rpl strategy & guidelines - moonstone...assessment, recognition of prior learning and credit...

Occupational Certificate: Insurance Claims Administrator SAQA ID: 99668, Credits: 131, NQF Level 4

RPL Strategy & Guidelines 5 November 2019 Version 3 Page 0 of 37

RPL Strategy & Guidelines

OCCUPATIONAL CERTIFICATE: INSURANCE CLAIMS

ADMINISTRATOR

SAQA 99668 NQF 4; CREDITS 131



TABLE OF CONTENTS

1. Legislative and Regulatory Framework

2. Definition of RPL

3. Underlying Principles for the Implementation of RPL

4. Qualifications and Part Qualifications on OQSF

5. RPL within the OQSF

6. Entry Level Requirements

7. Assessment Scope

8. RPL Process

9. External Integrated Summative Assessment

10. Knowledge Assessment

11. Practical Assessment

12. Workplace Assessment



LIST OF ACRONYMS

AQP Assessment Quality Partner

EISA External integrated summative assessment

NQF National Qualifications Framework

OQSF Occupational Qualifications Sub-Framework

QC Quality Council

QCTO Quality Council for Trades and Occupations

RPL Recognition of Prior Learning

SAQA South African Qualifications Authority

SDPs Skills Development Providers

SETAs Sector Education and Training Authorities



GLOSSARY OF TERMS

Access An entry to education and training of a particular qualification or

part qualification or entry to a final external summative

assessment.

Assessment The process of collecting evidence of candidate’s work to

measure and make judgements about the competence or non-

competence of specified National Qualifications Framework

occupational standards or qualifications and part qualifications.

Assessor A person who is registered by the relevant AQP in

accordance with established criteria to conduct internal and/or

external assessments for registered occupational qualifications

and part qualifications.

A person whose performance is being assessed by an assessor

registered with relevant institution.

Credit The value given within a learning programme for achieved

learning.

Informal Learning Learning that results from daily activities related to paid or

unpaid work, family or community life or leisure.

Formal Learning Learning that occurs in an organised and structured

education and training environment and that is explicitly

designated as such. Formal learning leads to the awarding of a

qualification or part qualification registered on the NQF.

Learning Outcomes A statement of measurable learning that describes what a

should know and/or be able to do as a result of learning.

Learning The acquisition of knowledge, skills, values and attitudes in a

particular occupation or trade

Monitoring A continuous process of the review of quality that can be

conducted internally and/or externally to recommend quality

improvements

Part Qualification An assessed unit of learning that is registered or to be

registered as part of qualification on the NQF with a clearly

defined purpose.

Professional Body SAQA Recognised body of expert practitioners in an

occupational field and includes an occupational body.



Recognised Prior Learning Principles and processes through which the prior

(RPL) knowledge and /or skills of a person are made visible and are

assessed for the purposes of certification, alternative access

and admission and future learning and development.

RPL Practitioner A person that functions in one or more aspects of RPL

provision, including policy development, advising, portfolio

course design and facilitation, assessment and moderation,

administration, monitoring and evaluation, research and

development.

Skills Development Providers A body which delivers learning programmes which culminate in

specified registered NQF occupational standards and

qualifications and part qualifications and manages the internal

assessment thereof

Work Experience Activities undertaken in the workplace, where acquisition of

skills, knowledge and attitudes are related to tasks, processes

and outcomes of a particular occupation.



1. LEGISLATIVE AND REGULATORY FRAMEWORK

In terms of the National Qualifications Act (Act 67 of 2008), QCTO is the Quality Council for trades

and Occupations as provided for in terms of the Skills Development Act of 1998.

In terms of Section 27(h) (ii), QCTO must develop and implement policy and criteria for

Assessment, Recognition of Prior Learning and Credit Accumulation and Transfer for the

qualifications and part qualification on the sub-framework.

The QCTO RPL Policy must be read in conjunction with the SAQA National Policy for the

Implementation of the Recognition of Prior Learning (March 2013) and the QCTO Assessment

Policy (19 March 2014).

The White Paper for Post-School Education (November 2013) explicitly states that Recognition of

Prior Learning (RPL) remains a key approach to redressing past injustices and recognising

competence gained through practical workplace learning and experience. It further states that RPL

will be applied more widely especially for young adults who wish to access programmes in colleges.

2. DEFINITION OF RPL

In terms of the SAQA definition, RPL is a process through which formal, non-formal and informal

learning are measured and mediated for recognition across different contexts and certified against

the requirements for credit, access, inclusion or advancement in the formal education and training

system or workplace.

The aim is to make it possible to obtain formal recognition for knowledge gained throughout life,

such as in workplaces and own reading or experiences. The RPL process also entails providing

support to ensure that knowledge is discovered and displayed in terms of a relevant qualification

registered on the National Qualifications Framework (NQF).

3. UNDERLYING PRINCIPLES FOR THE IMPLEMENTATION OF RPL

• be fair

• reliable

• valid

• ethical

• transparent

• be consistent across time, place

• use methodologies that are fit-for-purpose

• reflect a consistent level of higher cognitive challenge

• avoid unfair exclusion

• meet the quality standards of the part qualification



4. QUALIFICATIONS AND PART QUALIFICATIONS ON THE OQSF

The qualifications and part qualifications on the Occupational Qualifications Sub-framework (OQSF)

comprise Knowledge, Practical and Workplace experience components.

The requirements for delivery and assessment for the different modules within each component is

specified in an associated curriculum for the related qualification.

Obtaining an occupational qualification or part qualification requires a formal teaching and learning

environment, a practical / simulation environment (offered by accredited Skills Development

Provider(s)) as well as actual workplace experience (offered by Employer(s)) and a national

standardised External Integrated Summative Assessment (EISA) conducted at an accredited

assessment centre.

An EISA is compulsory for the awarding of the qualification or part qualification.

5. RPL WITHIN THE OQSF

The qualifications and part qualifications in the Occupational Qualifications Sub-Framework cover a

variety of contexts. This policy recognises that s might seek RPL for various reasons and depending

on various contexts. There are two main forms of RPL which reflect the different purposes and

different processes within which RPL takes place.

a) RPL for access:

Provides an alternative access route into a programme of learning/qualification for those who do not

meet the formal minimum requirements for admission RPL for access applies to learning

programmes offered by an accredited education institution, Skills Development provider or

workplace-based training provider.

b) RPL for credit:

To provide for the formal award of credits for, or towards a qualification or part-qualification

registered on the NQF.

