Unit of competency Outline

Date retreived
22/07/2026 9:44 AM AWST

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Manage complex life insurance claims

Manage complex life insurance claims

Unit of competency
National Code
FNSILF514
State Code
ODR88
TGA Status
Current
DTWD Status
Approved
Current Release Number
1.00
Current Release Date
27/01/2022
View on TGA
State Implementation and Classification
Approved Date
08/04/2022
Field of Education
081103 - Insurance And Actuarial Studies
Original Release Date
08/04/2022
Nominal Hours
55
Description
This unit describes the skills and knowledge required to manage people, information systems and other resources needed to manage life insurance claims of a complex nature.The unit applies to individuals who use specialised knowledge and skills to manage complex claims in the life insurance industry.No licensing, legislative or certification requirements apply to this unit at the time of publication.
Notes
Elements and Performance Criteria
1. Identify complexity of life insurance claim
  • 1.1 Review details of life insurance policy and determine complexity of claim according to organisational policies and procedures
  • 1.2 Document complexity of claim according to organisational policies and procedures
2. Conduct complex claim assessment
  • 2.1 Identify, review and apply policy terms, conditions and exclusions to claim according to organisational policies and procedures
  • 2.2 Analyse and document required information and evidence relevant to claim according to organisational policies and procedures
  • 2.3 Determine eligibility of claim according to policy terms and conditions
  • 2.4 Identify and analyse complex components of claim and document rationale for complexity
  • 2.5 Document additional factors and rationale for complexity of claim where required
  • 2.6 Document the need for further information and collect within required timeframes
3. Consult specialists regarding complex claims as required
  • 3.1 Identify need to appoint specialists to undertake claims assessment
  • 3.2 Engage and instruct appointed specialists as required
  • 3.3 Monitor specialist activities as required
  • 3.4 Document advice and information obtained from specialists and record subsequent actions required for completion of claims assessment
  • 3.5 Instruct specialists to address complexities according to codes of ethics and professional practice, and legislative and regulatory requirements
4. Assess and report on liability
  • 4.1 Review and analyse specialist information as required and determine if complexities have been addressed
  • 4.2 Determine liability according to information obtained from specialist as required
  • 4.3 Prepare recommendation and seek additional specialist advice where required
  • 4.4 Document rationale and communicate decision to required stakeholders
  • 4.5 Provide additional information as required and explain dispute process where a claim is not admitted
5. Finalise claim payments
  • 5.1 Determine authority level required to evaluate claim and review the decision as required
  • 5.2 Calculate and process payment according to organisational authority levels for approval, policies and procedures, code of ethics, and legislative and regulatory requirements, as required
  • 5.3 Communicate outcomes to required stakeholders
  • 5.4 Update policy and claim records and file documentation as required
  • 5.5 Communicate settlement details to required stakeholders according to organisational policies and procedures, and legislative and regulatory requirements
  • 5.6 Initiate reinsurance recovery as required
6. Finalise and close claim
  • 6.1 File required documentation on claim according to organisational policies and procedures
  • 6.2 Complete required medical, financial and closure fields in claims system according to organisational policies and procedures
  • 6.3 Update policy records in required systems according to organisational policies and procedures
  • 6.4 Close claim in required system and communicate closure to policy owner or authorised parties
No information
No information
Replaces
State Code National Code Title Type
AUR80 FNSILF504 Manage complex life insurance claims Unit of competency