SAQA 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.
SOUTH AFRICAN QUALIFICATIONS AUTHORITY 
REGISTERED QUALIFICATION: 

Occupational Certificate: Insurance Claims Administrator (Insurance Claims Assessor) 
SAQA QUAL ID QUALIFICATION TITLE
99668  Occupational Certificate: Insurance Claims Administrator (Insurance Claims Assessor) 
ORIGINATOR
Development Quality Partner - INSETA 
PRIMARY OR DELEGATED QUALITY ASSURANCE FUNCTIONARY NQF SUB-FRAMEWORK
-   OQSF - Occupational Qualifications Sub-framework 
QUALIFICATION TYPE FIELD SUBFIELD
Occupational Certificate  Field 03 - Business, Commerce and Management Studies  Finance, Economics and Accounting 
ABET BAND MINIMUM CREDITS PRE-2009 NQF LEVEL NQF LEVEL QUAL CLASS
Undefined  131  Not Applicable  NQF Level 04  Regular-ELOAC 
REGISTRATION STATUS SAQA DECISION NUMBER REGISTRATION START DATE REGISTRATION END DATE
Reregistered  EXCO 0425/24  2018-07-01  2025-12-30 
LAST DATE FOR ENROLMENT LAST DATE FOR ACHIEVEMENT
2026-12-30   2029-12-30  

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 qualification does not replace any other qualification and is not replaced by any other qualification. 

PURPOSE AND RATIONALE OF THE QUALIFICATION 
Purpose:
The purpose of this qualification is to prepare a learner to operate as an Insurance Claims Administrator (Insurance Claims Assessor). An Insurance Claims Administrator (Insurance Claims Assessor) assesses the validity of the claim against the contract in order to determine or recommend whether to settle or reject a claim and provide comments on risk improvements and moral risks.

A qualified learner will be able to:
  • Receive notification of a claim and investigate the validity thereof.
  • Assess a claim to determine the outcome of claims.
  • Mitigate and finalise the claims process.

    Rationale:
    According to the Insurance Sector Skills Plan (SSP), there are scarce skills identified within the industry. Whilst Insurance Claims Assessors were not explicitly named, it is one of the professional occupations in the sector where there is a scarcity of skills. This qualification is aimed at ensuring the development of qualified assessors to address this scarcity.

    Wide consultation with professional bodies such as the Insurance Institute of South Africa (IISA) and the Financial Planning Institute (FPI) was undertaken by the Insurance Sector Education and Training Authority (INSETA) prior to the development of the qualification. As a result, this Insurance Claims Assessor's occupational qualification in Short-term, Long-term, Health and Statutory insurance sectors was proposed.

    The qualification will provide knowledge and skills required by learners operating within the outlined sectors. It will also equip new entrants and those who are currently employed within the industry with knowledge and skills to competently function as Insurance Claims Assessors. Individuals operating in these sectors as Administrators, Claims Negotiators, Claims Officers and Insurance Claims Assessors will benefit from this qualification.

    This qualification will benefit individuals who have worked competently as Insurance Claims Assessors without formal education since they will have the acquired skills and knowledge recognised through the process of Recognition of Prior Learning (RPL).

    Qualified learners will have a competitive advantage to gain employment within the claims environment. The industry will benefit from the employment of qualified assessors who will perform their jobs effectively and thereby contribute efficiently to the economy. 
    		•

    LEARNING ASSUMED TO BE IN PLACE AND RECOGNITION OF PRIOR LEARNING 
    Recognition of Prior Learning (RPL):
    RPL for access to the external integrated summative assessment: Accredited providers and approved workplaces must apply the internal assessment criteria specified in the related curriculum document to establish and confirm prior learning. Accredited providers and workplaces must confirm prior learning by issuing a statement of result or certifying a work experience record.

    RPL for access to the qualification: Accredited providers and approved workplaces may recognise prior learning against the relevant access requirements.

    Entry Requirements:
    NQF Level 4 qualification or 3 years work experience in the Insurance industry. 

    RECOGNISE PREVIOUS LEARNING? 
    Y 

    QUALIFICATION RULES 
    This qualification is made up of the following compulsory Knowledge and Practical Skill Modules:

    Knowledge Modules:
  • 431204001-KM-01, Basics of insurance, Level 4, 17 Credits.
  • 431204001-KM-02, Claims handling procedures, Level 4, 11 Credits.
  • 431204001-KM-03, Professional Behaviour and Financial literacy, Level 4, 13 Credits.
    Total number of credits for Knowledge Modules: 41.

    Practical Skill Modules:
  • 431204001-PM-01, Receive a basic claim in order to assess the loss/ damage and verify the validity of the contract, Level 4, 20 Credits.
  • 431204001-PM-02, Assess the claim to determine validity, Level 4, 10 Credits.
  • 431204001-PM-03, Recommend to settle, conditionally settle or reject the claim, Level 4, 5 Credits.
  • 431204001-PM-04, Comment on risk improvements where applicable, Level 4, 5 Credits.
    Total number of credits for Practical Skill Modules: 40.