The qualifications on the OQSF sub-framework are occupational and comprise Knowledge,

Practical and Workplace experience components. These qualifications would therefore require a

formal teaching and learning environment, a practical /simulation environment as well as actual

workplace experience. The knowledge and skills are assessed through a formal external

integrated summative assessment component. The Assessment Quality Partner must also design

and implement a tool to conduct Recognition of Prior Learning at external summative assessment

stage to support the candidates that might have difficulties to seat for formal external integrated

summative assessment.

Within the context of the OQSF, the recognition of prior learning is the evaluation and

acknowledgement of the knowledge and skills that a has gained to enable access to:

• Qualifications on the OQSF

• The External Integrated Summative Assessment.



6. ENTRY LEVEL REQUIREMENTS

RPL for credit provides for the formal award of credits for, or towards a qualification or part-

qualification registered on the NQF. RPL for credit may only be conducted against the assessment

specifications for the relevant qualification or part qualification.

Candidates requiring RPL for credit must undergo an EISA conducted at a QCTO accredited

assessment centre and normally would be required to go through an RPL process for access first.

The Assessment Quality Partner must design and implement a tool to conduct RPL assessments at

external summative assessment stage to support the candidates that might have difficulties to sit for

formal External Integrated Summative Assessment.

A candidate wishing to be RPL’ed for credits against a part qualification needs an NQF Level 4

qualification or a minimum of 3 years relevant practical working experience in the same field as the

part qualification being RPL’ed. This experience should be continuous practical experience not more

than 1 year prior to application.

7. ASSESSMENT SCOPE

The purpose of this qualification is to enable the candidate to have an in-depth knowledge and

understanding of assessing claims within a relevant insurance subsector. The Insurance Claims

Assessor assesses the validity of the claim against the contract and legislation in order to

determine/ recommend whether to settle or repudiate a claim.

The process of RPL requires the candidate to produce a balance between current and historical

naturally occurring evidence as proof of ability to apply the skill and knowledge that the candidate

has obtained through various media of learning.

The RPL process also requires the candidate to reflect on the learning and application that has

ensued and assesses the candidate’s level of in-depth understanding and knowledge of the subject

matter.

The assessment will consist of a Knowledge, Practical and Workplace Assessment. After successful

completion of these components a candidate will qualify to enter the External Integrated Summative

Assessment.

The qualification consists of four parts:

• Statutory Insurance / Road Accident Fund

• Long-Term Insurance

• Short-Term Insurance

• Health Care Insurance

The Knowledge and Practical Assessments are compulsory, whereas the Workplace Assessment is

sector specific.



a. Knowledge Modules:

The purpose of this module is to introduce the candidate to insurance and general claims

processing. The Knowledge Assessment will consist of a written assessment using multiple choice

questions that will test their knowledge.

• Basics of insurance, NQF Level 04, Credits 17

• Claims handling procedures, NQF Level 04, Credits 11

• Professional Behaviour and Financial literacy, NQF Level 04, Credits 13

Total number of credits for Knowledge Modules: 41

During the self-assessment should the candidate assess themself as having limited or no knowledge

of a specific topic, they should do self-study and ensure that they are familiar with contents.

Candidates must obtain a minimum of 50% to successfully complete this module.

b. Practical Skill Modules:

The practical modules will be assessed in the form of a case study in the workplace. The candidate

will be required to use one or more claims that they receive during their normal workflow to be

assessed by their supervisor/mentor. There will be a checklist to be signed off by themselves and

their supervisor/mentor and submitted together with relevant documentation. Candidates are

required to sign a Declaration of Authenticity to verify that the Practical Evidence is their own work.

• Receive a basic claim in order to assess the loss/ damage and verify the validity of the

contract, NQF Level 04, Credits 20

• Assess the claim to determine validity, NQF Level 04, Credits 10

• Recommend to settle, conditionally settle or reject the claim, NQF Level 04, Credits 5

• Comment on risk improvements where applicable, NQF Level 04, Credits 5

Total number of credits for Practical Skill Modules: 40

c. Workplace Assessment:

The workplace assessment is a document that must be signed off by their supervisor/mentor. It is

important to know that the qualification is made up of four part qualifications:


• Long-Term Insurance

• Short-Term Insurance


The candidate will only complete the questionnaire for one of these part qualifications. The candidate

must ensure it is the qualification that they registered for.



The purpose of this task is to provide the candidate with an opportunity to present workplace related

evidence of applied competence against the Exit Level Outcomes and related qualification

assessment criteria for the RPL assessment in the Occupational Certificate: Insurance Claims

Administrator (Insurance Claims Assessor), NQF Level 4.

The candidate is required to identify areas where workplace evidence can be produced and include

authentic copies thereof.

Candidates are required to sign a Declaration of Authenticity to verify that the Workplace Evidence is

their own work.

1) Statutory Insurance / Road Accident Fund:

• Verification processes regarding Statutory claims, NQF Level 4, Credits 10

• Assessment processes regarding Statutory claims, NQF Level 4, Credits 15

• Finalisation processes of Statutory claims, NQF Level 4, Credits 25

2) Long-term Insurance:

• Receipt of notifications and verification processes regarding Long-term insurance,

NQF Level 4, Credits 15

• Assessment process regarding Long-term insurance, NQF Level 4, Credits 20

• Decisions for payments to relevant stakeholders regarding Long-term insurance,

NQF Level 4, Credits 15

3) Short-term Insurance:

• Verification processes regarding Short-term insurance, NQF Level 4, Credits 15

• Participation of assessment process regarding Short-term insurance, NQF Level 4,

Credits 25

• Making recommendation regarding Short-term insurance, NQF Level 4, Credits 10

4) Health Care Insurance:

• Receipt of notifications and verification processes regarding Health Care, NQF Level 4,

Credits 20

• Assessment processes regarding Health Care claim, NQF Level 4, Credits 25

• Decisions for payments to relevant stakeholders regarding Health Care claims, NQF Level 4,

Credits 5



8. THE RPL PROCESS OVERVIEW



How do I quality for RPL to obtain this qualification?

