Claims handling and client service
This domain tests how a claim is notified, evidenced, assessed against the policy wording and resolved, including when it is declined.
The claim pathway
Notification to the insurer, claim forms, evidence (death certificate, medical reports, specialist confirmation, financial records for income claims), assessment against the definition, exclusions, waiting periods and offsets, then a decision with reasons.
Service standards
Insurers are expected to acknowledge claims promptly, explain what information is needed, and decide within reasonable timeframes. The Fair Insurance Code (ICNZ) sets service commitments for member insurers; complaints processes and access to an approved dispute resolution scheme apply if a claim is disputed.
Vulnerable clients
Bereavement, illness and financial stress affect decision-making. Advisers should keep explanations clear, avoid pressure on immediate settlements, and record instructions.
Worked example
An income protection claim is declined because the insurer applied an any-occupation definition. The adviser reviews the policy wording, confirms the definition and waiting period, explains the reasons to the client, and helps them seek a review through the insurer's complaints process and then the dispute resolution scheme. The adviser does not promise a different outcome.
Traps
Coaching a client on what to say to an assessor; missing the notification or evidence deadlines; failing to tell the client about the complaints route; and assuming the claim decision is final when a review process exists.