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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD THAT HAS PASSED THE END DATE: 

Review a claims department to determine whether a business is protected by an organisation's business practices 
SAQA US ID UNIT STANDARD TITLE
120065  Review a claims department to determine whether a business is protected by an organisation's business practices 
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 5  Level TBA: Pre-2009 was L5  10 
REGISTRATION STATUS REGISTRATION START DATE REGISTRATION END DATE SAQA DECISION NUMBER
Passed the End Date -
Status was "Reregistered" 		 2018-07-01  2023-06-30  SAQA 06120/18 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2026-06-30   2029-06-30  

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 does not replace any other unit standard and is not replaced by any other unit standard. 

PURPOSE OF THE UNIT STANDARD 
This Unit Standard is intended for senior people in Long-Term insurance organisations who are responsible for ensuring sound business practice within a claims department.

The qualifying learner is capable of:
  • Evaluating the workflow in a claims department.
  • Analysing the effectiveness of a claims department structure.
  • Analysing people related risks in a claims department.
  • Recommending audit procedures for a claims department.
  • Evaluating the support systems available to a claims department. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    Learners should be competent in Communication and Mathematical Literacy at Level 4. It is assumed that learners are competent in the Unit Standards in the FETC: Long-Term Risk Assessment. 

    UNIT STANDARD RANGE 
    The typical scope of this Unit Standard is:
  • Workflow includes manual and electronic processes. 
    		•

    Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Evaluate the workflow in a claims department. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The workflow in a claims department is explained for a specific claims department. 

    ASSESSMENT CRITERION 2 
    The impact of technology on workflow is analysed in terms of efficiency and possible enhancement. 

    ASSESSMENT CRITERION 3 
    Gaps in the workflow are identified and their impact on the controls of the claims department are assessed in terms of exposure. 

    SPECIFIC OUTCOME 2 
    Analyse the effectiveness of a claims department structure. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The claims department organogram is interrogated in terms of critical or key responsibilities, accountability, strengths and weaknesses. 

    ASSESSMENT CRITERION 2 
    The effectiveness of individual work teams is evaluated with a view to optimising the use of resources. 

    SPECIFIC OUTCOME 3 
    Analyse people related risks in a claims department. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The key people in a claims department are identified in terms of their strengths and how critical each person is to the work of the claims department. 

    ASSESSMENT CRITERION 2 
    The profiles of individuals most appropriate to different positions within a claims department are identified and the potential risk to a business is explained if profiling is incorrect. 

    ASSESSMENT CRITERION 3 
    The importance of an effective performance management system is explained with reference to monitoring training needs and staff development, identifying inadequacies in workflow and protecting the organisation from poor risk management. 

    SPECIFIC OUTCOME 4 
    Recommend audit procedures for a claims department. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    Standard audit procedures in an organisation are identified and an indication is given of the objective of each audit and how each protects business practice. 

    ASSESSMENT CRITERION 2 
    Suggestions are made for financial or technical audits that could improve an organisation's business practice or increase the effectiveness of a claims department. 

    SPECIFIC OUTCOME 5 
    Evaluate the support systems available to a claims department. 

    ASSESSMENT CRITERIA     

    ASSESSMENT CRITERION 1 
    The role of the actuarial department in supporting the claims workflow is explained with reference to values and the consequences of changing values. 

    ASSESSMENT CRITERION 2 
    The role of forensics in supporting the claims workflow is explained with examples. 

    ASSESSMENT CRITERION 3 
    The role of legal support in supporting the claims workflow is explained with reference to contractual conflicts, litigation and legal opinion. 

    ASSESSMENT CRITERION 4 
    The role of the finance department in supporting the claims workflow is explained with reference to the payment of claims. 

    ASSESSMENT CRITERION 5 
    The strengths and weaknesses in support systems are evaluated with a view to reviewing ongoing current practice. 


    UNIT STANDARD ACCREDITATION AND MODERATION OPTIONS 
    This Unit Standard will be internally assessed by the provider and moderated by a moderator registered by a relevant accredited ETQA or an ETQA that has a Memorandum of Understanding with the relevant accredited ETQA. 

    UNIT STANDARD ESSENTIAL EMBEDDED KNOWLEDGE 
    N/A 

    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 identify problems, make decisions and recommendations and give feedback in reviewing a claims department. 

    UNIT STANDARD CCFO WORKING 
    The learner is able to work effectively as a member of a team in reviewing a claims department and evaluating the support systems. 

    UNIT STANDARD CCFO ORGANISING 
    Organise one's activities responsibly and effectively to maximise effectiveness and productivity. 

    UNIT STANDARD CCFO COLLECTING 
    The learner is able to critically evaluate information in order to evaluate workflow, analyse the effectiveness of a claims department and recommend audit procedures. 

    UNIT STANDARD CCFO COMMUNICATING 
    The learner is able to communicate effectively in reporting on the outcome of the review. 

    UNIT STANDARD CCFO SCIENCE 
    The learner is able to assess the effectiveness of an electronic system in maximising workflow in a department and identifying gaps. 

    UNIT STANDARD CCFO DEMONSTRATING 
    The learner is able to recognise the relationship between a good performance management system and risk in a claims department. 

    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 
    N/A 

    QUALIFICATIONS UTILISING THIS UNIT STANDARD: 
      ID QUALIFICATION TITLE PRE-2009 NQF LEVEL NQF LEVEL STATUS END DATE PRIMARY OR DELEGATED QA FUNCTIONARY
    Elective  57918   National Certificate: Short Term Insurance  Level 5  Level TBA: Pre-2009 was L5  Passed the End Date -
    Status was "Reregistered"     		 2023-06-30  INSETA 
    Elective  49860   National Diploma: Financial Services: Long-Term Risk Assessment  Level 5  NQF Level 05  Passed the End Date -
    Status was "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.
     
    NONE 


    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.