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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. Receive and clarify claim information
   • Receive and record information relating to claim accurately onto system
   • Advise customer of organisational claims procedures and respond to queries courteously and accurately
   • Verify completeness of information
   • Analyse all information against legislative requirements and organisational guidelines to decide for or against liability
   • Determine whether claim is routine and fully covered by policy
   • Pass claims not completely routine and within policy guidelines to appropriate staff
   • Communicate information which potentially impacts on future renewal of policy or renewal terms promptly to underwriter or other appropriate staff in keeping with organisational policy
2. Determine acceptability of claim
   • Determine acceptability of claim against policy specifications
   • Check reinsurance coverage
   • Refer queries on facts or valid acceptance of claim to specialists for advice, where required
3. Accept or reject claim
   • Process claim within required timeframes and according to organisational guidelines
   • Use effective decision-making process to accept or reject claims within timeframes in accordance with legislation, organisational policy and procedures, and codes of practice as applicable
   • Observe referral procedures where claim amounts are outside claims settlement and/or claims management authorities
   • Make decision on liability in light of need to withstand scrutiny in subsequent proceedings
4. Process claim
   • Register claim and process promptly in accordance with organisational guidelines and procedures
   • Pass payment information on to appropriate staff, where required
   • Inform customer of progress of claim
   • Record all claim information accurately
5. Document liability decisions
   • Communicate liability decisions clearly to the relevant parties in a manner required by legislation, operating procedures and codes of practice as applicable
   • Communicate reasons for decisions promptly to customer and other relevant parties
   • Document decisions to demonstrate basis on which decision was reached and all evidence and/or information that was considered, where appropriate
   • File documentation regarding decision according to organisational policy and procedure

Performance Evidence

Evidence of the ability to:

accurately process claims across a representative range of products, customers and conditions in accordance with legislation, regulations and organisational policy by:

receiving, recording and clarifying the claim information

making a determination on claim approval

notifying the customer of claim and payment outcomes

documenting and communicating outcomes to relevant parties.

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:

state the accountability requirements of individuals involved with insurance claims and identify the level at which claims should be referred to senior staff

explain the information technology and communications systems used for processing insurance claims

outline key features of organisational policy and procedures, and legislation, regulation and codes of practice relating to processing insurance claims

identify the rationale and principles of filing

identify and describe the organisation’s insurance products available to customers, including any conditions and terms for making claims.

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