Sechaba Medical Solutions and Others v Sekete and Others (216/2014) [2015] ZASCA 8 (11 March 2015)

Parties

Procedural Posture

Civil Appeal / Appeal From North Gauteng High Court

Legal Issues

1. 1 Whether a healthcare provider has a valid claim against a medical scheme in liquidation for services rendered to members.
2. 2 Whether authorisation of treatment by a medical scheme creates a contract between the healthcare provider and the scheme.
3. 3 Interpretation of sections 26(1)(b) and 59 of the Medical Schemes Act 131 of 1998 regarding payment obligations.

Ratio Decidendi

The Supreme Court of Appeal held that Life Healthcare’s claims against Gen-Health Medical Scheme were validly admitted as proved claims in the liquidation. The court found that pre-authorisation of treatment by Gen-Health created a contractual obligation to pay Life Healthcare for services rendered to its members. Section 26(1)(b) of the Medical Schemes Act requires a medical scheme to assume liability for and guarantee the benefits offered to members, which includes paying healthcare providers directly. Section 59(2) further obliges schemes to pay benefits to service providers within 30 days of receiving a claim. The court rejected the appellants’ argument that only members have a direct...

Court Disposition

Appeal dismissed with costs; claims by Life Healthcare admitted as proved claims in the liquidation.

Orders

• The appeal is dismissed with costs, such costs to be paid by the first appellant and the liquidators jointly and severally, the one paying the other to be absolved.
• No costs in relation to the appeal shall be recovered or paid out of the assets of Gen-Health Medical Scheme.