Unit of competency details

Unit descriptor 

This unit describes the performance outcomes, skills and knowledge required to receive and record or register claims including gathering the information, initial estimation and entering the claim into organisation records.

This unit is applicable to individuals working within enterprises and job roles subject to licensing, legislative, regulatory or certification requirements including legislation administered by the Australian Securities and Investments Commission (ASIC).

Application of the unit 

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

Prerequisite units 

Employability skills 

This unit contains employability skills.

Elements describe the essential outcomes of a unit of competency.

Performance criteria describe the performance needed to demonstrate achievement of the element. Where bold italicised text is used, further information is detailed in the required skills and knowledge section and the range statement. Assessment of performance is to be consistent with the evidence guide.

ELEMENT 

PERFORMANCE CRITERIA 

1. Receive notification of claim

1.1. Customer is advised of claims procedure

1.2. Customer is given comprehensive information on the organisation claims procedure, how to make a claim, and any forms required for claim are sent to customer

1.3. Customer queries are answered clearly and accurately

2. Receive claim

2.1. New claims advice is checked  to verify correct policy detail

2.2. Claims records are checked to ensure that the claim has not been registered previously

3. Record/register claim

3.1. Claims data is accurately entered  and claims are registered  in accordance with organisation procedures  and level of authority 

3.2. Where necessary government authorities are notified in the correct format

4. Estimate a claims reserve, including reinsurance as appropriate

4.1. A preliminary reserve/estimate is calculated, where appropriate, according to organisation reserving policy

4.2. For a routine claim, a determination may be made on acceptance or referral of claim in accordance with organisation policy and procedures

4.3. Need for internal or external service providers  is identified, if appropriate

4.4. Policy is checked for reinsurance  details, if applicable

4.5. Reinsurers are advised of potential claim, if applicable, by raising reinsurance advice 

4.6. Potential impact of the claim on the premium is reported as required

5. Create claim files or add information to existing files

5.1. Correspondence is filed in correct claims files and allocated to relevant claims operatives

5.2. All missing information, abnormalities or classification uncertainties are referred according to organisation policy

5.3. An appropriate date is entered into diary system, where necessary

5.4. All information is completed accurately and clearly, and in accordance with legislative and organisation requirements 

5.5. Completed documentation is filed or referred for processing if appropriate

REQUIRED SKILLS AND KNOWLEDGE 

This section describes the skills and knowledge required for this unit.

Required skills 

• communication skills to:

• determine and confirm information, using questioning and active listening as required
• relate to customers
• liaise with others, share information, listen and understand
• use language and concepts appropriate to cultural differences

• 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

• literacy skills to read and interpret documentation from a variety of sources and record and consolidate relevant related information
• research and analysis skills for accessing and interpreting relevant information
• organisational skills, including the ability to plan and sequence work

Required knowledge 

• IT and communications systems
• organisation and industry sector policy wording
• principles and methods of filing
• product knowledge, including any conditions and terms of reinsurance
• relevant legislation and regulations, organisation policy and procedures, underwriting guidelines and authorities

EVIDENCE GUIDE 

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:

• fully comply with organisation operating procedures, legislative requirements and industry codes of practice
• use accuracy and attention to detail and thorough checking of data.

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.

Guidance information for assessment 

RANGE STATEMENT 

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.

Claims checking  involves:

• manual checklists or through data entry validation on computer systems and may include:

• previous payment to claimant
• claim has been sent to the wrong insurer
• liability has not been accepted.

Entering  claims data may include:

• coding according to organisation requirements (entering statistical data).

Registering  claims may involve:

• entering claims reserve/estimate
• identifying interested parties
• identifying reinsurance involvement
• linking to relative policy
• observing limits to authority level
• recording in system.

Organisation procedures  may include:

• correspondence presentation
• initiation of new claims and processing of claims
• security procedures.

Authorities  may include:

• a written policy and procedures manuals that define the level of authority to make decisions on claims within the organisation
• guidelines/procedures relating to injury management and use of service providers.

Systems  may be:

• computerised, with record updating by electronic or manual data recording.

Service providers  may include

• accountants
• assessors
• auditors
• engineers
• investigators
• medical advisers
• private investigators
• surveyors
• others as required.

If reinsurance  is identified:

• check specific treaty and/or facultative coverage for catastrophic claims and allocate internal category code.

Reinsurance advice  may include:

• notifying the reinsurer of potential claim (if appropriate) by raising a credit/debit note.

Legislative and organisational requirements  may include:

• Health and Other Services (Compensation) Act
• industrial relations legislation
• Privacy Act
• social security legislation
• State and Territory workers compensation Acts and regulations
• taxation legislation.

Unit sector 

Insurance services

Competency field 

Co-requisite units