Abstract

Michael Mncedisi Willie

Medical schemes are insurance institutions that cover medical expenses in South Africa. These institutions reimburse their members for actual expenditure on health. The Medical Schemes Act (Act 131 of 1998) defines the business of a medical scheme as the business of undertaking liability in return for a contribution in order to make provision for obtaining any relevant health service. The Council for Medical Schemes (CMS) is an autonomous statutory body created by parliament to regulate the medical schemes industry in South Africa. The CMS handles complaints from members of medical schemes. The objective of the study was to assess factors that impact on the response time to complaints by members of medical schemes. Survival analysis techniques were employed to assess these factors. The regression models controlled for factors such as, medical scheme type, medical scheme size, severity of complaints and effects of the analysts. The model revealed the effect of analysts as a significant factor to response time to complaints. The findings of the study revealed useful results in terms of identifying analysts that take longer to resolve complaints. The study also revealed that the nature of complaints as an important factor to the response time. There is a need for the complaints department to be properly resourced and continuously train staff to ensure effective resolution of complaints in medical schemes.