    This qualification also requires the following Work Experience Modules:
  • 431204001-WM-01, Verification processes regarding Statutory claims, Level 4, 10 Credits.
  • 431204001-WM-05, Assessment processes regarding Statutory claims, Level 4, 15 Credits.
  • 431204001-WM-09, Finalisation processes of Statutory claims, Level 4, 25 Credits.
    Or
  • 431204001-WM-03, Receipt of notifications and verification processes regarding Long-term insurance, Level 4, 15 Credits.
  • 431204001-WM-07, Assessment process regarding Long-term insurance, Level 4, 20 Credits.
  • 431204001-WM-11, Decisions for payments to relevant stakeholders regarding Long-term insurance, Level 4, 15 Credits.
    Or
  • 431204001-WM-02, Receipt of notifications and verification processes regarding Health Care, Level 4, 20 Credits.
  • 431204001-WM-06, Assessment processes regarding Health Care claim, Level 4, 25 Credits.
  • 431204001-WM-10, Decisions for payments to relevant stakeholders regarding Health Care claims, Level 4, 5 Credits.
    Or
  • 431204001-WM-04, Verification processes regarding Short-term insurance, Level 4, Credits 15.
  • 431204001-WM-08, Participation of assessment process regarding Short-term insurance, Level 4, 25 Credits.
  • 431204001-WM-12, Making recommendation regarding Short-term insurance, Level 4, 10 Credits.
    Total number of credits for Work Experience Modules is 50 credits per relevant insurance sector. 
    		•

    EXIT LEVEL OUTCOMES 
    1. Identify, analyse and verify the validity of claims in the relevant insurance context.
    2. Assess, calculate and complete claims in the relevant insurance context.
    3. Finalise claims in the relevant insurance context. 

    ASSOCIATED ASSESSMENT CRITERIA 
    Associated Assessment Criteria for Exit Level Outcome 1:
  • 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.

    Associated Assessment Criteria for Exit Level Outcome 2:
  • Claims assessment form and inventory are completed.
  • Prescription periods are calculated.
  • Extent of claim is validated and quantum of the claim is calculated.

    Associated Assessment Criteria for Exit Level Outcome 3:
  • Risk improvement recommendations and claims recommendations are finalised.
  • Decisions on outcome of claims are finalised.

    Integrated Assessment:
    Integrated Formative Assessment:
    The skills development provider will use the curriculum to guide them on the stipulated internal assessment criteria and weighting. They will also apply the scope of practical skills and applied knowledge as stipulated by the internal assessment criteria. This formative assessment leads to entrance into the integrated external summative assessment.

    Integrated Summative Assessment:
    An external integrated summative assessment, conducted through the relevant Quality Council for Trades and Occupations (QCTO) Assessment Quality Partner is required for the issuing of this qualification. The external integrated summative assessment will focus on the exit level outcomes and associated assessment criteria. The external assessment will be conducted by means of written assessments conducted by registered assessors at accredited assessment centres over a period of not more than 3 hours. 
    		•

    INTERNATIONAL COMPARABILITY 
    A comprehensive international comparison between the South African Insurance Claims Administrator (Insurance Claims Assessor) occupational qualification and other Insurance Claims related qualifications offered in countries such as Australia, New Zealand and Canada respectively was undertaken. These countries were chosen due to the similarities between the qualifications.

    Australia:
    A Certificate IV in General Insurance code FNS41411 offered in Australia was found to compare favourably to the Occupational Certificate: Insurance Claims Administrator (Insurance Claims Assessor). The Australian qualification is mainly designed for the Insurance Administrators and Claims Officers. The purpose of the qualification is to capacitate qualified officers so that they can handle claims, issue domestic insurance contracts, deal with customer enquiries, appoint intermediaries to investigate standard claims and initiate claims recovery.

    Modules covered in the qualification include amongst others, the following:
    Compulsory Modules:
  • Serving the General Insurance Customer.
  • General Insurance Law and Regulation.
  • General Insurance Products.
  • Introduction to General Insurance Underwriting.
  • General Insurance Claims Handling.
  • New Zealand (NZ) Insurance Law and Regulation (NZ only).

    Elective Modules:
  • Business Fundamental Unit.
  • Business Fundamental Unit.

    Duration:
    The qualification is designed in such a way that it will take a maximum of 24 months (2 years) to complete.

    Entry requirements:
    There are no specific entry requirements specified.

    New Zealand:
    It was found that New Zealand offers an Insurance Claims Officer qualification which specialises in general insurance. This generic qualification covers areas such as house and contents, commercial, motor vehicle and marine insurance; or life insurance, which includes health insurance, disability insurance and superannuation.

