Unit of competency details

Unit descriptor 

This unit describes the performance outcomes, skills and knowledge required to understand, use and respond to information involving specialist terminology, such as medical or legal terminology (and processes), in insurance claims.

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 use of specialist medical and legal terminology 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. Interpret documents and instructions which contain specialist insurance terminology

1.1. Written and oral instructions  for a claim, using specialist terminology , are received, understood and documented

1.2. Claims documentation  containing specialist terminology is accurately interpreted

1.3. Checklists and sources of information for specialist terminology used in claims are used where appropriate

1.4. Abbreviations for specialist terms and related processes associated with insurance claims are understood

1.5. Clarification  is sought when necessary

2. Use appropriate specialist terminology in written and oral communication related to a claim

2.1. Appropriate specialist terminology is used in both written and oral communication with internal and external parties related to a claim

2.2. Specialist terminology related to insurance claims is spelt and pronounced correctly and used in appropriate context

2.3. Claims documentation is presented to a designated person  for verification, if required

3. Apply specialist terminology to claims tasks

3.1. Specialist terminology is used correctly in the completion of insurance claims tasks 

3.2. Assistance or clarification  is sought from specialist representatives  or designated person as required

3.3. All tasks  are conducted within accepted organisation and ethical codes of conduct including those relating to maintaining confidentiality, privacy and compliance 

4. Extend understanding of specialist terminology

4.1. Gaps in knowledge, such as relevant legislation , are identified and clarification is sought through appropriate source or person

4.2. Abbreviations for commonly used specialist terms and associated processes for insurance claims are identified and used where appropriate

4.3. Questions relating to specialist terminology used in insurance can be answered and terms defined

REQUIRED SKILLS AND KNOWLEDGE 

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

Required skills 

• well-developed communication skills to:

• accurately pronounce specialist terminology
• 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

• 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:

• read and interpret documentation from a variety of sources and record and consolidate relevant related information
• read and interpret legal/medical/insurance documents related to a claim
• understand and use vocabulary for a specific purpose
• clarify intended meaning and context
• follow written and oral sequenced instructions involving specialist terminology in insurance

• 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

Required knowledge 

• industry sector and organisation policy wording
• IT and communications systems
• organisation policy, procedures, underwriting/claims guidelines and authorities
• policy coverage/requirements
• procedures in relation to communication and the release of information, security and confidentiality
• relevant legislation and industry codes of practice
• types/categories of insurance policies
• legal terminology:

• insurance law
• commonly used legal terminology in insurance
• appropriate use of legal terminology within employee's area of responsibility within an insurance context
• relevant legal process as it relates to insurance and/or legal claims proceedings

• medical terminology:

• medical terminology used in insurance and sources of information

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:

• interpret instructions containing commonly used specialist terminology and abbreviations are responded to appropriately
• maintain knowledge of specialist terminology used in insurance
• use specialist terminology in insurance appropriately for the situation
• access an appropriate person/source of information to clarify unclear instructions or to locate missing information
• explain specialist terminology and processes applied to insurance to others in simple, non-specialist language with non-disclosable information is not communicated
• understand legal and financial consequences of misusing legal terminology
• conduct all work within accepted organisation and ethical codes of conduct including those relating to maintaining confidentiality, privacy and compliance.

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.

Written and oral instructions  may include:

• notices
• telephone calls
• terms and conditions of claim
• verbal instructions
• written advice.

Commonly used/appropriate specialist terminology  in insurance may relate to:

• legislation and regulations
• insurance policy and claims documentation
• risk management policies and practices
• legal terminology:

• courts and tribunals
• legal personnel
• legal systems, processes and procedures
• legal documentation
• abbreviations for legal terms

• legal terminology in insurance may vary according to:

• the area of law
• legal system/country to which claim relates
• a particular legal procedure
• the jurisdiction
• the type of policy or coverage

• medical terminology:

• knowledge of medical specialties and the names and titles of doctors working in specialist fields
• illnesses

• injuries
• diseases
• interrelated functions of the body, locations and diseases (e.g. functions of the skeletal system, locations of skeletal injuries, skeletal diseases)
• terms to describe onset and/or nature of disease
• medical conditions
• medical investigations and procedures
• abbreviations for medical and pharmacological terms
• medical equipment and instruments
• departments/sections in a hospital
• medications
• health insurance or WorkCover terminology
• Medicare terminology
• referrals.

Claims documentation  may include:

• case reports
• correspondence to a range of medical/hospital/legal professionals on claimant related matters
• database information
• files
• forms
• insurance policy documents and coverage details
• letters
• minutes
• telephone messages
• medical documentation:

• claimant medical history
• claimant medical records
• routine medical reports associated with the claim
• claimant test results.

Assistance or clarification  may be sought from:

• organisation policy, procedures and guidelines
• insurance information/databases
• claims manager/specialist or designated supervisor
• underwriter or underwriting specialist/manager
• other designated person/s
• medical terminology clarification/assistance:

• medical dictionary
• medical information sources/databases

• legal terminology clarification/assistance:

• legal dictionary
• glossary of commonly use legal terminology and processes used in insurance claims
• legal team representatives.

Specialist representatives or designated person  may include:

• claims manager/specialist or designated supervisor
• legal team representative
• underwriter or underwriting specialist/manager
• WorkCover or specialist medical representative.

Tasks  may include:

• contacting relevant internal or external parties
• dealing with enquiries
• drafting letters in response to claims case queries
• maintenance/update of claims files and databases (e.g. file notes, correspondence, reports)
• producing memos, reports
• medical terminology related claims tasks:

• research/arranging medical or psychological assessments for claim

• legal terminology related claims tasks:

• research for claim and related legal proceedings
• preparing documentation to support legal proceedings
• providing verbal and/or written advice and information on the status of legal proceedings for a claim.

Compliance  may include:

• all activities covered in this unit to be undertaken in line with the relevant current:

• legislation
• regulations
• organisation operating procedures
• codes of practice, where applicable.

Relevant legislation  may include:

• building or construction
• Consumer Credit Code
• contract law
• environmental
• hazardous materials
• industry codes of practice
• Insurance Agents and Brokers Act
• Insurance Contracts Act
• motor vehicle
• occupational health and safety (OHS)
• Privacy Act
• Statutes of limitations
• secrecy laws
• Trade Practices Act.

Unit sector 

Insurance services

Competency field 

Co-requisite units