Case Law[2024] ZACC 23South Africa
Swanepoel N.O. (Executor in the Estate Late Mignon Adelia Steyn) v Profmed Medical Scheme (CCT 336/22) [2024] ZACC 23; 2025 (1) SA 33 (CC); 2025 (2) BCLR 205 (CC) (9 October 2024)
Constitutional Court of South Africa
9 October 2024
Headnotes
Summary: Medical Schemes Act 131 of 1998 — substitution — transmissibility of right to just administrative action — procedural fairness — material non disclosure
Judgment
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## Swanepoel N.O. (Executor in the Estate Late Mignon Adelia Steyn) v Profmed Medical Scheme (CCT 336/22) [2024] ZACC 23; 2025 (1) SA 33 (CC); 2025 (2) BCLR 205 (CC) (9 October 2024)
Swanepoel N.O. (Executor in the Estate Late Mignon Adelia Steyn) v Profmed Medical Scheme (CCT 336/22) [2024] ZACC 23; 2025 (1) SA 33 (CC); 2025 (2) BCLR 205 (CC) (9 October 2024)
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sino date 9 October 2024
FLYNOTES:
INSURANCE – Medical schemes –
Non-disclosure
–
Right
to cancel membership – Alleged material information not
disclosed – Terminated membership based on misconception
that applicant suffered from gastric ulcer – Arthroscopy was
diagnostic procedure and not medical condition –
No material
diagnosis of condition – No duty to disclose it –
Non-disclosure not material – No evidence
before Appeal
Board to support its findings – Substitution warranted –
Appeal upheld –
Medical Schemes Act 131 of 1998
,
s 29(2)(e).
CONSTITUTIONAL
COURT OF SOUTH AFRICA
Case
CCT 336/22
In
the matter between:
CARLO
SWANEPOEL N.O.
Executor
in the Estate Late
MIGNON
ADELIA STEYN
Applicant
and
PROFMED
MEDICAL SCHEME
Respondent
Neutral citation:
Swanepoel N.O. (Executor in the Estate Late Mignon Adelia Steyn) v
Profmed Medical Scheme
[2024] ZACC 23
Coram:
Zondo CJ, Madlanga ADCJ,
Bilchitz AJ, Chaskalson AJ,
Dodson AJ, Majiedt J, Mathopo J, Theron J and
Tshiqi J
Judgments:
Majiedt J (unanimous)
Heard on:
14 March 2024
Decided on:
9 October 2024
Summary:
Medical Schemes Act 131 of 1998
— substitution —
transmissibility of right to just administrative action —
procedural fairness — material
non disclosure
ORDER
On
appeal from the Full Court of the High Court of South
Africa, Western Cape Division, Cape Town, the following order
is
made:
1.
The late filing of the application for leave
to appeal is condoned.
2.
The application for substitution is granted
and the executor of the
deceased estate is substituted for Ms Mignon Adelia Steyn
as applicant.
3.
Leave to appeal is granted.
4.
The appeal is upheld.
5.
The order of the Full Court is set aside
and substituted with
the following:
“
The
appeal is dismissed with costs, including the costs of two counsel
where so employed.”
6.
The respondent must pay the costs, including
the costs of two
counsel.
JUDGMENT
MAJIEDT J
(Zondo CJ, Madlanga ADCJ, Bilchitz AJ, Chaskalson AJ,
Dodson AJ, Mathopo J, Theron J
and Tshiqi J
concurring):
Introduction
and background
[1]
This is an
application for leave to appeal to this Court against a judgment of
the Full Court of the High Court of South
Africa, Western
Cape Division, Cape Town, which upheld an appeal against an order
from a single judge of that Division. Special
leave to appeal
was refused by the Supreme Court of Appeal and a
reconsideration application to the President of
that Court in terms
of
section 17(2)(f)
of the Superior Courts Act
[1]
met the same fate. The main issue concerns a medical scheme’s
right to cancel a member’s membership due to the
non disclosure
of allegedly material information in terms of section 29(2)(e)
of the Medical Schemes Act
[2]
(MSA). There is also an application to substitute the original
applicant, Ms Mignon Adelia Steyn (Ms Steyn), who
passed
away on 12 January 2023, with her attorney and the executor
of her estate, Mr Carlo Swanepoel (Mr Swanepoel).
Lastly, an application condoning the applicant’s late filing of
the record is unopposed.
[2]
The respondent is Profmed Medical Scheme (Profmed), a medical
scheme established under the MSA.
[3]
With regard to the condonation application, the delay is
negligible and the explanation for the default adequate.
Condonation
is therefore granted.
[4]
Ms Steyn was a member of Profmed until her membership was
terminated by Profmed pursuant to her alleged failure to disclose
material information on the prescribed membership application form
when she applied for membership of the scheme. Upon termination
of her membership, Ms Steyn lodged a complaint with the
Registrar of Medical Schemes (Registrar) contesting the termination.
The Registrar dismissed the complaint. Ms Steyn unsuccessfully
appealed to the Council for Medical Schemes
(Council)
against the Registrar’s findings. She then appealed the
decision of the Council to the Appeal Board,
also without any
success.
[5]
Ms Steyn launched an application in the High Court
for the review and setting aside of the decision of the
Appeal Board.
The High Court granted the application,
setting aside the ruling of the Appeal Board and ordering
Profmed to honour the
policy. Profmed’s appeal to the
Full Court was upheld. As stated, a further application
for special leave
to appeal and a reconsideration application to the
Supreme Court of Appeal were unsuccessful. The
unsuccessful
review application in the High Court was directed
at the findings of the Appeal Board. In this Court,
ultimately
the assessment on the merits will thus have to be in
respect of those findings.
Factual
matrix
[6]
The facts are mostly common cause, or not seriously disputed.
In November 2015, Ms Steyn applied for medical aid
insurance with Profmed. She completed the necessary medical
forms with the assistance of her husband and a representative
from
Profmed, a Ms Susan Brits. Subsequently, Profmed
accepted Ms Steyn and her dependants as members, and
their
membership officially commenced on 1 January 2016. Under
the heading “Medical Questionnaire”
the application form
contained an important caution:
“
This
section is extremely important. Any misstatement in, or
omission from this form may lead to refusal to admit any claims
for
treatment given, suspension, or termination of membership. A
12 month condition-specific waiting period may be applied
to any
condition declared, subject to the requirements of the
Medical Schemes Act, 1998
. It is essential to
declare all conditions/illnesses/symptoms, no matter how
insignificant they may seem . . . . Disclosure
is not limited
to the example conditions cited below. Related, consequent, and
suspected conditions must also be disclosed.”
[7]
The questionnaire contained a question, “[d]id you or
any of your dependants ever suffer from any of the following diseases
or medical conditions or disorders, or receive treatment, advice,
and/or medication for any of them?” This was followed
by
31 questions, one of which read: “Any affection of the
digestive system, liver, and gallbladder (e.g. gastric ulcers,
hernia, poor digestion, gallstones, spastic colon)?”
Ms Steyn answered the latter question in the negative, despite
having undergone a gastroscopy and colonoscopy which resulted in a
diagnosis of gastritis.
[8]
In the course of 2016, Ms Steyn and her dependants
underwent various medical procedures, amounting to R400 000.
The claims for these procedures were submitted to Profmed for
reimbursement. In a letter dated 7 November 2016,
Profmed terminated Ms Steyn’s membership with
retrospective effect from the date of inception, 1 January 2016.
The claims for reimbursement were thus declined. The
termination was based on the alleged non disclosure of specific
medical conditions, namely—
(a)
gastric ulcer;
(b)
breast aspiration;
(c)
wrist pains; and
(d)
hip problems.
[9]
In a further letter dated 13 December 2016, Profmed
stated that its grounds for termination were Ms Steyn’s
non disclosure of—
(a)
an MRI lumbar spine;
(b)
a breast aspiration; and
(c)
a gastroscopy and colonoscopy for a gastric ulcer, where the final
diagnosis was gastritis
.
Proceedings
before the Registrar
[10]
Following the
termination of her medical aid, Ms Steyn lodged a complaint with
the Registrar under
section 47
of the MSA for a ruling that the
termination of her membership was unlawful and that Profmed be
ordered to honour its commitments
to her and her dependants under the
policy.
[3]
In response,
Profmed relied on the grounds contained in its letter of
13 December 2016.
[4]
Profmed contended that Ms Steyn had failed to disclose that she
had—
(a)
a lumbar spine MRI on 3 December 2015;
(b)
a breast aspiration on 2 February 2015;
(c)
a gastroscopy and colonoscopy for gastric ulcers on 4 March 2015;
and
(d)
a migraine, abdominal pain and a gastric ulcer for which she
was
admitted to hospital on 4 September 2016.