If the answers to the below questions are yes, proceed with the process.

1. Do I have a minimum NQF Level 4 Qualification? Do I have a minimum of 3

years’ experience in a claim’s environment?

2. Was this experience relevant practical working experience?

3. Was this relevant to the field of one of the specified part qualifications?

4. Was this experience continuous not more than 1 year prior to this date?

Complete the Self-Assessment Questionnaire.

Make sure that you are competent and well experienced in the topics of the

assessment criteria as set out in the Self-Assessment Questionnaire.

Complete the Knowledge Questionnaire.

Your Assessment Quality Partner will provide you with a Knowledge Assessment

Questionnaire based on the assessment criteria to assess your knowledge as

claims administrator.

Complete the Practical- and Workplace Questionnaire

Your Assessment Quality Partner will provide you with a Practical- and

Workplace Assessment Questionnaire to assess your workplace knowledge as

claims administrator. The supporting documents to each of the assessment

criteria are obtainable from your workplace.

Your Supervisor will sign off that you adhere to all the assessment criteria

in the Practical- and Workplace Assessment Questionnaire

The candidate’s completed assessment instruments will be assessed by the

AQP. If the candidate is found competent by the AQP, the candidate will be

registered to write the final External Integrated Summative Assessment.

If the candidate is found competent for the completed assessments in Step 4, the

candidate will be registered to write the final External Integrated Summative

Assessment.

The External Integrated Summative Assessment (EISA) is a single national

assessment leading to the awarding of an Occupational Certificate.

Step 1

Step 2

Step 3

Step 4

Step 5



Explaining the steps:

Step 1:

If the answers to the below questions are yes, the candidate can proceed with the process:

• Do I have a minimum NQF Level 4 Qualification? Do I have a minimum of 3 years’

experience in a claim’s environment?

• Was this experience relevant practical working experience?

• Was this relevant to the field of one of the specified part qualifications?

• Was this experience continuous not more than 1 year prior to this date?

Step 2:

Complete the Self-Assessment Questionnaire.

The candidate must ensure that they are competent and well experienced in the topics of the

assessment criteria as set out in the Self-Assessment Questionnaire.

The qualification is made up of four part qualifications:



• Long-term Insurance

• Short-term Insurance

They will only complete the Workplace questionnaire for one of these part qualifications. The

Knowledge and Practical modules are generic modules.

Step 3:

The candidate can contact Moonstone Information Refinery at [email protected] and

register for RPL on the Claims Qualification. After registration they will receive all the necessary

communication on the way forward. The cost will be R7 500.00. This will include the R2 500.00 for

the External Integrated Summative Assessment.

Step 4:

The candidate must work through the Orientation Guide where they will receive an overview of the

RPL process and some guidance on the completion of their evidence. All relevant timeframes will

be discussed.

Step 5:

Complete the Knowledge Assessment on the Moonstone LMS. The Assessment Quality Partner will

provide them with a Knowledge Assessment based on the assessment criteria to assess their

knowledge as claims administrator. The candidate will need to achieve an overall 50% to pass the

Knowledge Assessment.

mailto:[email protected]



Step 6:

Complete the Practical- and Workplace Assessments in the workplace.

The Assessment Quality Partner will provide the candidate with a Practical- and Workplace

Assessment Questionnaire to assess their workplace knowledge as claims administrator. The

supporting documents to each of the assessment criteria are obtainable from the workplace and

should be recorded in a portfolio. It is important to know that they should submit their completed

Portfolio of Evidence.

The Supervisor/Mentor will sign off that the candidate adhere to all the assessment criteria in the

Practical- and Workplace Assessment.

The candidate’s completed assessment instruments will be assessed by the AQP. If the candidate

is found competent by the AQP, the candidate will be registered to write the final External Integrated

Summative Assessment.

Assessment results will be e-mailed to candidates within 21 days after final submission.

If the candidate is found competent for the completed assessments in, they will be registered to

write the final External Integrated Summative Assessment.

The candidate will have the opportunity to appeal any assessment outcome during the process.

• Candidates may not act in a dishonest way with regard to any assessment.

• Timelines for POE submissions will be agreed upon during the orientation session and must be

adhere to.

• Candidates need to achieve an overall 50% to pass the Knowledge Assessment. They have 1

hour to complete the Knowledge Assessment. If the candidate fails to complete the

assessment within 1 hour, they will automatically be logged out of the assessment and they will

obtain a FAILED mark.

• Candidates will be allowed one re-assessment for the Knowledge Assessment at an additional

cost of R250.

• Candidates have 40 days to complete the Practical Assessment. After completion, they must

submit assessment document toghether with relevent documentation used during the

assessment on the Moonstone LMS. If no documents are uploaded on or before the specified

date, the candidate will automatically obtain a NOT YET COMPETENT outcome.

• Candidates have 40 days to complete the Workplace Assessment. After completion, submit

assessment document toghether with relevent documentation used during the assessment on

the Moonstone LMS. If no documents are uploaded on or before the specified date, the

candidate will automatically obtain a NOT YET COMPETENT outcome.

• There will be no additional cost should additional evidence be required for the practical and

workplace modules. The candidate will have 3 opportunities to submit the correct Practical and

Workplace evidence.



9. EXTERNAL INTERGRATED SUMMATIVE ASSESSMENT (EISA)

The purpose is of the EISA is to promote consistency and credibility of the occupational

qualifications issued. The criteria for this assessment are specified in the assessment specifications

document and in the occupational qualifications document.

The external assessment will be conducted by means of written assessments at accredited

assessment centres approved by Moonstone Information Refinery (AQP) over a period of not more

than 3 hours.

In order to qualify for access to the External Integrated Summative Assessment, the will have

successfully completed all components of the qualification:

• The Knowledge Modules

• The Practical Skills Modules

• Workplace Experience

• Foundational Learning Competence (two learning areas: Communication and

Mathematical literacy)

After successful completion of the EISA certification will be done by the QCTO.

