Application
This unit describes the skills and knowledge required to investigate an insurance claim. Investigation may cover the degree of liability or a potential fraud and covers clarifying the brief, conducting the investigation and reporting on the findings.
It applies to individuals working in job roles involving specialist knowledge and functions including claims and underwriting in a range of insurance sectors and may be applied within organisations of various sizes and across a range of client bases.
Work functions in the occupational areas where this unit may be used are subject to regulatory requirements. Refer to the FNS Implementation Guide Companion Volume or the relevant regulator for specific guidance on requirements.
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
Elements describe the essential outcomes. | Performance criteria describe the performance needed to demonstrate achievement of the element. |
1. Clarify brief and instructions | 1.1 Clarify brief provided to investigator including facts of claim, insurer’s instructions and outcomes required 1.2 Check subject matter questions to be investigated |
2. Investigate claim | 2.1 Determine method of investigation 2.2 Collect and organise required information to make logical case 2.3 Carry out investigations in accordance with legislation, regulations and organisational operating procedures and codes of practice, if applicable 2.4 Record all data and information progressively and accurately 2.5 File and store securely all original documents, tapes, photographs and other material 2.6 Prepare and communicate appropriate changes in brief or instructions 2.7 Comply with any changes in brief or instructions |
3. Report on investigation | 3.1 Prepare and transmit comprehensive reports according to reporting guidelines 3.2 Provide copies of documents, tapes, photographs and other materials to insurer’s nominated person 3.3 Give facts and justification for conclusions to insurer’s nominated person 3.4 Make recommendations for action, with appropriate justifications, where required |
Evidence of Performance
Evidence of the ability to:
use appropriate investigation methodologies and maintain accurate records
comply with relevant legislation and regulatory requirements in investigating a claim
produce complete and accurate investigation reports
provide detailed scoping for investigating insurance claims including in-scope and out-of-scope areas
develop options to resolve issues or problems that have the potential to impact on work outcomes during investigations.
Note: If a specific volume or frequency is not stated, then evidence must be provided at least once
Evidence of Knowledge
To complete the unit requirements safely and effectively, the individual must:
outline key requirements of industry sector legal obligations and organisational procedures in relation to investigating claims
describe and implement appropriate investigation methods including:
interviews
surveillance
internet research
document authentication
observation
identify key features of relevant legislation, regulatory guidelines and industry sector codes of practice as they apply to:
insurance contracts
consumer protection
privacy
insurance investigation
explain the importance of report writing conventions in insurance investigations.
Assessment Conditions
Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the insurance services field of work and include access to:
organisational records
organisational policy, procedures, legislation and regulations as they relate to contracts of insurance
a range of common technology and software.
Assessors must satisfy NVR/AQTF assessor requirements.
Foundation Skills
This section describes language, literacy, numeracy and employment skills incorporated in the performance criteria that are required for competent performance.
Skill | Performance Criteria | Description |
Reading | 1.1, 1.2, 2.2 | Critically analyses plans and other documentation from a variety of sources and consolidates information to determine requirements |
Writing | 1.1, 2.4, 2.6, 3.1, 3.3, 3.4 | Accurately records conversations and other details, and transfers information into organisational systems Writes, edits and proofreads documents and reports to ensure clarity of meaning, and accuracy and consistency of information |
Oral Communication | 1.1, 2.6, 3.3, 3.4 | Interacts effectively in verbal exchanges, using active listening and questioning to convey and clarify information |
Numeracy | 2.2, 3.3 | Performs mathematical calculations to interpret and compare financial data and information |
Navigate the world of work | 2.3, 3.1 | Takes full responsibility for following policies, procedures and legislative requirements, and identifies organisational implications of new legislation or regulation |
Interact with others | 2.6, 3.3, 3.4 | Selects and uses appropriate conventions and protocols when communicating with a diverse range of colleagues and clients to build rapport and foster strong relationships |
Get the work done | 1.1, 2.1, 2.3, 2.5, 2.7, 3.2, 3.3 | Accepts responsibility for planning and sequencing complex tasks and workload, negotiating key aspects with others and taking into account capabilities, efficiencies and effectiveness Responds intuitively to problems requiring immediate resolution, drawing on past experiences to focus on the cause of a problem Uses digital technologies to access, enter and store information required to complete work tasks |
Sectors
Insurance services