[11]
The Registrar
understood the condition of gastritis, mentioned in Profmed’s
letter of 13 December 2016, to be a
gastric ulcer. In
reaching this finding in favour of Profmed, the Registrar relied on
Mahomed
[5]
which, in turn had relied on
Mahadeo
,
[6]
that the test for materiality is objective, with the question being:
would the reasonable person have considered the particular
fact
reasonably relevant to the risk and its assessment by the insurer?
The Registrar concluded that Profmed’s decision
to terminate
the membership was justified, as any reasonable person in Ms Steyn’s
position would have known to disclose
the gastroscopy and colonoscopy
procedures, as they were material. The Registrar also concluded
that the failure to provide
this material information hindered
Profmed’s ability to perform a comprehensive risk assessment on
Ms Steyn’s
application, potentially resulting in the
imposition of a waiting period had the information been properly
disclosed.
Proceedings
before the Council
[12]
In her appeal against the Registrar’s decision to the
Council, Ms Steyn set out her defences to the three grounds
raised
by Profmed as justification for terminating her medical
insurance. To demonstrate that she had subsequently
successfully
applied for membership of a competitor of Profmed,
Ms Steyn annexed to her affidavit in the proceedings before the
Council
her application form to Momentum Medical Scheme
(Momentum Form). In the Momentum Form, Ms Steyn
disclosed, among others, that she had a gastric ulcer and a hip
arthroscopy.
[13]
Profmed did not file an answering affidavit. During the
hearing, and in addition to the original three grounds which Profmed
had invoked in its 13 December 2016 letter and before the
Registrar, it placed reliance on the Momentum Form to
raise new
grounds for the termination of Ms Steyn’s membership,
being the non disclosure of—
(a)
a hip arthroscopy;
[7]
(b)
a heart murmur;
(c)
kidney stones; and
(d)
fibromyalgia.
[8]
[14]
Before the Council, Ms Steyn complained that she was
prejudiced by Profmed’s reliance on new grounds as she had not
been
given the opportunity to make submissions related to the
Momentum Form. The Council considered these new grounds as
it found that the appeal was wide, and so it was not restricted to
the record of the proceedings before the Registrar.
[15]
The Council formulated the test for materiality thus:
“
Materiality
of the non disclosure lies in the fact that the scheme was
denied the opportunity to make an accurate assessment
and mitigate
its risk by imposing a statutorily empowered condition specific
waiting period if it had been aware of a pre existing
medical
condition.”
[16]
The Council found in Profmed’s favour. It
concluded that, while the MRI scan and breast aspiration were not
matters
that warranted disclosure, the non disclosure of the
gastritis, although a “lesser condition than a gastric ulcer”,
was material, but made no finding regarding the hip arthroscopy.
The Council thus dismissed the appeal.
Proceedings
before the Appeal Board
[17]
Ms Steyn
appealed against the Council’s decision to the Appeal Board
in accordance with
section 50(3)
of the MSA.
[9]
The Appeal Board upheld the Council’s decision; it held
that the non disclosure of gastritis and a hip arthroscopy
were
material non disclosures. With regard to gastritis, the
Appeal Board said that gastritis and gastric ulcers
are
distinct; gastritis is less serious and more common. It then
applied the following test to establish materiality:
section 29A(2)(a)
of the MSA entitles medical schemes to impose
a waiting period for conditions not covered within the
prescribed minimum benefits
(PMBs).
[10]
Gastritis was not covered within the PMBs. Had gastritis been
disclosed, Profmed would have imposed a waiting period.
According to the Appeal Board, the non-disclosure prevented
Profmed from doing so and the non disclosure of gastritis
was
consequently material. As gastritis was not listed as a PMB by
Profmed, Ms Steyn was obliged to disclose gastritis
in her
application form.
[18]
The Appeal Board stated that there was nothing precluding
it from considering the new grounds emanating from the Momentum Form,
because Profmed only became aware of the information later and it was
a wide appeal. The Appeal Board did not elaborate
on why
it considered the appeal as a wide one. Thus, held the
Appeal Board, the non disclosure of the hip arthroscopy
was
also material as Ms Steyn suffered from arthritis, most likely
osteoarthritis. It held further that a hip arthroscopy
is also
not a PMB and so non disclosure prevented Profmed from applying
a condition-specific waiting period.
High Court
[19]
Following the decisions of the Registrar, Council and
Appeal Board (collectively, the Appeal Bodies), Ms Steyn
brought
a review application to the High Court, in which she
sought—
(a)
the review and setting aside of the Appeal Bodies’
rulings; and
(b)
the substitution of the Appeal Board’s ruling with
an
order—
(i)
declaring Profmed’s termination unlawful and setting
it aside,
and
(ii)
directing Profmed to honour its contract with Ms Steyn.
[20]
In her review application, Ms Steyn argued that the
Appeal Board had erred by relying on the additional grounds for
termination
raised by Profmed based on the Momentum Form (that
is, the hip arthroscopy), and the Appeal Bodies had all erred by
deeming
gastritis to be a material condition. Ms Steyn
submitted that Profmed had only relied on three grounds before the
Registrar,
and the additional grounds were raised for the first time
in oral argument before the Council. Given the principle that
parties
must know the case that they are called to meet and in
respect of which they must adduce evidence, and the principle of
hearing
the other side, Ms Steyn argued that the Appeal Bodies
had erred by—
(a)
considering the additional grounds;
(b)
not allowing her to adduce evidence regarding the additional
grounds;
(c)
not directing Profmed to adduce evidence regarding the additional
grounds; and
(d)
not taking into account that no evidence was adduced to demonstrate
that the non-disclosures resulted in Profmed’s decision to
terminate.
[21]
According to Ms Steyn, the Appeal Bodies had also
erred by deeming gastritis to be a material condition. The
Council’s
conclusion that gastritis is material was made absent
any factual basis; on the contrary, the evidence showed that
gastritis was
immaterial. Ms Steyn contended that no
evidence was presented by Profmed to show that the alleged
non disclosures
were material.
[22]
Ms Steyn submitted that the Appeal Board also erred
in that it applied the incorrect test for materiality. She
submitted
that the test is not determined with reference to the PMBs,
but that, where a condition is specifically mentioned, a reasonable
person ought to conclude that it has to be disclosed. Gastritis
was not mentioned by name and was therefore immaterial.
[23]
Ms Steyn
contended that, in terms of section 6 of the Promotion of
Administrative Justice Act
[11]
(PAJA), the Appeal Board’s ruling was—
(a)
materially influenced by an error of law (section 6(2)(d)
of
PAJA);
(b)
arbitrary and/or capricious (section 6(2)(e)(vi) of PAJA);
(c)
not rationally connected to its reasons (section 6(2)(f)(ii)(dd)
of PAJA); and
(d)
one where irrelevant
considerations were taken into account (section 6(2)(e)(iii) of
PAJA).
[12]
[24]
Profmed countered by arguing that the matter at hand was a
review and not an appeal, emphasising that Ms Steyn could not
merely
argue that the Appeal Bodies’ decisions were
wrong. Profmed argued further that Ms Steyn was expected
to
disclose the full information regarding any ailments, conditions,
illnesses or symptoms, regardless of how insignificant they may
seem. Lastly, Profmed submitted that Ms Steyn failed to
address the information regarding her Momentum Form when
given
the opportunity to do so before the Appeal Board.
[25]
The High Court
[13]
identified three issues to be determined—
(a)
whether the hearing before the Appeal Board was procedurally
fair;
(b)
whether the Appeal Board was correct in its finding that
Ms Steyn had a duty to disclose the hip arthroscopy and
gastritis, and that the non disclosure was material; and
(c)
whether to remit the
matter to the Appeal Board if it found in Ms Steyn’s
favour.
[14]
[26]
In relation to the procedural fairness of the Appeal Board’s
decision, the High Court held that:
(a)
The Appeal Board should have allowed Ms Steyn to
lead
evidence on the hip arthroscopy.
(b)
The Appeal Board had made a finding against Ms Steyn
without giving her an opportunity to lead evidence or be heard.
(c)
The Appeal Board incorrectly relied on new facts raised
by
Profmed at the last minute without giving Ms Steyn an
opportunity to respond to it.
(d)
Ms Steyn was prejudiced in that she was called upon to
answer a
case during the hearing of the matter which was not pleaded, and was
confronted with a finding that adversely affected
her based on facts
that were not properly presented and ventilated before the tribunal.