Once candidates have met the requirements of RPL and EISA by Moonstone, the AQP, they will be

certified by the QCTO once verification is successfully completed.

Please note:

The QCTO requires that all candidates undertaking occupational programmes registered on NQF

levels 3 - 4 be assessed against the Foundational Learning Competence (FLC) part qualifications

and if found “not yet competent” must complete the specified communication and mathematical

literacy courses. These are not an entry requirement but must be completed prior to registering for

the EISA qualification. Without the FLC, the QCTO will also not issue the final certificate.

The completion of this curriculum is over and above the Knowledge, Practical and Workplace

components. If the candidate has obtained their Grade 12 qualification, they are exempt from this

component.

If candidates have obtained their Grade 12 qualification, and they do not have their Grade 12

certificate, they need to contact the institution where they obtained the original certificate.

If the candidate did not completed Grade 12, what is the process they need to follow to ensure they

are competent in FLC?

The FLC is a challenge assessment so the candidate can write whenever they feel ready to. The

first possibility is to conduct a placement assessment. The placement assessment will determine if

the candidate is ready to write the FLC examination or if they require training in the learning

programme first. The placement assessment is a 3 hour written assessment and is implemented

across the two learning areas. This is an optional assessment that the IEB offers.



The second possibility is that candidates register directly for the FLC assessment. If they pass, they

achieve the credits. If they do not pass, they can get training and then rewrite. The Summative

Assessment is a 2,5 hour written assessment. There is a separate assessment per learning area –

Communication in English and Mathematical Literacy. The IEB is the AQP for this assessment and

needs to be completed to achieve the competence in the qualification.

For further information regarding registration, the candidate can contact

Inida Nofotyela on 011 483 9700 or e-mail [email protected] or

Sandile Buthelezi on 011 4839700 or e-mail [email protected]

Please note that the IEB do not offer the actual training but they have a list of training providers that

can be contacted if required on their website: www.ieb.co.za

Moonstone Information Refinery (Pty) Ltd is an Assessment Quality Partner

(AQP000330N2014010101) with the QCTO and not a Skills Development Partner and therefore not

in a position to provide any training to close assessment gaps.

Should a candidate not be successful with a Knowledge Assessment it will be their own

responsibility to either register with a Skills Development Provider for up-skilling or do self-study and

research.

Should a candidate not be successful with either the Practical or Workplace Assessment the

candidate will have to make arrangements within the workplace to gain the necessary exposure.

Assessment Standards

Integrated Assessment Focus Area 1: Identify, analyse and verify the validity of claims in the

relevant insurance context

Associated Assessment Criteria:

• Policy status, premium payment, policy holder details, co-insured and beneficiary to the policy

are verified and confirmed.

• Insured event is verified.

• Claims history, security requirements, loadings and exclusions applicable to policy are identified

and analysed

Integrated Assessment Focus Area 2: Assess, calculate and complete claims in the relevant

insurance context


• Claims assessment form and inventory are completed.

• Prescription periods are calculated.

• Extent of claim is validated, and quantum of the claim is calculated.



https://www.ieb.co.za/pages/foundationallearningcompetence)



Integrated Assessment Focus Area 3: Finalise claims in the relevant insurance context


• Risk improvement recommendations and claims recommendations are finalised

• Decisions on outcome of claims are finalised

Pass rate for the EISA are 70%

The AQP will provide the feedback on the outcome of the EISA via e-mail to the candidate

and certification will be done by the QCTO.



KNOWLEDGE MODULE DETAILS

MODULES, TOPICS AND ASSESSMENT CRITERIA SELF ASSESSMENT BY CANDIDATE

Modules Topics Assessment Criteria RPL EVIDENCE

Yes No Evidence Comment

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y IAC0101 List and discuss the benefits of

having an insurance

IAC0102 List and discuss the various

types of insurance making use of

examples (short term, long term, medical

covers and statutory insurance)

IAC0103 Define risks in relation to the

type of insurance

IAC0104 Given a scenario, identify the

risks and provide options to minimize the

risk

IAC0105 List and discuss the type of

benefits for the different types of cover

(insurance)

IAC0106 Define basic investment and

economic principles

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IAC0201 List and discuss internal role

players within the claims environment

with regard to their respective roles

(legal, sales, admin, forensics,

underwriting, Specialists, product

developers, etc.)

IAC0202 List and discuss external role

players within the claims environment in

relation to their roles (independent

medical referrals, brokers, attorneys,

other companies, etc.)

IAC0203 Elaborate on the assessor’s

role within the claims environment

IAC0204 Explain the assessor’s role and

responsibilities in relation to other role-

players such as legal, sales, admin,

forensics, underwriting, specialists,

product developers, etc.) focusing

discussions on at least two role-players



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IAC0301 Discuss the regulatory

environment within which a claims

assessor operates

IAC0302 Differentiate between industry

associations professional bodies

IAC0303 Identify the relevant codes

applicable to the different insurance sub-

sectors and discuss whether they are

legally binding or not (FAIS GCOC is for

instance legally binding whereas ASISA/

SAIA)

IAC0304 Identify the different OMBUD

schemes and discuss whether they are

statutory or voluntary

IAC0305 Explain the role and purpose of

alternative dispute resolution bodies

IAC0306 Identify the primary legislation

for the different sub-sectors

IAC0307 Distinguish primary legislation

from legislation that governs conduct and

relations

IAC0308 Explain the meaning of ethics

and integrity using examples of unethical

behaviour and possible consequences

as found in the legislation /

organisational policy / (fraud, processing

of false insurance claims)

IAC0309 Explain the three sources of

ethical standards (there are 3: law,

policies & procedures and moral stance

(personal value systems)

IAC0310 Explain the meaning of the

concepts 'confidentiality, respect' in

relation to client information



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IAC0401 Define an insurance contract in

relation to 'offer and acceptance'

IAC0402 List and discuss the elements

of a delictual act (intent/ negligence

conduct, wrongfulness, causation, loss

or harm and fault)

IAC0403 Differentiate between a

delictual act and contractual breach

IAC0404 Explain law of delict as it

relates to the insurance (strict liability,

vicarious liability, defences, remedies

and interest)

