Elements and Performance Criteria
- Receive a claim against a group life policy
- Review the member’s group history and eligibility for cover
- Manage relationships and information collection
- Identify important contact points and intermediaries, understanding each one’s role and responsibilities
- Identify communication channels most appropriate to each relationship
- Manage an information collection and communication strategy
- Where communication problems arise, refer the case to a suitably authorised team member
- Assess the claim
- Review claim submission to establish the circumstances of the member’s claimed condition
- Identify the appropriate policy wordings to establish assessment criteria
- Evaluate evidence to determine whether the assessment criteria are met
- Where cover was provided by means other than automatic acceptance, assess whether the client complied with all additional disclosure requirements
- Decide whether a benefit is payable
- For disability claims, consider the opportunity for rehabilitation
- Pay group life insurance benefits
- Determine entitlements as per relevant policy conditions, within authority levels and obtain sign-off where required
- Identify the parties authorised to receive the benefits paid by the insurer
- Communicate decisions to relevant parties, in accordance with procedures and regulatory requirements
- In the case of death benefits, evaluate dependent relationships and beneficiary nominations if necessary
- In the case of salary continuance claims, set in place ongoing assessment processes and ensure benefit is appropriately taxed prior to payment