(e)
The Appeal Board took irrelevant considerations into account
and
ignored relevant considerations in terms of section 6(2)(e)(iii)
of PAJA.
(f)
The hearing before the
Appeal Board was procedurally unfair, as envisaged in
section 6(2)(c) of PAJA.
[15]
[27]
Regarding the
materiality of the non-disclosure of gastritis, the High Court
held that the onus rested on Profmed to prove
materiality and that
the non-disclosure induced Profmed to conclude the contract and to
assume the risk it otherwise would not
have accepted.
[16]
In this respect, the Court cited
Regent Insurance
.
[17]
The Court also referred to
Oudtshoorn Municipality
,
[18]
where it was held that the question is whether a reasonable person in
the position of the applicant would have considered that
the risk
should have been disclosed. It cited
Qilingele
[19]
as authority that the enquiry as to the materiality of the
misrepresentation is focused on a particular assessment; the evidence
of the underwriter is crucial; and evidence of the insurer’s
particular approach to materiality would be relevant.
The
High Court held that the Appeal Board’s use of
whether a condition falls within the PMBs as a test for materiality
has the consequence that all conditions that are not within the PMBs
must be disclosed during application. If the insured
were to
fail to disclose an
immaterial
condition that is not on
the PMB list, then a medical scheme may terminate. This, held
the High Court, is flawed.
[20]
[28]
According to the
High Court, Profmed did not lead evidence to prove the
materiality of the alleged non disclosure of the
gastritis and
that such non disclosure induced it to contract with
Ms Steyn.
[21]
It
held that the Appeal Board’s finding in this regard was
influenced by an error of law.
[22]
The High Court held further that a hip arthroscopy is
merely a diagnostic procedure, which showed that there was
nothing
amiss with Ms Steyn’s hip. A reasonably prudent
person in her position would not have deemed this relevant
to the
risk of the insurer. It also concluded that gastritis is a
common condition which a reasonable, prudent person would
not deem as
relevant to the risk of the insurer.
[29]
Having found in
favour of Ms Steyn, the High Court elected not to remit the
matter to the Appeal Board, because it
reasoned that the matter
had already been adjudicated upon in multiple forums and remitting
the matter to the Appeal Board
would be of no consequence.
It concluded that remittal would simply result in the incurring of
further costs and the delay
of justice.
[23]
The High Court thus set aside the Appeal Board’s
decision, declared Profmed’s termination of Ms Steyn’s
membership unlawful, and set it aside and ordered Profmed to honour
the contractual commitments under Ms Steyn’s policy.
[24]
Full Court
[30]
Profmed appealed
to the Full Court, which reversed the decision of the
High Court.
[25]
Regarding the issue of procedural fairness relating to the hip
arthroscopy, the Full Court held that the evidence in
the
Momentum Form was relevant and the Appeal Board was correct
to consider it. The evidence complained of was
introduced by
Ms Steyn herself and the High Court had erred in saying
that Profmed raised new facts during argument without
giving Ms Steyn
an opportunity to respond, and that she was called upon to answer a
case that had not been pleaded.
[26]
It was for Ms Steyn to set out her argument and the grounds for
her appeal, and she manifestly failed to do so.
This did not
render the proceedings unfair.
[27]
The Full Court held further that administrative bodies are
generally not required to comply strictly with the rules
of evidence
and there is also usually no onus of proof applied.
[28]
[31]
Regarding the
error of law, the Full Court held that the Appeal Board did
not commit an error of law in finding the non disclosure
of the
“gastric condition” to be material.
[29]
It held that the test for materiality is whether a reasonable person
would have considered the information reasonably relevant
to the risk
and this aspect must have become apparent from the detail required in
the application form.
[30]
Because the gastric condition required a hospital visit for a
gastroscopy and colonoscopy, a reasonable person would have
considered these facts reasonably relevant to the risks and
subsequent assessment by Profmed, held the Court.
[31]
[32]
The Full Court
further held that the High Court had failed to have due regard
to the distinction between appeal and review
– it erroneously
delved into the merits.
[32]
The Full Court also held that there were no exceptional grounds
for the High Court’s substitution of the
Appeal Board’s
decision. It thus upheld Profmed’s appeal and set aside
the High Court’s decision.
[33]
Following upon her unsuccessful application to the
Supreme Court of Appeal for special leave to appeal
and the subsequent
unsuccessful reconsideration application to the
President of that Court, Ms Steyn now seeks leave to appeal in
this Court.
But before engaging with that application, the
substitution application bears consideration.
Issues
[34]
These are the issues that arise:
(a)
The application to substitute Ms Steyn as applicant with
her
attorney and the executor of her deceased estate, Mr Swanepoel,
and relatedly, Mr Swanepoel’s standing.
(b)
Jurisdiction and leave to appeal.
(c)
If leave to appeal is granted, the merits of the appeal.
This
entails determining—
(i)
whether the hearing before the Appeal Board was
procedurally
fair;
(ii)
whether the Appeal Board was correct in its finding that
Ms Steyn
had a duty to disclose the hip arthroscopy and
gastritis, and that the non disclosure was material; and
(iii)
whether to remit the matter to the Appeal Board if we were to
find in
Ms Steyn’s favour or to substitute this Court’s
decision for that of the Appeal Board.
Substitution
application
Parties’
submissions
[35]
The timeline of events relating to the substitution
application is of importance. Ms Steyn passed away on
12 January 2023,
after her application for leave to appeal
(main application) had been filed in this Court (on 22 November 2022)
and the
filing of an answering affidavit in opposition to the main
application (on 5 December 2022). On 9 May 2023,
the attorney who had been acting for her throughout, Mr Swanepoel,
was appointed as executor to Ms Steyn’s deceased
estate.
On 8 August 2023, this Court issued directions relating to
a number of issues in the main application.
In response, on
22 August 2023, written submissions were filed,
inexplicably citing the late Ms Steyn as the applicant
at a time
when Mr Swanepoel had already been appointed as the executor of
her deceased estate. Profmed’s written
submissions were
filed on 5 September 2023 and, on 3 November 2023,
this Court directed the parties to file
full written submissions in
the main application. They were filed in January 2024
(the applicant) and March 2024
(the respondent)
respectively.
[36]
On 23 January 2024, written submissions were filed,
citing Mr Swanepoel as the applicant and only thereafter, on
24 January 2024, was a notice of substitution and an
affidavit delivered to Profmed and filed with this Court on
29 January 2024.
Further affidavits and supplementary
written submissions in the substitution application followed.
[37]
When confronted at the hearing about the inordinate delay in
the filing of the substitution application and the filing of written
submissions on 22 August 2023 in the name of the late
Ms Steyn, counsel explained that Mr Swanepoel laboured
under the
bona fide
impression that under this Court’s
rule 7, any action was automatically stayed and that
substitution followed as a matter
of course. On his behalf it
was submitted that in his role as the executor of Ms Steyn’s
estate, Mr Swanepoel
may litigate on behalf of the estate.
Mr Swanepoel maintains that monetary benefits to the deceased
estate would include
the R400 000 in medical claims due by
Profmed under the policy.
[38]
Profmed opposes the substitution application and submits that
Ms Steyn’s passing is material to the application for
leave
to appeal. It contends that Mr Swanepoel had
deliberately chosen not to disclose Ms Steyn’s death when
he
had responded to this Court’s directives in Ms Steyn’s
name, even though she had already passed away.
Profmed argues
that no reasons have been provided for the timing of the substitution
application and the lack of disclosure of
Ms Steyn’s
passing. It contends that the effect of this failure to
disclose has been that this Court has considered
the application for
leave to appeal in the absence of knowledge of material facts that
may (or would) have influenced its decision
to issue the directives
on 8 August 2023, or to dismiss the application for leave
to appeal without more.
[39]
Profmed emphasises further the significance of the fact that,
prior to issuing the directives referred to above, this Court was
deprived of the opportunity to consider whether the executor had any
right to the relief sought in the review, and whether the estate
would have the same right to administrative justice in terms of PAJA,
to which Ms Steyn may have been entitled. Profmed
answers
this question in the negative – it submits that there is no
authority for the proposition that a person’s right
to
administrative justice survives their death and is transferred to
their deceased estate. Thus, according to Profmed, Mr Swanepoel
does not, in his capacity as the executor, have the authority to
litigate on behalf of Ms Steyn’s deceased estate in
respect of the review application. Consequently, Profmed
submits that the application for substitution is legally untenable
and ought to be dismissed.
Evaluation
[40]
Rule 7 reads:
“
7
Change of Parties
(1)
If a party dies or becomes incompetent to continue any proceedings,
the proceedings
shall thereby be stayed until such time as an
authorised representative or other competent person has been
appointed in the place
of such party, or until such incompetence
ceases to exist.