IAC0405 Define elements of a contract in

order for it to be legally binding

(contractual capacity, consensus,

physical possibility, legality, formalities)

IAC0406 Explain the following aspects of

an insurance contract (good faith,

reasonable man test, warranties,

interpretation of contract)

IAC0407 Discuss conditions for

rectification, discharge (contract ending)

and breach of contract and the

consequences of each

IAC0408 Identify and explain the parties

to an insurance contract (owner,

beneficiary, insured, cessionary, 3rd

party, different types of legal person-

natural person and juristic person, trusts

and sole proprietary

IAC0409 Define and apply legal

principles in relation to a claim



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IAC0501 Differentiate between insurable

interest in terms of long-term insurance

and short-term insurance by making use

of examples

IAC0502 Define the concept of an

'insured event' and its relevance to the

claim

IAC0503 Define 'over and under

insurance' and describe the

consequences thereof

IAC0504 Explain with examples the

concepts 'disclosures, material non-

disclosure and misrepresentation' and

the consequences thereof

IAC0505 Explain the differences

between indemnity and compensation in

relation to insurance claims

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IAC0101 Discuss the manners/ ways in

which a claim may be received and the

immediate actions required

IAC0102 Identify the type of claim to

determine supporting documentation

(including notification of statutory

insurance)

IAC0103 Discuss the importance of

specifying timeframes in respect of

various claims

IAC0104 Discuss the key considerations

to be taken into account when assessing

a claim (validity of the contract, benefits

of the contract and events covered,

parties to the contract, exclusions, sums

insured, underwriting, and premiums

status, interpretation of the specialists/

expert’s reports)

IAC0105 Calculate and verify the

claimed amount versus the adjusted

amount (benefit amount) taking into

consideration: average, contribution,

excess, betterment, salvage, TAX, VAT,

reconstruction/ risk management etc.

IAC0106 Describe the steps to follow in

finalizing a claim (feedback, claims, and

reporting



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ss

es

as g

ove

rned

by l

eg

isla

tio

n f

or

sch

em

e

IAC0201 Define the concept 'prescription

period' in relation insurance claims

IAC0202 Explain the prescription periods

as they apply to various claims

IAC0203 Describe the policy holder

protection and scheme rules and the

consequences of not adhering to the

rules

IAC0204 Explain the importance of the

contract conditions in relation to the

claims outcome

KM

-02-K

T03:

Co

mp

lain

ts

pro

ce

du

res

IAC0301 Explain the differences

between queries, complaints, disputes

and escalations using examples

IAC0302 List and explain the various

regulatory complaint procedures to be

adhered to when handling complaints

IAC0303 List and explain the various

processes to follow when handling

complaints (sources of complaints may

include internal, external and media)

4312

040

00-K

M-0

3,

Pro

fes

sio

nal B

eh

avio

ur

an

d F

inan

cia

l lite

racy,

NQ

F L

evel

04,

Cre

dit

s 1

3

KM

-03-K

T01:

Intr

od

uc

tio

n t

o B

usin

es

s C

om

mu

nic

ati

on

Skill

IAC0101 Discuss the main elements of

acceptable business writing (report,

letters, e-mail, etc.) making use of

examples

IAC0102 Explain the main elements of

communication skills to be employed in

order to ensure effective communication

with a customer

IAC0103 Define the main aspects of

good customer service (introduction and

greetings, obtain the necessary

information, provide the required

assistance, provide feedback and follow

up)

IAC0104 Explain the main principles of

conflict management

IAC0105 Explain the main principles of

negotiation

IAC0106 Given a scenario, explain how

a claims assessor will make an

appropriate decision based on the

gathered / provided facts



431204000-K

M-0

3, P

rofe

ss

ion

al B

eh

avio

ur

an

d F

inan

cia

l

lite

rac

y, N

QF

Lev

el

04, C

red

its 1

3

IAC0107 Discuss acceptable business

etiquette with regard to grooming,

presenting one-self interpersonal

relationships and conversational skills

IAC0108 Discuss acceptable meeting

protocol/ etiquette

KM

-03-K

T02:

Ba

sic

Fin

an

cia

l

Lit

era

cy

IAC0201 Identify the various formulae to

use in calculating the settlement amount

IAC0202 Explain how a claim assessor

should calculate basic claim ratios /

quantum/ amount

IAC0203 Interpret financial statements to

determine benefit allocation, earning

status, loss of income, business

overheads and interruptions

IAC0204 Identify and explain the

consequences of incorrect claim

assessor’s decisions regarding the

organisation's performance



PRACTICAL MODULE DETAILS

MODULES, PRACTICAL SKILLS AND

ASSESSMENT CRITERIA SELF ASSESSMENT BY CANDIDATE

Modules Practical

Skills Assessment Criteria

RPL EVIDENCE

Yes No Evidence Comments

431204000

-PM

-01, R

ece

ive

a b

as

ic c

laim

in

ord

er

to

ass

es

s t

he l

oss/

dam

ag

e a

nd

ve

rify

th

e v

ali

dit

y o

f th

e

co

ntr

act,

NQ

F L

evel 0

4, C

red

its

20

PM

-01-P

S0

1:

De

term

ine

wh

eth

er

the e

ve

nt

is in

su

red

un

der

valid

po

lic

y c

on

tra

ct

IAC0101 Policy and Act used to verify

information related to the claimant

(number and type)

IAC0102 The insured event is

established and the claim has

occurred within the terms of the

contract

IAC0103 Claim’s history and

underwriting acceptance of risk

verified

IAC0104 Insurable interest verified

IAC0105 Possible fraudulent indicator

(red flags) checked

IAC0106 Existence of other

insurances (reassurance, dual

insurance, other policies, etc.)

confirmed

IAC0107 More information (evidence)

or input has been requested where

necessary (or further investigation)

431204000

-PM

-02, A

sse

ss

the c

laim

to

dete

rmin

e

vali

dit

y,

NQ

F L

evel

04,

Cre

dit

s 1

0

PM

-02

-PS

01:

