FSPITS20 - SQA Unit Code H Advise and support clients making a claim in complex insurance cases

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1 Advise and support clients making a claim in complex insurance cases Overview This unit is about giving clients guidance on complex claims and on processing claims settlements. Clients often need guidance as to whether a claim will be met in full and the best course of action for them, bearing in mind the need to keep the loss to a minimum and that a claim may have an effect upon their future insurance position. Details of the claim must be obtained and submitted to insurers or their delegated representatives, including any supporting documentation where necessary. You will check the progress of the claim, resolving any queries raised by the insurer. The unit also involves using communication styles that are appropriate to different people and situations, and also carrying out tasks with due regard to your organisation s policies and procedures. Claims are complex when they are not routine and cannot be dealt with mechanistically, for example, when a claim involves negotiation and/or is technically demanding involving complex legal issues or substantial financial implications. 1

2 Performance criteria You must be able to: P1 Confirm that the intimation of the claim is accurate, complete and recorded correctly P2 Interpret policy wordings and conditions to determine the validity of complex claims and their impact upon the claims handling process P3 Evaluate the circumstances of the claim and assess both the client and product provider requirements in relation to the claim P4 Explain the likely outcomes of the claim to the client within your organisation s timescales P5 Identify, investigate and resolve any issues relating to complex claims in line with your organisation s polices and procedures P6 Identify and advise clients of the prescribed or most appropriate mechanism for resolving claims settlement disputes P7 Resolve difficulties associated with the claim according to business agreements, legal requirements, market practices and the limit of your authority P8 Monitor the operation of delegated authority agreements, binding authorities or scheme arrangements to ensure that prescribed claims handling procedures are being followed P9 Address any deviations in procedures promptly and correctly P10 Arrange interim payment where appropriate P11 Advise clients and all relevant parties when complex claims are settled and ensure that settlement cheques are issued P12 Refer all matters that are beyond your level of authority promptly to the relevant person, setting out clearly the circumstances and reason for the referral, making reasoned recommendations regarding future actions P13 Dispatch the appropriate correspondence and/or documentation within the timescales required P14 Maintain accurate and complete records 2

3 Knowledge and understanding You need to know and understand: Financial services specific knowledge and understanding 1. The structure of the insurance market, and the roles and responsibilities of the various parties within it as they impact upon your activities 2. How different policy wordings and conditions impact upon the validity of claims and the claims handling process Context specific knowledge and understanding 3. Your organisation's requirements relating to the application of codes, laws and regulatory requirements, including ethical standards and health and safety, as they impact on advising and supporting clients making a claim in insurance cases 4. The policy cover, terms and conditions relevant to your work including standard and non-standard extensions and/or limitations 5. Sources of advice and information relevant to advising and supporting clients making a claim 6. Your organisation s policy and procedures regarding communicating with clients 7. Your organisation s customer service procedures including those for dealing with complaints 8. How to access and amend customer records 9. How to handle late notification of claims 10. Your organisation s procedures for recording claims settlements 11. The roles and functions of other parties involved in progressing insurance claims 12. The actions to be taken by the insured following a loss 13. The documentation and/or information required to process a claim 14. The limits of your authority and the action required when a claim falls outside those limits 3

4 Additional Information Behaviours You must demonstrate that: 1. You show integrity, fairness and consistency in decision-making 2. You use information and knowledge effectively, efficiently and ethically 3. You show an understanding of others and deal with them in a professional manner Links to other NOS Signposting other relevant NOS There is a close relationship between these NOS and the NOS for General Insurance, which have been developed separately by the Financial Skills Partnership (formerly Financial Services Skills Council). These can be accessed via In addition, the Sector Skills Body, Skills CFA, have developed NOS which include the competences required for leadership and management, as well as customer service. The website address for Skills CFA is 4

5 Developed by Financial Skills Partnership Version number 1 Date approved November 2012 Indicative review date Validity Status Originating organisation Original URN Relevant occupations Suite Key words November 2015 Current Original Financial Skills Partnership FSPITS20 Finance Insurance Technicians / Supervisors Advice regarding insurance; claim; claims; claims settlement; claimant; guidance on making insurance claims; insurance; insurance advice; insurance broking; insurance cover; insurance policy; insurance support; insured; policies; risk; uninsured 5