(2)
Where an authorised or other competent person has been so appointed,
the Court may,
on application, order that such authorised or
competent person be substituted for the party who has so died or
become incompetent.”
[41]
Self evidently, the rules of this Court cannot grant
substantive rights in respect of the substitution application –
they merely govern aspects of procedure. Reliance on rule 7
in and of itself does not resolve the substantive questions
of law
relating to whether the cause of action and rights being litigated
are transmissible to the estate or the heirs. Rule 7(2)
provides that
an authorised person may apply to be substituted
for another party. It bears emphasis that “authorised”
self evidently must mean
authorised by law
.
[42]
The approach,
generally, is to treat substitution applications in the same manner
as applications to amend pleadings. The
overriding
consideration is whether substitution would cause irremediable
prejudice to the other party. As it was explained
in
Tecmed
:
[33]
“
The
settled approach to matters of this kind follows the considerations
in applications for amendments of pleadings. Broadly
stated it
means that in the absence of any prejudice to the other side, these
applications are usually granted . . . . the risk
of prejudice will
usually be less in the case where the correct party has been
incorrectly named and the amendment is sought to
correct the misnomer
than in the case where it is sought to substitute a different party.
But the criterion remains the same:
will the substitution cause
prejudice to the other side which cannot be remedied by an order for
costs or some other suitable order,
such as a postponement?”
[34]
[43]
Profmed contends that the prejudice it suffers by virtue of
the substitution application is twofold – first, that it has
been
required to deal with an application for leave to appeal absent
relevant and material facts that may have influenced this Court’s
decision to hear the application for leave to appeal rather than
simply dismissing it. Second, that should the substitution
be
granted, no case has been made out as to the entitlement of the
executor to the relief sought in the main application or the
application for leave to appeal.
[44]
Central to the
enquiry with regard to substitution is whether Ms Steyn’s
PAJA review claim is transmissible to her deceased
estate. If
not, then absent any review claim that the deceased estate itself may
have independently and separate from that
of Ms Steyn,
substitution is not legally tenable. In the High Court,
the applicant sought an order that the Appeal Board’s
ruling “be reviewed and set aside”; that its order be
substituted with orders (a) holding that the termination of
membership by Profmed “is ruled as being unlawful and is set
aside”; and (b) an order that Profmed “honour [its]
contractual commitments . . . . under the policy”. This
was plainly a review application against the decision of the
Appeal Board. Counsel accepted that the decision sought to
be reviewed is that of the Appeal Board, although an
order was
originally sought in the notice of motion against all three of the
first three respondents’ decisions. As
an aside, judging
by the averments in the applicant’s founding affidavit there,
the review was brought in the High Court
on both common law and
PAJA grounds. That is impermissible – all reviews must
now be brought under PAJA, which has
subsumed the common law review
grounds.
[35]
[45]
The claim in the notice of motion to “honour contractual
commitments” is undoubtedly one that is wholly dependent upon
the review of the Appeal Board’s decision – that
much was conceded by counsel. That claim, if upheld, had
a
direct financial interest for Ms Steyn, namely payment of her
medical claims by Profmed. If the claim was unsuccessful,
she
would have had to make payment from her own pocket. This
financial interest is an important factor that bears consideration
in
determining the transmissibility of the claim. A further
important factor is the nature of the claim, which is the next
topic
for discussion.
[46]
In
Mkhize
,
this Court clarified that the discussion of the nature of a right and
its transmissibility focuses specifically on the relief
that was
originally sought by the deceased in the matter.
[36]
That case concerned a dispute regarding the appointment as
iNkosi
(traditional leader) of
the
Mbuyazi
Traditional Community in KwaZulu Natal
.
The original applicant had launched a review application against the
Premier of KwaZulu Natal after the latter had
withdrawn his
recognition as
iNkosi
.
The original applicant passed away amidst the litigation and there
was then an application by the respondents that, amongst
others, the
review application be dismissed. This application was premised
on the argument that the
rights
of the deceased to be recognised as
iNkosi
were
personal to him and that these rights were not transmissible to his
heirs or anyone else. The contention was that there
was no
legal basis upon which the executrix or any heir could lay claim to
the traditional leadership position, in the absence
of a declaratory
order confirming the deceased as the rightful
iNkosi
.
[47]
This Court held in
Mkhize
that, when interpreting a
judgment or order, one must consider the “manifest purpose”
of that judgment or order and
the court’s intention must be
ascertained primarily from the language of the judgment or order
which must be read as a whole.
It stated that “[n]otably,
the discussion of the nature of the right and its transmissibility
focuses specifically on the
relief that was originally sought by the
deceased – his reinstatement as
iNkosi
”
.
[37]
In that matter, this Court disagreed with the
Supreme Court of Appeal’s finding that the
review and
monetary claim are distinguishable.
[48]
In our law of
succession the estate of a deceased person does not include rights
and liabilities of a purely personal nature attached
to that person
and that have terminated with the death of the deceased.
[38]
The right to fair administrative action can be claimed by a deceased
estate, but then the right is that of the estate, not
the deceased,
inasmuch as that right forms part of the assets and liabilities in
the estate and thus falls in the estate.
[39]
That has a direct impact on what can be claimed under the right.
Here, this Court’s approach in
Mkhize
suggests that the
personal claim to just administrative action of Ms Steyn is
transmissible to her deceased estate.
[49]
In this instance, we must holistically consider the components
of the claim relating to the contractual performance relief and the
claim for judicial review relief. Viewed thus, it appears to me
that the judicial review and contractual relief are transmissible.
If Ms Steyn had only claimed reinstatement as a member with no
attempt to recover unpaid claims, the proceedings would be
purely
personal in nature and would perish with her. Where, however,
the claim is for the reimbursement of expenses pursuant
to a wrongful
termination of membership – which has a financial component –
the claim would be transmissible.
[50]
The cause of
action for review must be transmissible where, as is the case here,
the estate has a financial interest in the outcome
of the review, and
not only a mere interest in the right underlying the review.
This approach finds support in
Mkhize
.
[40]
[51]
This raises a
different question whether a decision of a medical scheme (or any
entity of that scheme) constitutes administrative
action as defined
in section 1 of PAJA.
[41]
If it is administrative action, for the reasons given earlier, this
may not render it transmissible if the review relief
sought is
entirely personal to the deceased. Judicial review would be
competent only if the decision challenged is administrative
action.
Once that has been established, one must then enquire whether on the
facts and the pleadings it is a claim for judicial
review that is
transmissible.
[52]
This question was
answered in the negative in
Pennington
.
[42]
At the hearing, counsel for the applicant accepted that
Pennington
appears to be against the
applicant’s case. It seems to me that
Pennington
was not
correctly decided. Instead, as stated,
Mkhize
supports the view that
the PAJA claim is transmissible from Ms Steyn to the estate,
insofar as it concerns the decision of
the Appeal Board.
[53]
The following passage from
Mkhize
is instructive:
“
Beyond
this, however, the review application was brought by the deceased in
terms of the [PAJA], in terms of which anyone may institute
proceedings for the judicial review of an administrative action. A
review under PAJA determines, finally, whether an administrative
action is lawful or not. It is an objective exercise, the
outcome of which binds not only the litigating parties, but everyone
else.
The
review of administrative action attaches therefore not to the party
bringing the review, but to the exercise of public power
itself. It
stands to reason then, that Ms Mkhize had standing both to bring
and be substituted in the review application
by virtue of her
position as executrix of the estate and status as the legal guardian
of her minor son, Phathokuhle
.
This is not only because she has a direct and substantial
interest in the matter, but also because she was entitled to review
the Premier’s administrative action under section 6(1) of
PAJA. The Supreme Court of Appeal did
not have
explicit regard to the nature of a PAJA review, but the outcome it
reached is compatible with previous decisions of this
Court . . . .
Given that this Court has held that the review of public power
is a constitutional matter, it follows that
a broad approach to
standing must be taken in such reviews. That PAJA was enacted
to give effect to the constitutional right
to just administrative
action in section 33 of the Constitution, and so reviews under
PAJA are a way of enforcing the right
in section 33, also
implies that the broad standing requirements in section 38
should apply to the review of administrative
action.”
[43]
(Emphasis added).
[54]
The decision of the Appeal Board appears to me to
constitute administrative action. In terms of the definition of
administrative
action in PAJA, the Appeal Board’s decision
is by an organ of state exercising public powers and performing
public functions
under legislation. The Appeal Board
exercises a public function – its establishment under the MSA
serves the purpose
of scrutinising decisions of the Council and,
indirectly, those of the Registrar (since those decisions are
appealed to the Council).
