FNSPIM302
Determine claim liability


Application

This unit describes the skills and knowledge required to process a personal injury claim in accordance with organisational guidelines and procedures. It encompasses all aspects of processing a claim, including possible claim rejection.

It applies to individuals who use specialised knowledge and follow structured approaches using limited discretion and judgement within the claims management function.

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. Receive and clarify claim information

1.1 Enter claim information into relevant organisational systems

1.2 Process claim in accordance with required timeframes and according to relevant Acts, regulations and organisational procedures

1.3 Complete correspondence in accordance with organisational policy and procedures, and allocate to relevant claims personnel

1.4 Advise clients of organisational claims procedures and respond to queries in an appropriate manner

1.5 Check claim information for accuracy and validity in accordance with organisational policy and procedures

2. Determine status of claim

2.1 Analyse all information against regulatory requirements and organisational guidelines to determine liability

2.2 Refer claims to internal or external specialists where required and in accordance with organisational guidelines

3. Accept or reject claim

3.1 Determine liability decision in accordance with organisational guidelines, regulatory requirements, industry codes of practice and defined timeframes

3.2 Adhere to referral procedures where claim amounts are outside settlement and/or claims management authority

3.3 Determine decision on liability, considering review and feedback from external stakeholders

4. Document liability decision

4.1 Communicate liability decisions to relevant stakeholders in accordance with regulatory requirements, operating procedures and relevant codes of practice

4.2 Communicate reasons for decisions promptly to clients and other relevant stakeholders

4.3 Document decisions and file to demonstrate basis on which claim decision was determined, including all evidence and information that was considered, where appropriate

Evidence of Performance

Evidence of the ability to:

receive and clarify information and determine the status of a claim using organisational guidelines and regulatory requirements

document liability decision using organisational guidelines, and demonstrating knowledge of relevant Acts and regulations and organisational policies and procedures

analyse information to draw meaningful conclusions and determine correct action.

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:

interpret and describe the key features of insurance policies, reports and related documents

describe the key analysis and research methods used to determine claim liability

categorise data into meaningful terms

outline the major steps in claim liability decision-making processes

describe the key features relevant to determining claim liability of:

insurance policies, reports and related documents

organisational claims processing software

organisational operating procedures

relevant workers compensation, personal injury Acts and regulatory requirements.


Assessment Conditions

Assessment must be conducted in a safe environment where evidence gathered demonstrates consistent performance of typical activities experienced in the personal injury management 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.


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, 2.1, 3.3

Interprets information from a variety of sources and determines relevant related information

Writing

1.2, 1.3, 4.1-4.3

Completes documentation accurately following organisational procedures and protocols

Uses clear language, correct spelling and grammar and appropriate terminology to convey information to a range of personnel

Oral Communication

1.4, 3.3, 4.1, 4.2

Participates in verbal exchanges with a range of personnel, using appropriate language and listening and questioning skills to determine and confirm information

Navigate the world of work

1.2, 1.3, 1.5, 2.1, 2.2, 3.1, 3.2, 4.1

Recognises and follows relevant legislative requirements, referral procedures and organisational policy and procedures, and meets expectations associated with own role

Interact with others

2.2

Provides relevant information to others as required

Get the work done

1.1, 1.2, 1.3, 1.5, 2.1, 3.1-3.3, 4.3

Organises work according to defined requirements, using some analytical processes, and taking responsibility for decisions and sequencing tasks to achieve efficient outcomes

Uses systematic, analytical process in routine tasks, gathering relevant information and identifying and evaluating options to determine decisions

Uses the main features and functions of digital tools to complete work tasks


Sectors

Personal injury management