Unit of competency Outline
Date retreived
22/07/2026 7:54 PM AWST
22/07/2026 7:54 PM AWST
Whilst all efforts are made to provide accurate and timely information from the relevant source/documentation, please be aware that the information supplied may not be the most current version. The accuracy of the detail has not been confirmed by the Department and therefore should not be relied upon without first confirming the contents.
Manage complex life insurance claims
Manage complex life insurance claims
Unit of competency
National Code
FNSILF504A
FNSILF504A
State Code
WC244
WC244
TGA Status
Replaced
Replaced
DTWD Status
Replaced
Replaced
State Implementation and Classification
Approved Date
29/07/2014
Field of Education
081103 - Insurance And Actuarial Studies
Original Release Date
29/07/2014
Nominal Hours
45
Description
This unit describes the performance outcomes, skills and knowledge required to manage people, information systems and other resources needed to assess life insurance claims of a complex nature.
Notes
Elements and Performance Criteria
1. Confirm validity of the claim
- 1.1 Receive and acknowledge claim notification
- 1.2 Review details of the life insurance policy to ensure valid cover is in force
- 1.3 Establish that the claimant is authorised to deal with the policy
- 1.4 Compile necessary documentation
- 1.5 Check that documentation is correct and complete and address any gaps in accordance with procedures
- 1.6 Assess the organisational authority level required to process the claim and refer it to an appropriately authorised individual as necessary
2. Conduct complex claim assessment
- 2.1 Review and apply policy terms, conditions and definitions to identify payment criteria in accordance with procedures
- 2.2 Identify and review evidence against payment criteria in accordance with procedures
- 2.3 Review all information relevant to the circumstances of loss/damage/injury to establish a chain of events
- 2.4 Identify potential fraud indicators
- 2.5 Identify whether policy exclusions apply
- 2.6 Recognise the need for further information and collect as appropriate
3. Appoint specialists to assist in complex claims assessment as required
- 3.1 Identify the need to appoint specialists to undertake claims assessment
- 3.2 Engage and brief appointed specialists as required
- 3.3 Monitor specialists’ activities to ensure adherence to timelines, procedures and ethical and regulatory requirements
- 3.4 Interpret and utilise specialists' reports
4. Assess and report on liability
- 4.1 Identify whether the terms and conditions of the policy have been verifiably met
- 4.2 Assess liability in accordance with the terms and conditions of the policy
- 4.3 Where the claim is not admitted, communicate the decision to appropriate stakeholders
- 4.4 Where the claim is admitted, calculate
5. Finalise claim payments
- 5.1 Advise client of the consequences of proceeding with the payment
- 5.2 Obtain policy discharge, as appropriate
- 5.3 Process payment in accordance with organisational authority levels, procedures and ethical and regulatory requirements
- 5.4 Update all appropriate records in accordance with procedures
- 5.5 Communicate settlement details to appropriate stakeholders in accordance with procedures and regulatory requirements
- 5.6 Initiate reinsurance recovery, if appropriate
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.
Life insurance policy may include:
disability income
endowment
term life (including terminal illness and Total and Permanent Disablement (TPD))
trauma
whole of life.
Valid must include:
policy exists
policy is current
claimant is legally authorised to act on the policy.
Documentation may include:
claim forms
records of death
records of disablement
other medical records
statutory declarations and other such records.
Complex claims may be claims that involve:
legal procedures, including those that involve working across international boundaries
long-term settlements
complex medical conditions
complex technical determinations
high monetary impact
an important client base.
Procedures may include:
organisational complaints handling processes
organisational customer service charter
organisational guidelines
organisational policy
organisational privacy and confidentiality guidelines
organisational procedures.
Payment criteria may include:
death (including terminal illness)
invalidity (permanent or temporary disability)
trauma.
Policy exclusions may include:
pre-existing illnesses
medical conditions
high risk activities.
Further information may include:
medical evidence
financial evidence
interview records
surveillance records.
Specialists may include:
advisers
investigators
medical and related practitioners
solicitors
forensic accountants.
Ethical and regulatory requirements may include:
corporations legislation
life insurance legislation
privacy legislation
Australian Securities and Investments Commission (ASIC) regulatory guides
industry Codes of Practice
professional Codes of Practice.
Appropriate stakeholders may include:
internal parties:
administrators
investigation agencies
medical officers
trustees
client and associated parties:
assignees
beneficiaries
executors
lawyers
life insured
next of kin
policy owners.
Consequences may include:
loss or reduction of future life insurance cover
termination of the present contract
inability to claim again for the same event under the present contract.
Policy discharge may include:
acceptance by client of amount of settlement
acceptance by client of timing of settlement
acceptance by client of terms of settlement.
Life insurance policy may include:
disability income
endowment
term life (including terminal illness and Total and Permanent Disablement (TPD))
trauma
whole of life.
Valid must include:
policy exists
policy is current
claimant is legally authorised to act on the policy.
Documentation may include:
claim forms
records of death
records of disablement
other medical records
statutory declarations and other such records.
Complex claims may be claims that involve:
legal procedures, including those that involve working across international boundaries
long-term settlements
complex medical conditions
complex technical determinations
high monetary impact
an important client base.
Procedures may include:
organisational complaints handling processes
organisational customer service charter
organisational guidelines
organisational policy
organisational privacy and confidentiality guidelines
organisational procedures.
Payment criteria may include:
death (including terminal illness)
invalidity (permanent or temporary disability)
trauma.
Policy exclusions may include:
pre-existing illnesses
medical conditions
high risk activities.
Further information may include:
medical evidence
financial evidence
interview records
surveillance records.
Specialists may include:
advisers
investigators
medical and related practitioners
solicitors
forensic accountants.
Ethical and regulatory requirements may include:
corporations legislation
life insurance legislation
privacy legislation
Australian Securities and Investments Commission (ASIC) regulatory guides
industry Codes of Practice
professional Codes of Practice.
Appropriate stakeholders may include:
internal parties:
administrators
investigation agencies
medical officers
trustees
client and associated parties:
assignees
beneficiaries
executors
lawyers
life insured
next of kin
policy owners.
Consequences may include:
loss or reduction of future life insurance cover
termination of the present contract
inability to claim again for the same event under the present contract.
Policy discharge may include:
acceptance by client of amount of settlement
acceptance by client of timing of settlement
acceptance by client of terms of settlement.
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:
apply highly developed analytical and administrative skills to complex claims assessment
maintain and apply a thorough understanding of all aspects of claims procedures and administrative requirements
perform tasks in accordance with relevant procedures and regulatory requirements.
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 records
access to organisational policies and procedures.
Method of assessment
A range of assessment methods should be used to assess practical skills and knowledge. The following examples 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
Overview of assessment
Critical aspects for assessment and evidence required to demonstrate competency in this unit
Evidence of the ability to:
apply highly developed analytical and administrative skills to complex claims assessment
maintain and apply a thorough understanding of all aspects of claims procedures and administrative requirements
perform tasks in accordance with relevant procedures and regulatory requirements.
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 records
access to organisational policies and procedures.
Method of assessment
A range of assessment methods should be used to assess practical skills and knowledge. The following examples 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
Replaced By
| State Code | National Code | Title | Type |
|---|---|---|---|
| AUR80 | FNSILF504 | Manage complex life insurance claims | Unit of competency |
| State Code | National Code | Title | Type |
|---|---|---|---|
| D776 | FNS51312 | Diploma of Life Insurance | Qualification |