Class Code: 00454

IOWA DEPARTMENT OF ADMINISTRATIVE SERVICES –

HUMAN RESOURCES ENTERPRISE

INSURANCE COMPLAINT ANALYST

DEFINITION

Evaluates citizens' complaints regarding claim settlement and underwriting practices of insurers to properly advise the concerned parties; performs related work as required.

The Work Examples and Competencies listed are for illustrative purposes only and not intended to be the primary basis for position classification decisions.

WORK EXAMPLES

Obtains information on claims rejected for payment by property, casualty, or accident and health insurers by interviewing policyholders and claimants to determine the validity of the complaints.

Analyzes insurance policies of complainants by evaluating and interpreting the contract to determine the extent of coverage, the exclusions specified, and the conditions affecting the payment of claims; analyzes the facts of the case by reviewing and evaluating the incidents pertinent to the claims to determine whether the policy coverage extends to such incidents.

Requests the claims and underwriting files of insurers and reviews them to determine if they have made a "good faith" investigation of the claims and to determine if they have met the obligations set forth in the policy before rejecting the claim.

Analyzes the evidence by reviewing and evaluating the reasons for the claims' rejection to determine the basis for rejection; suggests or orders that the claim be paid within reasonable time by citing sections of the Iowa Code or policy provisions that pertain to the insurer's obligation if it is decided that the insurer is liable.

Evaluates complaints directed against insurers concerning unfair insurance trade practices as defined by Iowa law by reviewing laws enacted against such practices to determine if there is a basis for action on such complaints.

Drafts proposed orders, witness statements and affidavits for use in administrative proceedings.

COMPETENCIES REQUIRED

Knowledge of contract law.

Knowledge of quasi-judicial procedures as they pertain to the conduct of hearings or the prosecution of cases before hearings.

Knowledge of investigative techniques.

Ability to analyze information and recognize trends.

Ability to acquire a knowledge of the Iowa Code as it pertains to insurance contracts and the laws governing the operation of insurers.

Ability to acquire a knowledge of unfair trade practices in the insurance field.

Ability to acquire a knowledge of the various types of insurance field.

Ability to acquire a knowledge of the various types of insurance and insurers.

Ability to analyze and interpret insurance policy language in detail to determine the extent of coverage, the specified exclusions, and the conditions affecting the payment of claims.

Ability to interpret and apply sections of the Iowa Code that pertain to the business operation of insurers, insurance contract requirements, and the obligation of insurers to pay claims, to various types of insurance policies.

Ability to deal skillfully and tactfully with insurers with the public in gathering information necessary to determine the liability for the payment of claims.

Displays high standards of ethical conduct. Exhibits honesty and integrity. Refrains from theft-related, dishonest or unethical behavior.

Works and communicates with internal and external clients and customers to meet their needs in a polite, courteous, and cooperative manner. Committed to quality service.

Displays a high level of initiative, effort and commitment towards completing assignments efficiently. Works with minimal supervision. Demonstrates responsible behavior and attention to detail.

Responds appropriately to supervision. Makes an effort to follow policy and cooperate with supervisors.

Aligns behavior with the needs, priorities and goals of the organization.

Encourages and facilitates cooperation, pride, trust, and group identity. Fosters commitment and team spirit.

Expresses information to individuals or groups effectively, taking into account the audience and nature of the information. Listens to others and responds appropriately.

EDUCATION, EXPERIENCE, AND SPECIAL REQUIREMENTS

Graduation from an accredited law school;

OR

graduation from an accredited four-year college or university and equal to three years of full time experience in multi line insurance adjusting or underwriting;

OR

high school graduation or G.E.D. and any combination of multi line insurance adjusting or underwriting experience and accredited undergraduate college or university course work which totals seven years (thirty semester hours equals one year of experience);

OR

graduate from an accredited four-year college or university and equal to three years of full time experience in investigating and recognizing violations of state laws or regulations and preparing cases proving such violations for presentation at administrative hearings.

SELECTIVE CERTIFICATION

For certain designated positions the Appointing Authority, with Iowa Department of Administrative Services – Human Resources Enterprise prior approval, may request those applicants possessing a minimum of twelve semester hours of education, six months of experience, or a combination of both, or a specific certificate, license, or endorsement in the following areas:

354 Law Degree

Applicants desiring to be considered for such designated positions must list applicable coursework, experience, certificate, license, or endorsement on the application.

Effective Date: 9/98 TA