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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Assess a Long-term insurance claim 
SAQA US ID UNIT STANDARD TITLE
119263  Assess a Long-term insurance claim 
ORIGINATOR
SGB Insurance and Investment 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY
-  
FIELD SUBFIELD
Field 03 - Business, Commerce and Management Studies Finance, Economics and Accounting 
ABET BAND UNIT STANDARD TYPE PRE-2009 NQF LEVEL NQF LEVEL CREDITS
Undefined  Regular  Level 4  NQF Level 04 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Reregistered  2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2024-06-30   2027-06-30  

In all of the tables in this document, both the pre-2009 NQF Level and the NQF Level is shown. In the text (purpose statements, qualification rules, etc), any references to NQF Levels are to the pre-2009 levels unless specifically stated otherwise.  

This unit standard replaces: 
US ID Unit Standard Title Pre-2009 NQF Level NQF Level Credits Replacement Status
117104  Administer a long term insurance claim  Level 3  NQF Level 03  Complete 

PURPOSE OF THE UNIT STANDARD 
This unit standard is intended for Long-term claims assessors and will be useful for underwriters, broker supervisors, senior claims clerks, new business clerks, policy servicing personnel and learners in the industry who wish to follow a career path in Long-term claims assessing.

The qualifying learner is capable of:
  • Gathering and recording information to assess a Long-term claim.
  • Applying knowledge of Long-term risk in order to assess a Long-term claim.
  • Accessing and use appropriate media in order to assess a Long-term claim
  • Interpreting and evaluating data in order to assess a claim.
  • Making claims decision. 

  • LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
  • Communication at NQF Level 3.
  • Mathematical Literacy at NQF Level 3.
  • Computer Literacy at NQF Level 3.
  • Recognition of Prior Learning for 100 hours / ten credits workplace experience in Long-term claims assessing. 

  • UNIT STANDARD RANGE 
  • Sources of information or media include, but are not limited to: Company products; underwriter's guidelines; reinsurance guidelines, books, dictionaries; medical dictionaries; medical and pharmacological guides, books, journals; a register of doctors and dentists; underwriting reference library; LOA life registry system; Internet; Intranet; Extranet; relevant Insurance Acts; the Chief Medical Officer.
  • Protocols include, but are not limited to: Replacement agreement; disability agreement; dread disease, impairment, HIV/AIDS and other medical agreements.
  • Claims include death and benefits.
  • Limits of authority include authorisation procedures that may vary from one organisation to another and relate to the sum insured, product and experience. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Gather and record information to assess Long-term risk. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    A policy document is analysed to determine the type of claim. 

    ASSESSMENT CRITERION 2 
    A client's personal history is analysed to determine the validity of the benefits in a Long-term policy. 

    ASSESSMENT CRITERION 3 
    Additional information that may be required is identified and collected in accordance with the relevant protocols. 

    ASSESSMENT CRITERION 4 
    Statements of ownership are analysed to determine the legal claimant. 

    ASSESSMENT CRITERION 5 
    Agreements with reinsurers are interpreted to determine the organisation's responsibility for assessing the claim. 

    ASSESSMENT CRITERION 6 
    All relevant information is considered and used to create a synopsis. 

    SPECIFIC OUTCOME 2 
    Apply knowledge of Long-term risk to the assessment of a claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    The impact of health, occupation, avocations, and hazardous pursuits on the assessment of a claim is explained with examples. 

    ASSESSMENT CRITERION 2 
    The importance of the nominated occupation and duties on assessment of a claim is explained with reference to disability claims. 

    SPECIFIC OUTCOME 3 
    Access and use appropriate media in order to assess a Long-term claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    A variety of media are accessed and evaluated in terms of reliability and validity. 

    ASSESSMENT CRITERION 2 
    The consequences of not referring to appropriate media are explained with reference to risk to the insurer, the underwriter and the client. 

    ASSESSMENT CRITERION 3 
    Relevant LOA protocols are identified and applied to the assessment of Long-term risk. 

    ASSESSMENT CRITERION 4 
    Current and past underwriting standards are considered to determine potential non disclosure. 

    ASSESSMENT CRITERION 5 
    The role of the Ombudsman in Long-term insurance is explained with reference to claims disputes. 

    SPECIFIC OUTCOME 4 
    Interpret and evaluate data in order to assess a claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Knowledge of anatomy and physiology is applied to assess the validity of a claim. 