This is very similar to internal
appeals within other public bodies. Thus, the Appeal Board
is performing a public function
when it exercises its statutory
appeal power over a decision of a scheme to terminate the membership
of one of their members.
The conclusion is therefore
inescapable that the Appeal Board is an organ of state whose
decisions constitute administrative
action.
[55]
In this regard, the MSA is designed to limit the contractual
freedom of medical schemes by placing regulatory control over a range
of their decisions (including decisions affecting their relationship
with their members, like the decisions in the present case).
Importantly, though, those decisions directly impact members’
fundamental right to access to medical care.
[56]
In sum therefore, Ms Steyn’s PAJA claim to just
administrative action is transmissible to her deceased estate.
The decision of the Appeal Board constitutes administrative
action and is not merely personal in nature. The application
for substitution must therefore be granted. In view of this
conclusion, a related matter which requires brief consideration,
is
Mr Swanepoel’s standing to bring this application.
Mr Swanepoel’s
standing
[57]
Section 38 of
the Constitution provides a broad scope for legal standing.
[44]
Mr Swanepoel seeks to act on behalf of the late Ms Steyn in
a review application in which he alleges that a right
in the
Bill of Rights has been infringed. He plainly falls
within the purview of section 38. Further,
given that the
review of public power is a constitutional matter, a broad approach
to standing must be taken.
[45]
As stated, this is a PAJA review, which seeks to determine whether
administrative action is lawful or not, the outcome of
which binds
not only litigating parties, but everyone else. The review of
administrative action therefore attaches not to
the party bringing
the review (the applicant), but to the exercise of public power
itself. These rights are thus not
of a “purely personal
nature”. Therefore, self evidently Mr Swanepoel
has standing to be substituted
in the review application.
[58]
There is another compelling basis on which he has standing –
by virtue of section 6(1) of PAJA, which states that any
person
may institute proceedings in a court or tribunal for the judicial
review of administrative action. It would be legally
untenable
to conclude in the face of section 6(1), that these rights are
merely personal, or to liken them to claims such
as one for damages
under the
actio iniuriarum
(infringements of personality
rights). For all these reasons, Mr Swanepoel has the
requisite standing to bring this
PAJA review application and to be
substituted for the late Ms Steyn.
Jurisdiction
and leave to appeal
[59]
The grounds of jurisdiction outlined in section 167(3)(b)
of the Constitution have been the subject of a number of judgments
of
this Court and they are well established (by that I must not be
understood to say they are without complexity; they are not).
Before us, Profmed accepts that the subject of the appeal before the
High Court and the Full Court concerned administrative
action in the form of a decision taken by the Appeal Board.
However, Profmed submits that the Full Court judgment
is
manifestly not a decision on a constitutional issue. According
to Profmed, although the applicant has attempted to suggest
that
there are constitutional issues that arise from the Full Court
judgment, it is clear that no such issues arise.
What was
required, contends Profmed, was at least some basis for asserting
that the Full Court failed to uphold the applicant’s
constitutional rights relating to the Appeal Board proceedings.
It submits that no such case has been made out in this
Court.
[60]
By virtue of the
finding that the review claim is transmissible from Ms Steyn to
the deceased estate, this Court’s constitutional
jurisdiction
is engaged. The issue relating to standing bears on section 38
of the Constitution
[46]
and
that of judicial review implicates section 33 of the
Constitution.
[47]
The
procedural unfairness component of the review is a constitutional
issue beyond the factual disputes about the materiality
of the
non disclosures of the various conditions.
[61]
The appeal also
raises a point of law of general public importance – whether
the materiality of a non disclosure on the
objective common law
test constitutes an adequate ground permitting a medical aid to
terminate membership, or whether, as has been
most recently
reaffirmed in
Regent Insurance
,
[48]
an insurer must also prove that the non disclosure induced it to
enter the contract. This is an arguable point of law
of general
public importance, because it will govern all cases where a medical
aid seeks to terminate a member’s membership
on grounds of
non disclosure.
[62]
We must decide whether the argument advanced by Profmed that
the reference to “the non disclosure of material
information”
in section 29(2)(e) of the MSA means that it
is sufficient for a medical scheme to prove that the non disclosure
was
objectively material for it to be able to terminate the
membership without also having to prove the additional common law
element
of showing that the non disclosure, in fact, induced it
to enter into the contract. This argument was necessary,
because
Profmed failed to adduce any evidence to show that it was, in
fact, induced to enter into the contract by the non disclosure.
If we were to find that the statutory test does not do away with the
inducement element in the common law test, the law point will
be
particularly important, because that would entail that the statutory
test and the common law test are the same. A medical
aid
wanting to terminate membership on grounds of non disclosure
will have to show what its membership acceptance practices
are in
relation to applicants who make full disclosure and have similar
health histories to that of the member they want retrospectively
to
terminate for non disclosure.
[63]
A further
consideration why this Court’s constitutional jurisdiction is
engaged is that medical aids provide a gateway for
many in South
Africa to the right to have access to health care services.
Decisions of the Appeal Board may thus in
certain (I
calculatedly do not say
all
)
circumstances implicate that right. It is, to some extent,
analogous to the position of the South African Social Security Agency
and its contracted entity, Cash Paymaster Services, whose
role was considered in
Allpay
II
[49]
in respect of the right to social assistance in section 27(1)(c)
and (2) of the Constitution to be “the gatekeeper of
the right
to social security [which] effectively controls beneficiaries’
access to social assistance”.
[50]
To that extent, medical aid schemes perform similar functions in
respect of healthcare.
[64]
It is furthermore in the interests of justice that leave be
granted to decide this matter so that clarity be provided regarding
the issue of the materiality of the non disclosure of medical
conditions in respect of membership of medical aids, a matter
that
affects a significant number of people.
Merits
Applicant’s
submissions
[65]
The applicant’s
PAJA review grounds have been set out earlier.
[51]
Regarding the hip arthroscopy, the applicant submits that a hip
arthroscopy is merely a diagnostic tool, and an insured cannot
be
expected to disclose a non existent condition. According
to the applicant, the Full Court judgment has the consequence
that, should an insured fail to disclose each and every visit to
medical establishments or to doctors’ appointments,
irrespective
of the diagnosis (material or immaterial), the insurer
will have the right to terminate medical cover. The applicant
contends
that the procedural unfairness lies in Profmed initially
relying on three grounds of termination and later adding further
grounds
(the hip arthroscopy). In addition, Ms Steyn was
then deprived of the opportunity to lead evidence pertaining to the
hip arthroscopy.
[66]
In respect of gastritis, the applicant submits that the
Appeal Board concluded that, because gastritis is not on the
list of
PMBs, it is to be treated as a material condition. The
applicant points out that section 29(2) of the MSA makes no
mention
of PMBs. It is submitted further that PMBs have no
bearing on the materiality of non disclosures, because it is
used
in a completely different context. If the Appeal Board’s
reasoning is followed, this would mean that an insured
who applies
for medical insurance can circumvent section 29(2)(e) of MSA by
not disclosing any of the plethora of medical
conditions listed in
the PMBs.
[67]
The applicant
submits that the Full Court overlooked the fact that Profmed’s
application form did not require the disclosure
of diagnostic
procedures. It also overlooked that the gastroscopy had
established that Ms Steyn did not have a gastric ulcer,
but
merely gastritis and that Profmed had presented no evidence that
gastritis gives rise to a material risk on Profmed’s
part.
According to the applicant, the High Court had correctly found
that the onus rests on the insurer to prove materiality
and Profmed
did not lead any evidence to discharge that onus. The
High Court had also correctly relied on
Oudtshoorn Municipality
[52]
and
Regent Insurance
.
[53]
Respondent’s
submissions
[68]
Profmed submits that the Full Court was correct to find
that the Appeal Board committed no reviewable irregularity,
taking
into account that the core issue for the Appeal Board to
determine was whether the non disclosure was related to material
information. According to Profmed, it was apparent from the
detail required in the application form, that the information
regarding the gastric condition was “reasonably relevant to the
risk and its assessment by an insurer”. A reasonable
person would consider a “gastric condition” relevant to
their risk of assessment especially when considering the facts
surrounding Ms Steyn’s condition (that is, the suspicion
of a gastric ulcer, the hospital visit, and the gastroscopy).
Profmed submits that Ms Steyn had admitted that she did not
disclose that she suffered from gastritis.
