Sechaba Medical Solutions (Pty) Ltd & others v Sekete & others

Gen-Health Medical Scheme, registered under the Medical Schemes Act 131 of 1998, was placed in final liquidation in October 2010 after a period of curatorship. Sechaba Medical Solutions (Pty) Ltd acted as the scheme’s administrator and later assisted in the preparation and submission of members’ claims in the liquidation. Life Healthcare Group (Pty) Ltd, representing a number of hospitals and medical facilities, rendered medical services to Gen-Health members prior to liquidation. After obtaining pre-authorisation from Gen-Health for treatment, Life Healthcare submitted claims exceeding R5 million for proof in the liquidation. The assistant Master admitted these claims as proved. Sechaba and the liquidators challenged the admission on review, contending that Life Healthcare had no lawful claim directly against the medical scheme. The High Court dismissed the review, and the matter came before the Supreme Court of Appeal.

The appeal was dismissed with costs, payable jointly and severally by the first appellant and the liquidators. No appeal costs were to be recovered from the assets of Gen-Health Medical Scheme.

The case authoritatively confirms that medical schemes in South Africa are generally obliged to pay healthcare providers directly for authorised services rendered to members. It clarifies that pre-authorisation by a medical scheme creates a contractual foundation between the scheme and the healthcare provider and affirms the interpretation of sections 26(1)(b) and 59 of the Medical Schemes Act in favour of healthcare providers, particularly in insolvency contexts.