    ASSESSMENT CRITERION 2 
    Benefits affected by a specific claim are identified for three case studies. 

    ASSESSMENT CRITERION 3 
    Legal, financial, insurance and medical aspects of a claim are interpreted and a decision is made as to whether or not to refer a case to a senior claims assessor. 

    SPECIFIC OUTCOME 5 
    Make a claims decision. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    All the factors in a specific claim are considered in order to make a claims decision within own mandate. 

    ASSESSMENT CRITERION 2 
    The consequences of exceeding own limit of authority are explained with reference to the risk to the assessor, insurer and client. 

    ASSESSMENT CRITERION 3 
    The logic behind the claims decision is indicated and information to inform a client of a claims decision is collated for further processing. 

    ASSESSMENT CRITERION 4 
    Reasons for limits of authority imposed on claims assessor are explained and an indication is given of additional knowledge required to progress to the next level. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
  • An individual wishing to be assessed (including through RPL) against this unit standard may apply to an assessment agency, assessor or provider institution accredited by the relevant ETQA or an ETQA that has a Memorandum of Understanding with the relevant ETQA.
  • Anyone assessing a learner against this unit standard must be registered as an assessor with the relevant ETQA or with an ETQA that has a Memorandum of Understanding with the relevant ETQA.
  • Any institution offering learning that will enable achievement of this unit standard or assessing this unit standard must be accredited as a provider with the relevant ETQA, or with an ETQA that has a Memorandum of Understanding with the relevant ETQA.
  • Moderation of assessment will be conducted by the relevant ETQA according to the policies and guidelines for assessment and moderation of that ETQA, at its discretion, in terms of agreements reached about assessment and moderation between various ETQAs (including professional bodies). 

  • UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    The products marketed by a Long-term insurance organisation. 

    UNIT STANDARD DEVELOPMENTAL OUTCOME 
    N/A 

    UNIT STANDARD LINKAGES 
    N/A 


    Critical Cross-field Outcomes (CCFO): 

    UNIT STANDARD CCFO IDENTIFYING 
    The learner is able to see the world as a set of related systems in identifying potential fraud in applications and claims. 

    UNIT STANDARD CCFO ORGANISING 
    The learner is able to organise and manage his/her own activities responsibly and effectively to maximise productivity and provide an efficient service to clients. 

    UNIT STANDARD CCFO COLLECTING 
    The learner is able to collect, organise and evaluate information in order to make a claims decision. 

    UNIT STANDARD CCFO COMMUNICATING 
    The learner is able to communicate effectively in order to explain the logic behind a claims decision and in creating a written synopsis of information relevant to a case. 

    UNIT STANDARD CCFO SCIENCE 
    The learner is able to use a computer to assist in processing information required to assess a claim. 

    UNIT STANDARD CCFO DEMONSTRATING 
    The learner is able to recognise potential problems and make a decision to pay a claim or to refer a case to a senior underwriter. 

    UNIT STANDARD ASSESSOR CRITERIA 
    N/A 

    REREGISTRATION HISTORY 
    As per the SAQA Board decision/s at that time, this unit standard was Reregistered in 2012; 2015. 

    UNIT STANDARD NOTES 
    This unit standard replaces unit standard 117104, "Administer a long term insurance claim", Level 3, 2 credits. 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Elective  49529   Further Education and Training Certificate: Long-Term Risk Assessment  Level 4  NQF Level 04  Reregistered  2023-06-30  INSETA 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS UNIT STANDARD: 
    This information shows the current accreditations (i.e. those not past their accreditation end dates), and is the most complete record available to SAQA as of today. Some Primary or Delegated Quality Assurance Functionaries have a lag in their recording systems for provider accreditation, in turn leading to a lag in notifying SAQA of all the providers that they have accredited to offer qualifications and unit standards, as well as any extensions to accreditation end dates. The relevant Primary or Delegated Quality Assurance Functionary should be notified if a record appears to be missing from here.
     
    1. CKP Development Agency (Pty) Ltd. 
    2. Intec College 
    3. RJM Educational Consulting PTY LTD 
    4. The Institute of Health Risk Managers (Pty) Ltd 



    All qualifications and part qualifications registered on the National Qualifications Framework are public property. Thus the only payment that can be made for them is for service and reproduction. It is illegal to sell this material for profit. If the material is reproduced or quoted, the South African Qualifications Authority (SAQA) should be acknowledged as the source.