[69]
Regarding procedural fairness, Profmed submits that Ms Steyn’s
complaint is not that she was deprived of an opportunity
to make
representations, but rather that the Appeal Board should have
precluded Profmed from referring to the hip arthroscopy.
Profmed contends that it was entitled to refer to this non disclosure
and the Appeal Board was entitled to take it into
account.
There was nothing precluding Ms Steyn from advancing any
explanations regarding the hip arthroscopy in her
written argument or
evidence before the Appeal Board. It is submitted further
that Ms Steyn had every reasonable
opportunity to make
representations to the Appeal Board and that the Appeal Board
was not entitled to disregard the documents
evidencing the
non disclosures before it as they were manifestly relevant.
Thus, submits Profmed, the Full Court
was correct to reject this
ground of review.
[70]
In respect of the alleged error of law, Profmed submits that,
while the High Court had found that the Appeal Board made
an error of law in not applying
Regent Insurance
, the
Full Court did in fact apply
Regent Insurance
.
Thus, Profmed submits, the Full Court had correctly interpreted
section 29(2)(e) of the MSA. Profmed supports
the
Full Court’s reasoning in respect of the PMBs.
[71]
Profmed submits that there is usually no onus of proof applied
in proceedings before administrative bodies and Ms Steyn’s
reliance on Profmed’s onus is misplaced. The only issue
for determination before the Appeal Board was whether
the
non disclosures related to material information. According
to Profmed, it is apparent from the signed application
form that a
reasonable and prudent person would have considered the information
concerned as reasonably relevant to the risk and
its assessment by an
insurer. There was no error by the Appeal Board in finding
that the information ought to have been
disclosed, thus submits
Profmed. Even if there was an error of law, a mere error of law
is not sufficient for an administrative
act to be set aside; an error
will not be material if it does not affect the outcome of the
decision.
[72]
Profmed’s position regarding the test for materiality is
that the assessment of the materiality of non disclosures
requires
an enquiry as to whether the undisclosed information ought
to have been disclosed to afford the medical scheme the opportunity
to assess the risks to the medical scheme of undertaking liability in
respect of that applicant, and for the purposes of considering
its
entitlement to exercise its limited right to impose upon the
applicant the waiting periods provided for by section 29A.
[73]
According to
Profmed, the materiality or otherwise of a misrepresentation must be
dealt with objectively. It contends that
this approach is
consistent with the well established common law test for
materiality set out in
Oudtshoorn Municipality
and
President Versekeringmaatskappy
.
[54]
Profmed points out that the test relied on in
Qilingele
(and the High Court)
was criticised in
Clifford
.
[55]
According to Profmed, the Full Court applied the correct
test for materiality and the non disclosures were accordingly
material. Lastly, Profmed submits that Ms Steyn has not
made out a case for arbitrariness.
The
legislative framework
[74]
Section 29(2)(d) and (e) of the MSA provides
that a medical scheme, like Profmed, may cancel or suspend a member’s
membership on the grounds of, inter alia, committing any fraudulent
act or the non disclosure of a material condition.
It
reads:
“
(2)
A medical scheme shall not cancel or suspend a member’s
membership . . . except on the grounds
of—
. . .
(d)
committing any fraudulent act; or
. . .
(e)
the non disclosure of material information.”
[75]
Section 29A(2)(a) of the MSA, which deals with waiting
periods, provides:
“
(2)
A medical scheme may impose upon any person in respect of whom an
application is made for membership
or admission as a dependant, and
who was previously a beneficiary of a medical scheme for a continuous
period of up to 24 months,
terminating less than 90 days immediately
prior to the date of application—
(a)
a condition-specific waiting period of up to 12 months, except in
respect of any treatment
or diagnostic procedures covered within the
prescribed minimum benefits.”
Analysis
Procedural
fairness of the hearing before the Appeal Board
[76]
The Appeal Board
was legally duty bound to ensure that the proceedings before it were
conducted in a procedurally fair manner.
[56]
It was required to have “an open mind and a complete picture of
the facts and circumstances within which the administrative
action is
to be taken. In that way the functionary is more likely to
apply his or her mind to the matter in a fair and regular
manner.”
[57]
[77]
A fair
administrative procedure is fact-dependent.
[58]
There must be a reasonable opportunity to make representations.
[59]
It was expressed thus in
Turner
:
[60]
“
The
principles of natural justice do not require a domestic tribunal to
follow the procedure and to apply the technical rules of
evidence
observed in a court of law, but they do require such a tribunal to
adopt a procedure which would afford the person charged
a proper
hearing by the tribunal, and an opportunity of producing his evidence
and of correcting or contradicting any prejudicial
statement or
allegation made against him . . . . The tribunal is required to
listen fairly to both sides and to observe ‘the
principles of
fair play’”.
[61]
[78]
In
De
Lange
,
[62]
this Court stated:
“
Everyone
has the right to state his or her own case, not because his or her
version is right, and must be accepted, but because,
in evaluating
the cogency of any argument, the arbiter, still a fallible human
being, must be informed of the points of view of
both parties in
order to stand any real chance of coming up with an objectively
justifiable conclusion that is anything more than
chance.”
[63]
[79]
The Appeal Board
dismissed Ms Steyn’s objection to Profmed’s reliance
on the hip arthroscopy for two reasons,
the first one was that
Profmed only became aware of the information later, from Ms Steyn’s
application to another medical
scheme; and, secondly, that in any
event, the Appeal Board had before it a wide appeal. Both
these grounds of dismissal
are misconceived. First, on the
common cause facts before the Appeal Board, Profmed raised
Ms Steyn’s “hip
problems” already in the
letter of termination dated 7 November 2016.
Secondly, as far as the wide appeal
is concerned, despite Ms Steyn’s
request to do so, the Appeal Board denied her an opportunity to
lead evidence
pursuant to her objection to the evidence introducing
the hip arthroscopy. This was a serious procedural
irregularity, in
contravention of the PAJA fair procedure
requirement.
[64]
[80]
Despite its initial reliance in its letter of 7 November 2016,
amongst others, on Ms Steyn’s non disclosure
of her
“hip problems”, no mention at all was made of this in
Profmed’s letter of 13 December 2016 in
response to
Ms Steyn’s referral to the Registrar.
Unsurprisingly, the Registrar in his ruling made no reference
at all
to these “hip problems”, plainly because Profmed had
abandoned further reliance on it. Ms Steyn alluded
in her
founding affidavit before the Council to this abandonment of the hip
problems by Profmed, who did not file any opposing
papers.
Ms Steyn’s averments thus remained unchallenged.
Before the Council, Profmed, having failed to address
these
allegations on affidavit, chose to deal with the hip problems issue
in oral argument only. Strangely, though, the Appeal Board
considered this aspect adversely to Ms Steyn without any
evidence being led before it. What was therefore a non issue
before the Registrar, uncontested before the Council and absent any
further evidence before the Appeal Board, ended up being
decided
against Ms Steyn.
[81]
The prejudice that Ms Steyn suffered is manifest –
she was deprived of the opportunity to lead evidence on the hip
arthroscopy
issue. Ms Steyn indicated in her papers in the
High Court that, had she been afforded the opportunity, she
would
have led evidence that the hip arthroscopy did not constitute
treatment for any ailment and that it was merely a diagnostic tool.
Ms Steyn’s objection to the introduction of the evidence
relating to her alleged hip problems and the Appeal Board’s
failure to afford her an opportunity to lead evidence in response,
must be assessed against the backdrop alluded to earlier.
She
had been guided by her husband and a representative of Profmed,
Ms Susan Brits, in filling in the application forms.
[82]
The answer by Profmed to Ms Steyn’s complaint of
prejudice, that Profmed’s oral argument was based on an
annexure
to Ms Steyn’s own affidavit and that there can
accordingly be no possible prejudice, does not bear scrutiny.
First,
section
50(4)
provides that any person who lodges an appeal under subsection (3)
shall submit with his or her appeal written arguments
or explanations
of the grounds of appeal. Ms Steyn filed written argument
where she, in the alternative to her written
submissions, applied for
leave to lead additional evidence with regard to new grounds raised
by Profmed or to lead evidence with
regard to any other submissions
and allegations made by Profmed. This was refused.
[83]
Secondly,
Profmed’s
argument also flies in the face of the
audi alteram partem
(hear the other side) principle.
