ABSTRACT

This study sought to investigate determinants of delays in the payment of private health insurance claims in Kenya. The study was guided by the following research questions: What is the influence of internal industry practices on the payment of private health insurance claims processing in Kenya? What is the influence of systems availability on the payment of private health insurance claims in Kenya? What is the influence of laws and regulations on the payment of private health insurance claims in Kenya? What is the influence of insurance fraud on the payment of private health insurance claims in Kenya? The study was anchored to the agency and moral hazard theories. A survey research design to collect primary data from the field in this study where questionnaires which were administered to 105 respondents. Research assistants were used to collect data from the respondents. The data was analyzed using descriptive and inferential statistics. The descriptive methods used comprised of the percentages, frequencies, means and standard deviations that showed the trends in the data. Inferential methods which included correlation analysis and regression analysis were also used. In addition, statistical assumptions were made prior to regression analysis. The study found out that internal industry practices had a negative significant influence on delay in payment of health insurance claims. This was the same for systems availability and to laws and regulation. However, insurance fraud showed a positive significant influence with coefficients. The study concluded that the information available in the policy claim process was un-clear and could not be easily understood for instance when filling in the claim forms. The study also concluded that the hospitals had not adopted an integrated IT system to enhance claim processing and that systems failure in hospitals often led to loss of data relevant to claims thus that led to delay in processing. The study recommended that a universally agreed standard for loss calculation was needed and also the need for merging the organizational regulations with those of the country.