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SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED UNIT STANDARD: 

Analyse a potentially fraudulent Long-Term insurance claim 
SAQA US ID UNIT STANDARD TITLE
120067  Analyse a potentially fraudulent 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 5  Level TBA: Pre-2009 was L5 
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 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 Claims Assessors who assess long-term risk.

The qualifying learner is capable of:
  • Exploring the concept of fraud in Long-Term insurance.
  • Analysing circumstantial evidence of fraud.
  • Analysing medical related inconsistencies in a Long-Term claim.
  • Applying technical knowledge to analyse a potentially fraudulent claim. 

  • 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:
  • Disability includes occupational and accidental disability.
  • Dread disease includes HIV/AIDS.
  • Inconsistencies in reports include, but are not limited to, inquest reports, police reports, eyewitness' statements, declarations, historical data and financial reports.
  • Irregularities in appearance of documentation include, but are not limited to, death reports, ID documents, marriage certificates and doctors' certificates. 

  • Specific Outcomes and Assessment Criteria: 

    SPECIFIC OUTCOME 1 
    Explore the concept of fraud in Long-Term insurance. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Actions that could constitute fraud are identified in cases of death. 

    ASSESSMENT CRITERION 2 
    Actions that could constitute fraud are identified in cases of disability and dread disease. 

    ASSESSMENT CRITERION 3 
    Actions that could constitute fraud are identified in relation to functional impairment. 

    ASSESSMENT CRITERION 4 
    The implications of the financial payout are investigated with reference to the client's financial status. 

    ASSESSMENT CRITERION 5 
    Possible motives for committing fraud are identified with reference to the beneficial and causal link. 

    SPECIFIC OUTCOME 2 
    Analyse the circumstantial evidence of fraud. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Inconsistencies in reports are identified with reference to the details of the case. 

    ASSESSMENT CRITERION 2 
    Irregularities are identified and substantiated in the appearance of legal and other documentation. 

    ASSESSMENT CRITERION 3 
    Other circumstantial evidence that could indicate potential fraud is identified with reference to time and place. 

    SPECIFIC OUTCOME 3 
    Analyse medical related inconsistencies in a Long-Term claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Indications of inconsistencies in medical reports are identified for five case studies. 

    ASSESSMENT CRITERION 2 
    Reports of a selected medical practitioner are analysed for consistency in style and format. 

    ASSESSMENT CRITERION 3 
    Patterns that could indicate possible fraudulent practice by a medical practitioner, funeral parlour or hospital are identified with examples. 

    ASSESSMENT CRITERION 4 
    The relationship between diagnosis and inception of a policy is identified in a potentially fraudulent claim. 

    SPECIFIC OUTCOME 4 
    Apply technical knowledge to analyse a potentially fraudulent claim. 

    ASSESSMENT CRITERIA
     

    ASSESSMENT CRITERION 1 
    Claims are checked for build up on the national database. 

    ASSESSMENT CRITERION 2 
    A cluster of factors that could indicate a fraudulent claim are identified and explored to expedite the further settlement of a claim. 


    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 about potentially fraudulent insurance claims.
  • The learner is able apply information and make recommendations about a potentially fraudulent claim. 

  • UNIT STANDARD CCFO COMMUNICATING 
    The learner is able communicate effectively in analysing, documenting and presenting information about a suspected fraudulent claim. 

    UNIT STANDARD CCFO SCIENCE 
    The learner is able using a computer effectively to identify over insurance on a national data base. 

    UNIT STANDARD CCFO CONTRIBUTING 
    The learner is able to see the relationship between circumstantial evidence, inconsistencies and irregularities and to identify beneficial and causal links in fraudulent Long-Term insurance claims. 

    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  49860   National Diploma: Financial Services: Long-Term Risk Assessment  Level 5  NQF Level 05  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. 



    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.