This unit applies to those involved in disability claims management that is prolonged and requiring ongoing supervision within the life insurance sector.
Not applicable.
1. Manage claim review procedures and determine ongoing assessment criteria | 1.1 Recognise the need to undertake a review of the insurer's continuing liability against an ongoing disability claim 1.2 Identify appropriate periodical claimant submissions 1.3 Maintain contact with the claimant and other relevant parties 1.4 Review claim file and apply policy terms, conditions and definitions to establish ongoing assessment criteria |
2. Review the claim | 2.1 Receive appropriate periodical claimant submissions for comparison with ongoing assessment criteria 2.2 Review submissions and identify the need for additional information, where appropriate 2.3 Where necessary, plan information collection in accordance with ethical and regulatory requirement |
3. Appoint specialists to assist in additional information collection, as required | 3.1 Identify the need to appoint specialists to undertake claims investigations 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, as appropriate 3.4 Interpret and utilise specialists' reports |
4. Conduct assessment of the ongoing claim | 4.1 Review claimant submissions and specialist reports against ongoing assessment criteria 4.2 Evaluate whether the ongoing assessment criteria have been satisfied 4.3 Communicate the results of assessments to relevant parties |
5. Adjust benefits as required | 5.1 Calculate benefit entitlements in accordance with policy terms and conditions and procedures 5.2 Where necessary, apply and calculate partial disability benefits in accordance with policy terms and conditions and procedures 5.3 Where necessary, apply offsets and/or indexation to benefits in accordance with policy terms and conditions 5.4 Where necessary, interpret and apply criteria for ceasing income-stream benefit payments, in accordance with policy terms and conditions, procedures and ethical and regulatory requirements |
Required skills
communication skills to:
gather and check information
liaise and share information with others
communicate appropriately with people from diverse backgrounds
conduct structured interviews with case management
IT skills to:
use computer applications (word processing, spreadsheet, database, specific purpose computer systems)
access and update records electronically
access web-based information services
numeracy skills to interpret numeric data and relevant statistics and calculate benefit entitlements
organisational skills to efficiently plan and sequence work
problem solving skills to address errors in life insurance documentation
reading skills to:
read and understand relevant procedures
read and understand life insurance policies
read and interpret life insurance claims and supporting documentation
research and analysis skills to:
identify and interpret relevant information
analyse information and data
maintain currency of products and services knowledge
writing skills to:
accurately record information
prepare professional letters and emails.
Required knowledge
the ability to apply and explain as relevant to the management of disability claims:
industry practice and ethical standards in disability claims management
life insurance administrative requirements
life insurance policy payment criteria
life insurance policy terms and conditions
organisational procedures
practice in prudential risk associated with disability claims in insurance
procedure and practice in insurance claims investigation
product information
relevant regulatory requirements.
The evidence guide provides advice on assessment and must be read in conjunction with the performance criteria, required skills and knowledge, range statement and the Assessment Guidelines for the Training Package.
Overview of assessment | |
Critical aspects for assessment and evidence required to demonstrate competency in this unit | Evidence of the ability to: apply highly developed analytical and administrative skills maintain and apply a thorough understanding of claims procedures, policy guidelines and administrative requirements perform tasks in accordance with relevant procedures and regulatory requirements. |
Context of and specific resources for assessment | Assessment must ensure: competency is demonstrated in the context of the work environment and conditions specified in the range statement either in a relevant workplace or a closely simulated work environment access to and the use of a range of common office equipment, technology, software and consumables access to records access to organisational policies and procedures. |
Method of assessment | A range of assessment methods should be used to assess practical skills and knowledge. The following examples are appropriate for this unit: evaluating an integrated activity, which combines the elements of competency for the unit, or a cluster of related units of competency observing processes and procedures in workplaces verbal or written questioning on underpinning knowledge and skills evaluating samples of work accessing and validating third party reports setting and reviewing workplace projects and business simulations or scenarios. |
Guidance information for assessment |
The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.
Need to undertake a review may include: | a change in the claimant's situation anomalies detected during the initial claim assessment indexation scheduling medical updates new and relevant information recovery benchmarks standard scheduling as per processes and procedures suspicions of fraud. |
Periodical claimant submissions may include: | activities questionnaires other medical, financial and occupational information progress claim forms progress medical reports rehabilitation reports. |
Relevant parties may include: | accounting and finance professionals advisers carers claimant consultants legal or other practitioners medical professionals reinsurer trustees workers compensation. |
Additional information may include: | additional claimant forms functional capacity evaluation information related to moral risks interview records medical reports meeting notes official, general and other correspondence psychological assessment records of telephone conversations reports from others such as assessors, insurers, medical providers and others surveillance tax documentation vocational assessment. |
Ethical and regulatory requirements may include: | Australian Securities and Investments Commission (ASIC) regulatory guides corporations legislation life insurance legislation privacy legislation professional Codes of Practice. |
Specialists may include: | advisers Chief Medical Officer consultants forensic accountants investigators medical professionals solicitors surveillance professionals. |
Procedures may include: | organisational complaints handling processes organisational customer service charter organisational guidelines organisational policy organisational privacy and confidentiality guidelines organisational procedures. |
Results of assessments may include: | decision to alter benefit payments decision to cease benefit payments decision to continue benefit payments unaltered. |
Life insurance
This unit contains employability skills.
No licensing, legislative, regulatory or certification requirements apply to this unit at the time of publication.