An Investigation into the Causes of Claims Mismanagement in Medical Aid Societies: Case of Psmas

Abstract

Claims management is imperative for the viability of Medical Societies. This assertion is buttressed by the ever-present war among medical aid societies, their members and service providers. The main objective of the research was to investigate the causes of claims mismanagement in medical aid societies, zeroing on Premier Service Medical Aid Society and the study revealed plausible sources from which the claims mismanagement emanates, the challenges involved in claims management, the strategies which can be adopted by companies to manage them and the associated benefits of effective claims management in Medical Aid Societies.

The study adopted descriptive research design using disproportionate stratified random sampling. The primary data from structured questionnaires was then analyzed and presented using tables, graphs and charts in conjunction with secondary data. The study revealed, studies prior, focused on challenges of claims management in traditional insurance institutions and less has been done on medical insurance. The findings, exposed the existence of claims mismanagement in Medical Aid Societies, causes identified includes medical inflation, mismatch between contributions and associated benefits and fraud which is perpetrated by associated stakeholders. In this thesis, recommendations were made to try and rectify this position.