That principle is encapsulated in the procedural aspects of the MSA
before a matter reaches the Appeal Board. Section 47(1)
requires a Registrar, where a complaint has been lodged
with the
Council, to furnish the party complained against with full
particulars of the complaint and to request that party to furnish
the
Registrar with written comments within 30 days of such notice or
on such time as the Registrar may allow. Section 48(1)
requires any person who is aggrieved by any decision relating to a
settlement of a dispute or complaint in terms of section 47(1),
to appeal to the Council. Section 48(3) provides that an
appeal to the Council shall be in the form of an affidavit
directed
to the Council whereas an appeal to the Appeal Board in terms of
section 50(4) of the MSA is lodged by filing
written argument or
explanations of the grounds of his appeal. Unlike
section 47(1), sections 48 and 50, dealing
with appeals to
the Council and to the Appeal Board respectively, are silent on
whether a respondent (medical scheme) is obliged
to file a response
in the form of an answering affidavit to the grounds of appeal lodged
in terms of section 48(3) or written
submissions in response to
the grounds of appeal filed in terms of section 50(4).
However, both sections empower the
chairpersons of these institutions
to determine the procedure for the hearing.
[84]
The Appeal Board’s approach appears to be grossly
unfair – not only was Ms Steyn faced with an unpleaded
case,
but she was also denied her express request to be granted an
opportunity to adduce evidence to meet the new unpleaded averments
regarding her alleged non disclosure of hip problems. The
Full Court concluded that—
“
the
[High Court] erred in its finding that the appellant raised new
facts during argument without giving the first respondent
an
opportunity to respond. . . . this is fortified by the fact that the
first respondent was not called on to answer a case which
had not
been pleaded”.
[85]
But, as explained, that conclusion is not borne out by the
evidence. It is also not correct, as the Full Court found,
that Ms Steyn had “manifestly failed” to set out her
argument and the grounds of appeal. This finding does
not
accord with the facts that I have outlined – Ms Steyn did
in fact set out her grounds of appeal, which included
the fact that
the proceedings before the Council were procedurally unfair.
[86]
The Full Court
cited
Lambert
that, “as a general
proposition, administrative bodies are generally not required to
comply strictly with the rules of evidence
and there is also usually
no onus of proof applied”.
[65]
There can be no quarrel
with that general statement concerning the incidence of the onus of
proof in respect of proceedings before
administrative bodies.
The difficulty though is that, here, the passage was cited by the
Full Court as part of its discussion
regarding the procedural
unfairness challenge by Ms Steyn. Self evidently the
passage in
Lambert
has no bearing on that
particular challenge.
[87]
In the very next paragraph of its judgment, continuing its
discussion in respect of the procedural unfairness challenge, the
Full Court
stated:
“
The
administrative respondents are all administrators established with
specific knowledge regarding the medical schemes industry,
the
challenges confronted by these schemes and mechanisms put in place to
safeguard members of the schemes. These respondents
are also
familiar with the conditions and benefits which these schemes are
obliged to provide.”
[66]
[88]
That is fallacious reasoning and suggests that the Registrar,
Council and Appeal Board must be trusted to, without fail, come
to the correct conclusion regarding the materiality of
non disclosure. It is tantamount to saying that the
decisions
of those Appeal Bodies are the law of the Medes and
Persians. For these reasons
,
I hold that the proceedings before the Appeal Board were unfair.
Duty
to disclose the hip arthroscopy and gastritis, and whether the
non disclosure was material
[89]
Two issues must be
addressed under this rubric
–
first,
the duty of disclosure regarding the hip arthroscopy and gastritis
and, secondly, whether the non disclosure was material.
In
respect of the first issue as far as it concerns the facts – i
t
bears repetition that Ms Steyn had been guided by a
representative of Profmed, Ms Susan Brits, in filling in
the
application form. Furthermore, the hip arthroscopy was
performed during June 2014, according to the applicant, some
17 months prior to the application for Profmed membership when
the application form was completed. In terms of the MSA,
an
insurer may only require an insured to provide medical information
within the 12 month period preceding the date of
application.
[67]
[90]
The next question
is whether the non disclosure was material. A duty of
disclosure would only arise in circumstances
where a medical
condition can be regarded as material. The applicant’s
forceful contentions that some guidance can
be obtained from cases
concerning similar provisions in the now repealed Short Term
Insurance Act,
[68]
such
as
Regent Insurance
and
Oudtshoorn Municipality
,
are sound. Both section 53(1) of the Short Term
Insurance Act and section 29(2)(e) of the MSA contain the
words
“material non disclosure”. There is strong
support in our case law for drawing analogy between cases
on similar
provisions in different statutes. In
Ferreira
,
[69]
this Court referred to such kindred statutory provisions (Sachs J
called them “sibling statutory provisions”).
There,
it was noted that the Investigation of Serious Economic
Offences Act
[70]
and the
Insolvency Act
[71]
provided for inquisitorial procedures not dissimilar to those in
section 417 of the Companies Act
[72]
which was under scrutiny.
[73]
[91]
In general, it is
understood that the
in
pari materia
(on
the same subject) rule is of some persuasion when an identical
provision is found in a statute that is similar in object, purpose,
and subject matter to the one being interpreted.
[74]
Statutory provisions
in pari materia
,
unless clearly repugnant, are to be read together. Where
different statutes deal with the same or kindred subject matter,
they should, in a case of uncertainty or ambiguity, be construed in a
manner so as to be consonant and interdependent – the
content
of the one statutory provision may shed light upon the uncertainties
of the other.
[75]
This
accords with foreign jurisprudence. It has been held in the
United States of America that the use
of “the
same language in two statutes having similar purposes” creates
a “presum[ption] that Congress intended
that text to have the
same meaning in both statutes”.
[76]
That presumption guides the interpretive analysis unless there is a
good reason – grounded in context, history, or
legislative
purpose – to depart from that shared reading.
[77]
[92]
In sum therefore,
while not determinative, some guidance can be gained from
section 53(1) of the Short Term Insurance
Act. The
following principles can be distilled from cases that relate to the
Short Term Insurance Act.
[78]
The test is objective, that is,
whether
information should have been disclosed is judged, not from the point
of view of the insurer, but from that of the notional
reasonable and
prudent person.
[79]
The
question is thus whether the reasonable person would have considered
the fact not disclosed as relevant to the risk and its
assessment by
an insurer. This brought the
Short Term
Insurance Act in line with the common law.
[80]
T
he
onus to prove materiality rests on the insurer.
[81]
Furthermore,
the
insurer must prove that the non disclosure induced it to
conclude the contract – the insurer must show that the
non disclosure caused it to issue the policy and assume the
risk
.
Applied to the present matter, the determination whether there should
have been a disclosure is objective. Profmed
bore the onus of
proving not only the materiality of non disclosure, but also
that it was induced to conclude the agreement.
[93]
Section 29(2)(e)
of the MSA does not define what information is deemed material.
It also does not explain how the materiality
of information should be
determined. The responsibility was left to medical schemes
themselves to deal with this in their
rules in relation to
materiality. In this instance, rule 12.4,
[82]
which refers to material non disclosure as a ground for the
cancellation of membership, does not set out the standard to be
applied in determining whether information is material.
However, Profmed’s application form does define material
information
as relating to disclosure of medical conditions.
[94]
What requires determination is whether medical conditions
would include both medical examinations and diagnostic procedures.
Profmed argues that it does and the applicant answers that question
in the negative – that mere diagnostic procedures are
excluded. What is apparent from the authorities is that one
only has an obligation to disclose material information.
A mere
diagnostic medical procedure which resulted in no material diagnosis
of a condition cannot be classified as a material non disclosure,
and a prudent and reasonable person would not regard it as such.
[95]
In light of the conclusion that an analogy may be drawn with
section 53(1) of the Short Term Insurance Act, plainly,
there
is no basis for a finding that the statutory test in
section 29(2)(e) dispenses with the inducement element in the
common
law. Section 29(2)(e) does not elevate materiality
into a condition that is sufficient for termination without proof
of
inducement. It must be interpreted such that it requires the
common law inducement element to be satisfied before membership
can
be terminated. This interpretation is fortified by the broader
scheme of the MSA, to extend medical cover as far as possible
and to
limit medical schemes’ “election” not to contract
with members. Further support for that interpretation
is to be
found in section 39(2) of the Constitution which requires a
court to interpret legislation in a manner which promotes
the spirit,
purport and objects of the Bill of Rights. Medical aids are
essential gateways to realising the right to access
health care
services under section 27(1)(a) of the Constitution.
