Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

FNSILF504 Mapping and Delivery Guide
Manage complex life insurance claims

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency FNSILF504 - Manage complex life insurance claims
Description
Employability Skills
Learning Outcomes and Application This unit describes the skills and knowledge required to manage people, information systems and other resources needed to assess life insurance claims of a complex nature.It applies to those involved in complex non-standard claims management within the life insurance sector.No licensing, legislative or certification requirements apply to this unit at the time of publication.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the life insurance field of work and include access to:

office equipment, technology, software and consumables

organisational records, policy and procedures.

Assessors must satisfy NVR/AQTF assessor requirements.
Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: 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
       
Element: 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
       
Element: 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
       
Element: 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
       
Element: 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
       


Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

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.

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

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

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
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 
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 
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 
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 
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 

Forms

Assessment Cover Sheet

FNSILF504 - Manage complex life insurance claims
Assessment task 1: [title]

Student name:

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I declare that the assessment tasks submitted for this unit are my own work.

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Result: Competent Not yet competent

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Assessor name:

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Assessment Record Sheet

FNSILF504 - Manage complex life insurance claims

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

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Student signature:

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