Conduct complex claim assessment

2.1 Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures

2.2 Identify and review evidence against payment criteria in accordance with procedures

2.3 Review all information relevant to circumstances of loss, damage or injury to establish chain of events

2.4 Identify potential fraud indicators

2.5 Identify whether policy exclusions apply

2.6 Recognise need for further information and collect as appropriate

3. Appoint specialists to assist in complex claims assessment as required

3.1 Identify need to appoint specialists to undertake claims assessment

3.2 Engage and brief appointed specialists as required

3.3 Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements

3.4 Interpret and utilise specialists' reports

4. Assess and report on liability

4.1 Identify whether terms and conditions of policy have been verifiably met

4.2 Assess liability in accordance with terms and conditions of policy

4.3 Where claim is not admitted, communicate decision to appropriate stakeholders

4.4 Where claim is admitted, calculate payments due

5. Finalise claim payments

5.1 Advise client of consequences of proceeding with payment

5.2 Obtain policy discharge, as appropriate

5.3 Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements

5.4 Update all appropriate records in accordance with procedures

5.5 Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements

5.6 Initiate reinsurance recovery, if appropriate

Evidence of the ability to:

perform complex claims management tasks in accordance with relevant procedures and regulatory requirements including:

checking and validating notifications

analysing claims to identify exclusions, potential fraud and other matters that would result in denial of the claim

assessing and reporting liability including interpretation of specialist reports and calculating benefits as required

communicating settlement details and updating documentation.

Note: If a specific volume or frequency is not stated, then evidence must be provided at least once.

To complete the unit requirements safely and effectively, the individual must:

explain organisational procedures for assessing risk and processing complex life insurance claims

explain the checks and balances required to ensure due process and procedures are followed

explain the current industry practice and ethical standards in management of life insurance claims

explain dispute resolution policy and procedures in the event of disputation by the claimant

identify the key stakeholders and specialists in the management of life insurance claims

explain life insurance policy payment criteria

explain life insurance policy terms and conditions

describe key features of relevant regulatory requirements that apply to life insurance.