    Upon completion the learner will be able to:
  • Analyse the claim and decide whether it is covered by the policy.
  • Appoint insurance loss adjusters and private investigators when required.
  • Manage long-term claims and reassess them regularly.
  • Make recommendations for the settlement of claims.
  • Inform clients if claims are accepted and how they will be allocated.
  • Organise payments to clients.
  • Organise the repair or replacement of lost items.
  • Make sure all enquiries and payments are dealt with timely.
  • Keep clients' files updated.
  • Record payments made and received.
  • Contact independent experts in the case of disputes and attend disputes tribunals.

    Entry requirements:
    There are no specific entry requirements to become an Insurance Claims Officer.

    Canada:
    Although the title of the qualification offered in Canada differs from the South African occupational qualification, the study has shown that the content of these qualifications compares favourably. The qualification offered is called Insurance Adjusters and Claims Examiners NOC 1312. It is divided into two groups: Insurance Adjusters and Claims Examiners. Insurance Adjusters investigate insurance claims and determine the amount of loss or damages covered by insurance policies. Insurance Claims Examiners examine claims investigated by Insurance Adjusters and authorise payments.

    Insurance Adjusters perform some or all of the following duties:
  • Investigate circumstances surrounding insurance claims to determine validity of claim.
  • Inspect automobile, home or other property damage.
  • Take statements and consult with claimants, accident witnesses, doctors and other relevant individuals and examine records or reports.
  • Determine amount of loss or damages covered by insurance policies.
  • Negotiate settlement of claims.
  • Prepare adjustment reports.

    The Insurance Claims Examiners, on the other hand, are expected to perform some or all of the following duties:
  • Review, examine, calculate and authorise insurance claims investigated by insurance adjusters.
  • Examine adjusters' reports and similar insurance claims or precedents to determine extent of insurance coverage.
  • Ensure claims are valid and settlements are made according to company practices and procedures.
  • Consult lawyers, doctors or other relevant individuals to discuss insurance claims.
  • Approve automobile, fire, life, disability, dental or other insurance claims.

    Similarities:
    The similarities have been found in some of the tasks or duties to be performed by a qualified learner. In addition to this, entry requirements are also comparable to the Australian as well as the New Zealand qualifications. In both cases, learners are expected to have acquired at least three years of relevant experience to qualify for admission to learning as a substitute for the formal education.

    In all qualifications offered in other countries, it was found that the purpose of the qualification is to perform and assess the damage and to minimise the cost of claims to an insurance company. This is similar to the purpose statement of the South African occupational qualification.

    Differences:
    The main differences identified include, amongst others, the title of the occupation, duration and structure of the qualifications. The title of a South African qualified learner is 'Insurance Claims Administrator (Insurance Claims Assessor) whereas in New Zealand, a qualified learner is called 'Insurance Claims Officer and General Insurer'.

    The New Zealand qualification has some tasks that are not covered in the South African occupational qualification. For an example, it has been noted that a qualified learner is expected to appoint Insurance Loss Adjusters and Private Investigators. This task is not included in the South African occupational qualification.

    Conclusion:
    Based on the findings of the comparability study, it is concluded that the Occupational Certificate: Insurance Claims Administrator (Insurance Claims Assessor) compares favourably to other qualifications offered in some countries. 
    		•

    ARTICULATION OPTIONS 
    This qualification articulates horizontally to:
  • Further Education and Training Certificate: Short-term Insurance, Level 4 (ID: 66610).
  • Further Education and Training Certificate: Long-term Insurance, Level 4 (ID: 49649).
  • Further Education and Training Certificate: Retail Insurance, Level 4 (ID: 66609).
  • Further Education and Training Certificate: Wealth Management, Level 4 (ID: 66613).
  • Further Education and Training Certificate: Medical Claims Assessing, Level 4 (ID: 49356).

    This qualification articulates vertically to:
  • Occupational Certificate: Insurance Agent: Insurance Underwriter, Level 5 (ID: 91784).
  • Higher Certificate in Insurance, Level 5 (ID: 93999).
  • National Certificate: Short-term Insurance, Level 5 (ID: 57918). 
    		•

    MODERATION OPTIONS 
    N/A 

    CRITERIA FOR THE REGISTRATION OF ASSESSORS 
    N/A 

    NOTES 
    Qualifying for External Assessment:
    In order to qualify for the external summative assessment learners must have a copy of a completed and signed Statement of Work Experience as well as proof of successful completion of all knowledge and practical skill modules outlined in the curriculum including Foundational Learning Competence.

    Additional legal or physical entry requirements:
    No additional legal or physical entry requirements are required.

    Criteria for the accreditation of providers
    Accreditation of providers will be done against the criteria as reflected in the relevant curriculum on the Quality Council for Trades and Occupations (QCTO) website.

    The curriculum title and code is: Insurance Claims Assessor and 431204001. 

    LEARNING PROGRAMMES RECORDED AGAINST THIS QUALIFICATION: 
     
    NONE 


    PROVIDERS CURRENTLY ACCREDITED TO OFFER THIS QUALIFICATION: 
    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.