Overall job content
The overall role of The European Certified Insurance Claims Officer SQF 5 is to receive, investigate, evaluate and register claims infor-mation and documentation to assess the validity of a claim and to decide whether to accept and approve, in full or in part, or decline a claim in accordance with
- The terms and conditions of the policy
- The guidelines and practices of the company
- The codes of good practice of the industry
- The laws and regulations of the country
The profile covers any class of insurance, including reinsurance business and it is intended for a Level 5 Claims Officer dealing with all classes of business within the European insurance market and who may be representing both a local or foreign firm
The certificate holder does not have to have training within all insurance classes, but can be certified based on any class.Exams applying for accreditation of European Certified Insurance Claims Officer must meet the following criterias within knowledge, skills and competences.
The country’s legal principles, regulations, directives and code of ethics which may have effect on claims business.
Receive incoming notification of standard claims, generate corresponding records and take first action according to company guidelines
Act in a professional and ethical way.
The policy cover, terms and conditions relevant to your work including standard extensions and/or limitations.
Investigate and Evaluate claims
Work organized and systematically in order to record details of claims accurately; identify and request missing information and/or documentation.
Methods of claims assessment and investigation and the resources his/her organization has to conduct these activities.
Determine whether to approve in full or in part or decline, liability and/or payment of claims through considering factors under 2 above, within authorised limits
Handle claims economically, efficiently, promptly and fairly.
Methods and prescriptions of loss mitigation, recovery and salvage.
Approve the claim, fully or partly
Communicates with others in a supervisory position within his/her area of responsibility and authority
The organization’s policies and procedures for processing claims and payment of claims.
Reject the claim, fully or partly
Establish cause-and-effect relation in order to apply policy provisions, limits and excesses / franchises depending on proximate cause of the claim, indemnity requested, liability and/or negligence if applicable.
Reserving, subrogation, contribution principles.
Communicate effectively with the customer in order to;
Create a balance between interests of customer and the organization.
The organization’s customer service standards and procedures, including those for dealing with complaints.
Think critically in order to
Roles & responsibilities of various parties (agents, broker, etc) involved in or influencing the claims handling process
Use induction in order to identify claims which are valid or not valid through combining pieces of information and documentation.
The roles and functions of other parties engaged in claims activities (repairers, surveyors, loss adjusters, doctors,etc.)
Identify own need for continued education and learning.
Authorized experts, suppliers and/or repairers used by your organization to settle claims
Involve relevant parties in the claims settlement process and negotiate the solution
Company guidelines for how to handle suspicions of fraud
Signs of fraud in a claim and the action required.