- Bestmed cancelled Wanani Emmanuel Sitsula’s medical aid membership, claiming he did not disclose asthma when he joined the scheme.
- The High Court found that Sitsula had no asthma diagnosis when He joined, and that Bestmed did not properly consider his medical evidence.
- The court ordered Bestmed to reinstate his membership, pay his covered medical expenses, and cover all legal costs for the application.
A medical scheme cannot cancel a member’s cover just because medication was prescribed for a condition that was never officially diagnosed.
This is according to the High Court in Pretoria, which ordered Bestmed Medical Aid Scheme to reinstate a member whose cover was terminated following alleged non-disclosure of asthma. The court found that the decision was arbitrary and not properly justified.
Bestmed cancelled membership over alleged non-disclosure
Wanani Emmanuel Sitsula took his case to the High Court after Bestmed cancelled his medical aid membership on 3 July 2026, saying he had failed to disclose asthma when he rejoined the scheme in February 2026.
Sitsula had already been a Bestmed member for 11 years. When he became a permanent employee at the Consumer Goods and Services Ombud, he was required to join Bestmed, which was the employer’s preferred medical scheme.
The dispute began when Sitsula fell ill and was admitted to hospital in June 2026. Bestmed refused to authorise or pay for his treatment, claiming he had not disclosed asthma because a general practitioner had prescribed him asthma medication in 2024 and 2025.
However, a pulmonologist who examined Sitsula while he was in hospital ruled out asthma and any other lung conditions. Sitsula submitted medical reports and other documents to Bestmed, but the scheme still cancelled his membership. He appealed and provided even more medical evidence, but Bestmed stuck to its decision in August.
Sitsula then turned to the Council for Medical Schemes to lodge a formal dispute. He was told resolving his complaint could take up to 120 days, and that there was no urgent process for cases needing immediate intervention.
He argued he could not wait that long because his condition needed more medical attention and might require urgent treatment. His medical reports showed he could need hospitalisation, specialist care, or surgery.
Court finds termination was not properly justified
Judge NGM Mazibuko found the matter was urgent, as Sitsula risked not being able to get the medical treatment he needed while waiting for the normal dispute process. The judge also looked at whether Bestmed’s decision could be reviewed under administrative law.
The court decided Bestmed was not exercising public power or performing a public function when it cancelled the membership. This meant its decision could not be reviewed under the Promotion of Administrative Justice Act or the principle of legality.
However, the judge said the contract between Sitsula and Bestmed required the scheme to act honestly, fairly, and reasonably. The court found Sitsula could challenge the cancellation through a contractual review, since Bestmed had to exercise its decision-making powers fairly and not act arbitrarily.
No confirmed asthma diagnosis when membership began
Judge Mazibuko found that Sitsula had not hidden any diagnosed medical condition when he joined Bestmed. Although a general practitioner had previously prescribed asthma medication, there was no confirmed asthma diagnosis when he applied for membership.
The judgment noted that Section 29(2)(e) of the Medical Schemes Act says a medical scheme cannot cancel or suspend a member’s cover, or that of a dependant, except for non-disclosure of important information.
The court also questioned whether Bestmed had properly looked at the medical evidence Sitsula submitted during his appeal. Sitsula had given medical reports, lung function tests, and other records, including a 24-month medical history that Bestmed requested.
But the court found no evidence that Bestmed properly considered this information before making its decision on the appeal. Judge Mazibuko questioned why Bestmed wanted the extra medical records and whether they were even relevant to the alleged non-disclosure.
The judgment also said there was no clear evidence that these extra records were important to the decision being appealed. The court concluded Bestmed had not justified cancelling Sitsula’s membership and that the decision was arbitrary and irrational.
Bestmed ordered to restore medical cover
The court set aside the decisions by Bestmed and its internal appeal committee to cancel Sitsula’s membership. Bestmed was ordered to reinstate his medical aid membership and pay all medical expenses covered under the policy. The scheme was also told to pay the legal costs of the application.
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