This unit applies to job roles involving specialist knowledge and functions in a range of insurance sectors and may be applied within organisations of various sizes and across a range of customer bases.

It may be applied where skills are needed to manage a non-routine and complex insurance claim such as major losses, bodily injury losses, long-term settlement, and claims involving legal procedures across international boundaries.

ELEMENT

PERFORMANCE CRITERIA

1. Analyse claim to determine validity

1.1. Validity of claim is assessed against organisation and policy acceptance criteria for relevant type and category of policy

1.2. Information is confirmed as accurate, comprehensive and authentic

1.3. Inclusive validity is sought from specialists for advice where required

1.4. Reinsurer is notified of any claim immediately

2. Evaluate the impact of a claim

2.1. Data relating to the extent of the loss, damage or injury situation is analysed and claim estimates sought and reviewed

2.2. Claim is compared to expected payment projections for the product type, and business impact is determined

2.3. Strategies to minimise negative impact of any non-routine/complex claim are determined within requirements to meet policy obligations

2.4. Necessity for urgent action to protect organisation interests is determined

3. Determine settlement options

3.1. Settlement options are identified within policy obligations, organisation, legislative and legal requirements

4. Manage support arrangements to resolve the claim

4.1. Liaise with relevant parties to identify and meet support requirements such as partnering with external experts to ensure clients' needs are met

4.2. Manage any legal processes from a non-routine/complex claims perspective, including international legal system requirements, if applicable

4.3. Employ mediation skills to resolve issues or disputes associated with a significant claim, as required

5. Identify any required changes to policy or procedures

5.1. Circumstances of claim are documented for consideration in portfolio review

5.2. Changes to policy and procedures are instigated to minimise further loss in similar circumstances, if appropriate

6. Report findings and update records

6.1. Actions, procedures and outcomes are documented and recorded promptly and accurately

6.2. Stakeholders are provided with accurate and timely advice regarding claim proceedings

6.3. Finalised claims files are stored and maintained according to organisation policy and legislative requirements and codes of practice, as applicable

Required skills

highly developed communication skills to:

mediate with clients and others

determine and confirm information, using questioning and active listening as required

relate effectively to customers

liaise with others, share information, listen and understand

use language and concepts appropriate to cultural differences

well-developed numeracy and IT skills to:

perform calculations related to achieving required outcomes

use computer applications (word processing, spreadsheet, database, specific purpose computer systems) to assist in achieving required outcomes

access and update records electronically

access web-based information services

well-developed literacy skills to interpret complex policy documentation, read and interpret documentation from a variety of sources and record and consolidate relevant related information

learning skills to maintain knowledge of changes to compliance legislation and requirements

well-developed evaluation and problem solving skills to identify any issues that have the potential to impact on work outcomes and to develop options to resolve these issues when they arise

self-management skills for complying with ethical, legal and procedural requirements research and analysis skills for accessing and interpreting relevant information

organisational skills, including the ability to plan and sequence work

dispute resolution skills

Required knowledge

industry compliance requirements

organisation business objectives

organisation policy, procedures, guidelines and authorities

regulatory body requirements

relevant common law, legal systems and procedures

roles/responsibilities/jurisdiction of specialists and other authorities

types and categories of insurance policies, industry codes of practice, insurance trends and relevant legislation

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:

interpret data and apply concepts within organisation business objectives

negotiate an acceptable outcome to ensure mutual benefit.

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 organisation records

access to organisation policies and procedures.

Method of assessment

A range of assessment methods should be used to assess practical skills and knowledge. The following examples, in combination, 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.

Types and categories of policies include:

accidental damage

additional benefits

burglary/theft

business interruption

business special risks

commercial

commercial motor

construction risks

crop

defined events

directors and officers

domestic

electronic equipment

employee fraud

engineering plant

environment and pollution

fire and perils

general and products liability

glass

Industrial Special Risks (ISR)

livestock

machinery breakdown

money

multi-risk

package contracts

personal accident and illness

professional indemnity

public liability

sprinkler leakage

transit

travel.

Specialists may include:

agents

investigators

medical practitioners

solicitors.

Non-routine/complex claims may involve:

claims involving legal procedures, including those that involve working across international boundaries

claims involving long-term settlements

complex claims involving major losses/bodily injury losses, etc.

complex technical determinations

high monetary impact

important client base.

Relevant parties may include:

broker or agent

claimant

client

consultants

government or statutory authorities

insured

legal or other practitioners

manufacturers

medical

mortgagee

principal

reinsurer

subcontractor

suppliers

third party

trustee.

External experts may include:

accountants

architects

building consultants

engineers

legal

medical

quantity and other surveyors

repairers

state/local governments

valuers

other relevant experts as required.

Mediation may be:

simple or complex and involve highly developed interpersonal and analytical skills and the application of mediation and dispute resolution techniques.

Documentation may include:

legal, government, professional and other documents

meeting notes

minutes

official, general and other correspondence

reasons for recommending certain actions and settlement options over others

records of telephone conversations

reference to all data and information considered

reports from others such as loss adjusters, assessors, insurers, medical providers and others

the basis on which the decision was determined.

Stakeholders may include:

claimants

claims managers/specialists

insurance broker

reinsurers

underwriters

other relevant parties.

Unit sector

Insurance services

This unit contains employability skills.