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Follow the links below to find material targeted to the unit's elements, performance criteria, required skills and knowledge

Elements and Performance Criteria

1. Confirm validity of claim
   • Receive and acknowledge claim notification
   • Review details of life insurance policy to ensure valid cover is in force
   • Establish that claimant is authorised to deal with policy
   • Compile necessary documentation
   • Check that documentation is correct and complete, and address any gaps in accordance with procedures
   • Assess organisational authority level required to process claim and refer it to an appropriately authorised individual as necessary
2. Conduct complex claim assessment
   • Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures
   • Identify and review evidence against payment criteria in accordance with procedures
   • Review all information relevant to circumstances of loss, damage or injury to establish chain of events
   • Identify potential fraud indicators
   • Identify whether policy exclusions apply
   • Recognise need for further information and collect as appropriate
3. Appoint specialists to assist in complex claims assessment as required
   • Identify need to appoint specialists to undertake claims assessment
   • Engage and brief appointed specialists as required
   • 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
   • Identify whether terms and conditions of policy have been verifiably met
   • Assess liability in accordance with terms and conditions of policy
   • Where claim is not admitted, communicate decision to appropriate stakeholders
   • Where claim is admitted, calculate payments due
5. Finalise claim payments
   • Advise client of consequences of proceeding with payment
   • Obtain policy discharge, as appropriate
   • Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements
   • Update all appropriate records in accordance with procedures
   • Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements
   • Initiate reinsurance recovery, if appropriate

Performance Evidence

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.

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Knowledge Evidence

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.

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