Ev

alu

ate

info

rma

tio

n t

o m

ak

e a

dec

isio

n

IAC0101 The extent of the claim has

been validated

IAC0102 Quantum has been

formulated (quantified) to determine

the cost of the claim

IAC0103 Referrals for further

information or investigation have been

done where necessary



431204000-P

M-0

3, R

eco

mm

en

d

to s

ett

le, c

on

dit

ion

all

y s

ett

le o

r

reje

ct

the c

laim

,

NQ

F L

evel

04,

Cre

dit

s 5

PM

-03-P

S0

1:

Ma

ke

a d

ec

isio

n

or

rec

om

me

nd

ati

on

IAC0101 A recommendation or decision

to settle has been made


to reject has been made


to conditionally settle has been made

431204000-P

M-0

4, C

om

me

nt

on

ris

k im

pro

vem

en

ts w

here

ap

pli

cab

le,

NQ

F L

evel

04,

Cre

dit

s 5

PM

-04-P

S0

1:

Mit

igate

fu

ture

ris

ks

IAC0101 Moral and physical risk

improvements are recommended

IAC0102 Referrals for recoveries and

salvage (subrogation) are made when

necessary

IAC0103 Amendments to the policy are

recommended

Step 4:

Compile a portfolio of evidence in the particular part qualification. This will be practical natural

occurring work evidence. The candidate must use the specific matrix and ensure that suitable

evidence is included in the portfolio.

1. All evidence must be their own work.

2. All evidence must not be older than 12 months.

3. All evidence must be signed off by their supervisor/mentor.

4. A declaration must be signed by the candidate and their supervisor/mentor stating that the

work is authentic and valid.



WORK EXPERIENCE DETAILS

STATUATORY INSURANCE /

ROAD ACCIDENT FUND

COMPLETION BY

CANDIDATE

COMPLETION

WORKPLACE MENTOR

Modules Work

Experiences

Main Work

Activities

RPL

Applicable

Evidence

Document CONFIRM

SIGNATURE

Yes No Document

Description Yes/No

431204000

-WM

-01,

Ve

rifi

cati

on

pro

ce

ss

es r

eg

ard

ing

Sta

tuto

ry c

laim

s,

NQ

F L

evel

4,

Cre

dit

s 1

0

WM

-01-W

E01

:

Pa

rtic

ipati

on

of

ass

es

sm

en

t

pro

ce

ss

WA0101 Participate

in induction

(orientation) process

WA0102 Receive

allocated claims for

assessment

WM

-01-W

E02

: P

art

icip

ate

in

vali

dati

on

pro

ce

sse

s w

ith

in 6

0 d

ays

of

lod

gem

en

t o

f th

e c

laim

WA0201 Check for

substantial

compliance with the

Act

WA0202 Calculate

prescription periods

WA0203 Check for

duplicate claims

WA0204 Do a home

affairs check

(mortality)

WA0205 Check for

possible fraud

WA0206

Acknowledge the

claim or object to

validity of the claim or

repudiate the claim

WA0207 Request

outstanding

documentation if a

valid claim was

lodged



431204000-W

M-0

5,

As

se

ss

me

nt

pro

ce

ss

es r

eg

ard

ing

Sta

tuto

ry c

laim

s,

NQ

F L

evel

4,

Cre

dit

s 1

5

WM

-05-W

E01

: P

art

icip

ate

in

qu

an

tifi

cati

on

of

cla

ims

wit

hin

120

da

ys o

f lo

dg

em

en

t o

f th

e c

laim

WA0101 Scrutinise

the documents on

file

WA0102 Determine

heads of damage

(category of

compensation

claim)

WA0103 Request

outstanding

documentation

when applicable

WA0104 Verify the

link between the

accident and

injury/death

WA0105 Verify

status of the third

party with home

affairs

WA0106 Verify if

the medical

treatment is

sufficient

WA0107 Evaluate

the serious injury

assessment form

WA0108 Participate

in the appointment

of relevant experts

WA0109 Quantify

value of benefits on

receipt of reports

WA0110 Consider

any prior payments

linked to the same

accident

WA0111 Participate

in processes

specific to each

heads of damage



431204000-W

M-0

5,

As

se

ss

me

nt

pro

ce

ss

es r

eg

ard

ing

Sta

tuto

ry c

laim

s,

NQ

F L

evel

4,

Cre

dit

s 1

5

WM

-05-W

E01

: P

art

icip

ate

in

qu

an

tifi

cati

on

of

cla

ims

wit

hin

120

da

ys

of

lod

gem

en

t o

f th

e

cla

im

WA0112 Participate

in quantum and/or

merits decision

making processes

WA0113 Participate

in the preparation of

an offer of

settlement

WA0114 Review

the acceptance or

rejection of the

settlement

WA0115 Draw up

an undertaking for

future medical

expenses

WM

-05-W

E02

: P

art

icip

ate

in

th

e p

ost

cla

im s

ett

lem

en

t p

roce

ss

es

WA0201

Acknowledge

receipt of

undertaking

WA0202 Instruct a

case manager to

prepare a relevant

treatment plan

WA0203 Request

and scrutinize the

file

WA0204 Assess the

undertaking and

prepare an excel file

WA0205 Determine

the clinical

appropriateness

and accuracy of the

invoice

WA0206 Capture

relevant details on

excel file

WA0207 Approve

payment of invoice

or authorization of

treatment

WA0208 Initiate

payment of invoice



431204000

-WM

-09,

Fin

ali

sati

on

pro

ce

ss

es o

f

Sta

tuto

ry c

laim

s,

NQ

F L

evel

4,

Cre

dit

s 2

5

WM

-09-W

E01

: P

art

icip

ate

in

th

e c

laim

fin

ali

zati

on

pro

ce

ss w

ith

in 3

mo

nth

s o

f

cla

ims

sett

lem

en

t

WA0101 Request

the allocated file

from the relevant

department

WA0102 Obtain

proof of payment

from relevant

departments

WA0103 Check that

relevant outcome

was achieved

WA0104 Escalate

any outstanding

payments

WA0105 Finalize

the claim




HEALTH CARE INSURANCE COMPLETION BY

CANDIDATE

COMPLETION

WORKPLACE MENTOR

Modules Work

Experiences

Main Work

Activities

RPL

Applicable

Evidence

Document CONFIRM

SIGNATURE

Yes No Document

Description Yes/No

431204000-W

M-0

2,

Re

ce

ipt

of

no

tifi

cati

on

s a

nd

ve

rifi

cati

on

pro

ce

ss

es

re

gard

ing

He

alt

h C

are

,

NQ

F L

evel

4,

Cre

dit

s 2

0

WM

-02-W

E01

: P

art

icip

ate

in

in

du

cti

on

(ori

en

tati

on

) p

roce

ss

WA0101 Familiarise

oneself with

organisational

processes and

procedures

WA0103 Participate

in a variety of

applicable in-house

training

programmes

WA0104 Participate

in departmental

meetings and / or

one-on-one

coaching sessions

431204000-W

M-0

2,

Re

ce

ipt

of

no

tifi

cati

on

s a

nd

veri

fic

ati

on

pro

ce

ss

es

re

gard

ing

He

alt

h C

are

,

NQ

F L

evel

4,

Cre

dit

s 2

0

WM

-02-W

E02

: R

eceiv

e a

llo

cate

d

cla

ims

fo

r a

sse

ss

me

nt

WA0201 Conduct

procedural checks

to validate the

membership details

(membership status,

beneficiary’s, policy

status, premium

status, claims

history, type of plan,

etc.)

WA0202 Analyse

the factual

information on the

claim/invoice



431204000-W

M-0

6,

As

se

ss

me

nt

pro

ce

ss

es r

eg

ard

ing

Healt

h C

are

cla

im,

NQ

F L

ev

el 4

, C

red

its 2

5

WM

-06-W

E01

: A

naly

se

an

d

eva

lua

te t

he r

ele

va

nt

do

cu

me

nta

tio

n r

ec

eiv

ed

wit

hin

a

thre

e m

on

th p

eri

od

WA0101 Assess

and interpret claim

information

according to claim

guidelines

WA0102 Apply

technical abilities

and knowledge to

identify

discrepancies and

where necessary

refer to independent

specialist and other

parties

WM

-06-W

E02

: R

efe

r to

ind

ep

en

de

nt

sp

ecia

list

an

d

rele

va

nt

part

ies w

ith

in a

th

ree

mo

nth

pe

rio

d

WA0201 Initiate and

communicate

specific instructions

for evaluation from

an independent

specialist

WA0202 Initiate and

communicate

specific instructions

for evaluation from

other medical

parties

431204000

-WM

-10,

De

cis

ion

s f

or

pay

me

nts

to

re

leva

nt

sta

ke

ho

lde

rs

reg

ard

ing

He

alt

h C

are

cla

ims

, N

QF

Lev

el

4,

Cre

dit

s 5

WM

-10

-WE

01

: P

art

icip

ate

in

cla

ims

dec

isio

n p

roce

ss

es

WA0101

Recommend

outcome of claim

WA0102 Finalise

documentation




LONG-TERM INSURANCE COMPLETION BY

CANDIDATE

COMPLETION

WORKPLACE MENTOR

Modules Work

Experiences

Main Work

Activities

RPL

Applicable

Evidence

Document CONFIRM

SIGNATURE

Yes No Document

Description Yes/No

431204000-W

M-0

3,

Re

ce

ipt

of

no

tifi

cati

on

s a

nd

ve

rifi

cati

on

pro

ce

ss

es

re

ga

rdin

g L

on

g-t

erm

insu

ran

ce, N

QF

Lev

el

4,

Cre

dit

s 1

5

WM

-03-W

E01

: P

art

icip

ate

in

ind

ucti

on

(o

rie

nta

tio

n)

pro

ce

ss

WA0101 Familiarise

oneself with

organisational

processes and

procedures

WA0103 Participate

in a variety of

applicable in-house

training programmes

WA0104 Participate

in departmental

meetings and / or

one-on-one coaching

sessions

WM

-03-W

E02

: R

eceiv

e a

llo

cate

d c

laim

s f

or

ass

es

sm

en

t

WA0201 Conduct

procedural checks to

validate the policy

contract (life assured,

policy status,

premium status,

ownership, re-

assurance, claims

history, etc.)

WA0202 Analyse the

factual information as

provided on

application form and

all relevant medical

test results and forms

WA0203 Analyse

timeline applicable on

policy to determine

any material non-

disclosures



431204000-W

M-0

3,

Re

ce

ipt

of

no

tifi

cati

on

s a

nd

veri

fic

ati

on

pro

ces

se

s r

eg

ard

ing

Lo

ng

-te

rm

insu

ran

ce, N

QF

Lev

el

4,

Cre

dit

s 1

5

WM

-03-W

E01

: P

art

icip

ate

in

in

du

cti

on

(ori

en

tati

on

) p

roce

ss

WA0204 Collect and

summarise medical

history prior to

inception or risk

effecting change

applied to the policy

WA0205 Request

relevant outstanding

information in the

event of insufficient

medical history or

additional medical

information reports

WA0206 Determine

whether the accepted

risk should be

referred for re-

underwriting

431204000

-WM

-07,

As

se

ss

me

nt

pro

ce

ss

re

gard

ing

Lo

ng

-te

rm i

nsu

ran

ce,

NQ

F L

evel

4,

Cre

dit

s 2

0

WM

-07-W

E01

: P

art

icip

ate

in

th

e v

ali

dati

on

pro

ces

s o

f

the p

oli

cy c

on

tra

ct

WA0101 Source the

relevant policy

document based on

date of

commencement of

the cover in order to

determine relevant

definition

WA0102 Apply the

relevant criteria in the

definition to

determine the level of

cover

WA0103 Summarise

the received claim

documentation and

medical reports

WA0104 Draw a

conclusion taking all

the summarised facts

into consideration



431204000-W

M-0

7,

As

se

ss

me

nt

pro

ce

ss

re

gard

ing

Lo

ng

-te

rm i

nsu

ran

ce

,

NQ

F L

evel

4,

Cre

dit

s 2

0

WM

-07-W

E02

: P

art

icip

ate

in

th

e

vali

dati

on

of

the c

laim

ed

ev

en

t

WA0201 Assess and

interpret case

information and make

a recommendation

according to claims

guidelines

WA0202 Apply

technical abilities and

knowledge to identify

discrepancies and

where necessary



parties

WM

-07-W

E03

: A

naly

se

an

d e

va

luate

th

e r

ele

van

t d

oc

um

en

tati

on

re

ce

ived

WA0301 Initiate and

communicate specific

instructions for

evaluation from an

independent medical

specialist or other

medical parties

WA0302 Consider re-

assurance as per the

agreement and

initiate and

communicate with the

relevant company

when necessary

WA0303 Identify

circumstances that

warrants a need for

referral to the legal

department, medical

officer or forensic

department for further

investigation where

required

WA0304 Identify and

present a complex

claim to the claims

committee or claims

forums for discussion

and evaluation



431204000

-WM

-11,

De

cis

ion

s f

or

pay

me

nts

to

re

lev

an

t s

tak

eh

old

ers

re

ga

rdin

g L

on

g-t

erm

in

su

ran

ce

,

NQ

F L

evel

4,

Cre

dit

s 1

5

WM

-11-W

E01

: R

efe

r to

in

de

pe

nd

en

t s

pe

cia

list

an

d e

xte

rnal

part

ies

WA0101 Initiate and

communicate specific

instructions for

evaluation from an

independent medical

specialist or other

medical parties

WA0102 Consider re-

assurance as per the

agreement and

initiate and

communicate with the

relevant company

when necessary

WA0103 Identify

circumstances that

warrants a need for

referral to the legal

department, medical

officer or forensic

department for further

investigation where

required

WA0104 Identify and

present a complex

claim to the claims

committee or claims

forums for discussion

and evaluation

WM

-11-W

E02

: P

art

icip

ate

in

cla

ims

dec

isio

n p

roce

ss

es o

r re

qu

es

t

ou

tsta

nd

ing

do

cu

me

nta

tio

n

WA0201 Request

support team to

obtain additional

outstanding

documentation

WA0202 Make a

decision to approve,

repudiate, decline,

defer, void, cancel or

re-construct the claim

taking all facts into

consideration

WA0203 Draft

decision letters and

forward to authorised

parties




SHORT-TERM INSURANCE COMPLETION BY

CANDIDATE

COMPLETION

WORKPLACE MENTOR

Modules Work

Experiences

Main Work

Activities

RPL

Applicable

Evidence

Document CONFIRM

SIGNATURE

Yes No Document

Description Yes/No

431204000

-WM

-04,

Ve

rifi

cati

on

pro

ce

ss

es r

eg

ard

ing

Sh

ort

-te

rm i

nsu

ran

ce

,

NQ

F L

evel

4,

Cre

dit

s 1

5

WM

-04-W

E01

: P

art

icip

ate

in

ind

ucti

on

(o

rie

nta

tio

n)

pro

ce

ss

WA0101 Familiarise

oneself with

organisational

processes and

procedures

WA0103 Participate

in a variety of

applicable in-house

training programmes

WA0104 Participate

in departmental

meetings and / or

one-on-one coaching

sessions

WM

-04-W

E02

: R

eceiv

e a

llo

cate

d

cla

ims

fo

r a

sse

ss

me

nt

WA0201 Conduct

procedural checks to

validate the claim

against the contract

(policy holder, risk

address, items at risk,

sum insured, no claim

bonus, etc.)

WA0202 Analyse the

factual information as

provided on policy

contract against claim

WA0203 Review all

relevant information

on file



431204000

-WM

-08,

Pa

rtic

ipati

on

of

ass

es

sm

en

t p

roce

ss r

eg

ard

ing

Sh

ort

-te

rm i

nsu

ran

ce,

NQ

F L

evel

4,

Cre

dit

s 2

5

WM

-08-W

E01

: P

art

icip

ate

in

th

e v

ali

dati

on

of

the c

laim

ed

eve

nt

WA0101 Secure an

appointment with

policy holder

WA0102 Conduct an

interview with the

policy holder at risk

address

WA0103 Establish

ownership and

existence of claimed

items

WA0104 Apply

contribution (dual

insurance) where

applicable

WA0105 Evaluate

security

measurement against

policy requirements

WA0106 Determine

nature of loss against

proximate cause

WA0107 Collect

applicable evidence

from the scene

WA0108 Calculate

the value at risk

against the sum

insured

WA0109 Conduct

previous insurance

checks

WA0110 Conduct a

financial check on the

policy holder

WA0111 Conduct

police checks

WA0112 Conduct

interview with

witnesses and alibi’s

where applicable



431204000

-WM

-08,

Pa

rtic

ipati

on

of

ass

es

sm

en

t p

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ss r

eg

ard

ing

Sh

ort

-te

rm i

ns

ura

nce

,

NQ

F L

evel

4,

Cre

dit

s 2

5

WM

-08

-WE

02

: A

naly

se

an

d e

va

luate

th

e

rele

va

nt

do

cu

me

nta

tio

n r

ece

ive

d

WA0201 Assess and

interpret case

information and make

a recommendation

according to claims

guidelines

WA0202 Apply

technical abilities and

knowledge to identify

discrepancies and

where necessary



parties

WA0203 Validate and

quantify the claim

431204000

-WM

-12, M

akin

g

rec

om

me

nd

ati

on

re

gard

ing

Sh

ort

-

term

in

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,

NQ

F L

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4,

Cre

dit

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0

WM

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E01

: P

art

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ate

in

cla

ims

dec

isio

n p

roce

ss

es b

y m

ak

ing

a

rec

om

me

nd

ati

on

WA0101 Make

recommendation on

risk improvements

WA0102 Participate

in making salvage

recommendation

WA0103 Compile and

submit final report

Step 5:

Complete the Knowledge, Practical and Workplace RPL Assessment. It is important to know that

the candidate should submit your completed Portfolio of Evidence.

After successfully completing the assessment registration to write the final External Integrated

Summative Assessment can be done.

The External Integrated Summative Assessment is a single national assessment leading to the

awarding of an Occupational Certificate. The External Integrated Summative Assessment ensures

that the assessment of occupational qualifications and part qualifications is standardized, consistent

and credible.

Certification will be done by the QCTO after successful completion of the External Integrated

Summative Assessment.

rpl strategy & guidelines - moonstone...assessment, recognition of prior learning and credit...

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