[96]
As stated, in
terms of the common law and also under section 29(2)(e) of the
MSA, an insurer has to prove that the non disclosure
of a
material element induced it to enter into the contract. On
Profmed’s argument, proof of the objective materiality
of the
non disclosure without a need for further proof of the
additional element that it was as a matter of fact induced by
that
non disclosure, is sufficient. Plainly, Profmed was driven
to resort to this line of argument that the test in
section 29(2)(e)
dispenses with the need to prove inducement, because it did not
adduce any evidence to show that it was,
in fact, induced to enter
into the contract by the non-disclosure. This is a subjective
test
–
was
Profmed induced by the failure to disclose a material fact to issue
the policy? In making the enquiry, “evidence
that the
insurer had a particular approach to risks of the kind in question
would be relevant and could be cogent”.
[83]
[97]
Regent Insurance
is authority for the proposition
that, as is the case with an insurer under section 53(1) of the
Short Term Insurance
Act, proof of inducement is required on
Profmed’s part in respect of the non disclosure by
Ms Steyn. As stated,
no such evidence was adduced by
Profmed. At the very minimum, Profmed had to adduce evidence
relating to its membership acceptance
practices in respect of
applicants who make full disclosures and have similar health
histories to that of the member they want
retrospectively to
terminate for non disclosure. There is none.
[98]
The Full Court
misdirected itself by completely ignoring the fact that the
uncontroverted evidence of Dr Swanepoel, a
laparoscopic and
vascular surgeon, about the nature of a gastroscopy was never
considered by the Appeal Board. Ms Steyn’s
version that she was not diagnosed with a gastric ulcer was also not
considered. I accept that in some instances an administrator
may not attach too much weight to a factor when making their decision
and that would not necessarily imply that the administrator
did not
consider that factor.
[84]
However, in this case relevant evidence was not considered at all.
[99]
In my view, a mere medical examination and diagnostic medical
procedure which resulted in no material diagnosis of a condition
cannot
be classified as a material non disclosure and a prudent,
reasonable person would not regard it as such. The evidence
that gastroscopy and colonoscopy are merely medical examinations and
the explanation provided by Dr Swanepoel and the applicant
regarding gastritis is not in dispute. The Full Court thus
misdirected itself when it found that the applicant was required
to
disclose any of these medical examinations and diagnostic medical
procedures.
[100]
It seems to me that Profmed had terminated Ms Steyn’s
membership based on a misconception that she suffered from a gastric
ulcer. The Registrar ruled that Ms Steyn should have
disclosed that she underwent “gastroscopy and colonoscopy
on
4 March 2015 for a gastric ulcer” when the question
was not whether she had undergone a medical examination
for a
possible gastric ulcer, but whether she had actually suffered from
any of the listed diseases or medical conditions or disorders,
of
which a gastric ulcer was an example, or received treatment for them.
Plainly, on the uncontested evidence, the gastroscopy
in fact
revealed that she was not suffering from a gastric ulcer but
gastritis, a common medical condition which presents as heartburn
and
can often be relieved by self medication. The Registrar,
Council and Appeal Board all overlooked the distinction
between
the two conditions.
[101]
The Full Court erred in its finding that gastritis
requires an emergency visit to a hospital – no evidence was
adduced
in support of this proposition. It was common cause
that gastritis does not give rise to material risk. Ms Steyn’s
evidence of the difference between gastritis and a gastric ulcer was
supported by Dr Swanepoel’s expert evidence.
He
testified that gastritis, commonly known as heartburn, or symptoms of
indigestion, is an irritation and inflammation of the
stomach lining
and is a very common condition with about half of the population
suffering from it. A gastric ulcer, on the
other hand, is an
open sore in the lining of the stomach and is a more serious
condition. In light of this unchallenged evidence,
a reasonable
person in Ms Steyn’s position could not have considered
that gastritis should be disclosed and, moreover,
its non disclosure
is immaterial. The Council, and later the Appeal Board,
simply ignored this evidence and found
that Profmed was denied the
opportunity to make an accurate assessment and mitigate its risk by
imposing a statutorily empowered
condition specific waiting
period. In doing so, they erred.
[102]
The Appeal Board concluded that, because gastritis does
not form part of the PMBs, it is to be treated as a material
condition.
The Appeal Board’s rationale seemingly
was that those conditions that are included in the PMBs need not be
disclosed
by an insured when she applies for medical cover, while
those that are not included in the list must be disclosed.
Gastritis
is not included in the list. That rationale is
fundamentally flawed. Section 29(2)(c) of the MSA makes no
mention
of PMBs as the test to be applied regarding materiality.
It goes against trite principles of statutory interpretation for
the
Appeal Board to have read a requirement into section 29(2)(c)
which is not mentioned there. If it was the Legislature’s
intention that the standard of materiality is to be linked to the
PMBs, then such a reference would have been included in the MSA.
PMBs are provided for in a completely different context in the MSA in
section 29A – it has no bearing at all on the
materiality
or otherwise of non disclosures.
[103]
When one considers the PMBs themselves, it is noteworthy that
they are largely made up of material, and not immaterial,
conditions.
Notable examples are HIV, an array of cancers and a
number of conditions the list itself describes as
“life threatening”.
The list also includes
“gastric or intestinal ulcers” which the Appeal Board
accepted is a more serious condition
than gastritis. This
demonstrates the flawed logic in the Appeal Board’s
reasoning. On that approach, it
would mean that an insured who
applies for medical insurance can circumvent section 29(2)(e) by
not disclosing any of the
plethora of material conditions listed in
the PMBs. Conversely, if the insured fails to disclose an
immaterial condition
that does not appear on the list (such as the
common cold), then the insurer may lawfully repudiate the insurance.
This approach
is untenable, as it will achieve exactly the opposite
of what section 29(2)(e) expressly envisages, that the insured
must
disclose material information when she applies for medical
cover.
[104]
The Full Court erred when it held that “there was
no indication in the decision by [the Appeal Board] that a
non
disclosure (of a pre existing medical
condition) is linked to the enquiry of (or whether it relates to) a
prescribed minimum
benefit condition”. This completely
ignores the fact that the Appeal Board, in its own written
reasons, expressly
mentioned the PMBs. The Full Court
overlooked the fact that: Ms Steyn was not asked in the
application form whether
she had undergone diagnostic examinations;
the gastroscopy established that she did not have a gastric ulcer,
but merely gastritis;
and Profmed presented no evidence whatsoever
that gastritis gives rise to a material risk on Profmed’s part.
[105]
There is no dispute that Ms Steyn underwent a hip
arthroscopy prior to 2015 – she conceded this fact. The
arthroscopy
was, however, plainly a diagnostic procedure and not a
medical condition. There was no evidence to suggest that there
was
something wrong with Ms Steyn’s hip and, as stated,
she was denied an opportunity to adduce evidence to the contrary.
There was no evidence before the Appeal Board to support its
findings that the fact that Ms Steyn had undergone a hip
arthroscopy implied that she suffered from arthritis, most likely
osteoarthritis, affecting large joints such as knees, hips, and
wrists. These findings of the Appeal Board erroneously
assumed that there was something to be disclosed.
[106]
As stated, the hip arthroscopy was a diagnostic tool and not a
medical condition. There was thus no duty to disclose it and,
moreover, non disclosure was not material. Furthermore,
and in any event, the hip arthroscopy was performed during June 2014,
approximately 17 months prior to Ms Steyn’s
completion of the Profmed form. In terms of section 29A(7)
of the MSA, an insurer may only require an insured to provide medical
information within 12 months from date of application.
This is a further reason why the hip arthroscopy did not have to be
disclosed. In the premises, the PAJA review must be upheld.
What bears consideration next is the appropriate remedy.
Remedy:
substitution or remittal
[107]
The question that
arises is whether to remit the matter for reconsideration
[85]
or to substitute the impugned decision.
[86]
The test for substitution is well
established.
[87]
The primary factors that bear consideration are—
(a)
whether a court is in as a good a position as the original
decision maker to make the decision;
(b)
whether the outcome, if remitted, is a foregone conclusion;
and
(c)
other relevant factors like
delay, bias, or the incompetence of an administrator.
[108]
The ultimate
consideration is whether a substitution order is just and equitable.
This
will involve a consideration of fairness to all implicated parties
and whether anything
would be gained by remitting it.
[88]
It will be recalled that the High Court substituted the
Appeal Board’s ruling with one in favour of Ms Steyn.
That appears to me to be the correct course of action in this
instance. I agree with the applicant that the outcome is a
foregone conclusion. Profmed is plainly, on all the facts and
circumstances in no position to gainsay any of the evidence
adduced
by Ms Steyn or that which she would have been able to adduce in
respect of the hip arthroscopy had she been afforded
the opportunity
to do so. Profmed had numerous opportunities to do so before
the Appeal Bodies and the High Court
but failed to do so.
This Court is in
as
good a position as the Appeal Board, since none of its expertise
is still required and this Court has before it all the
pertinent
information, none of which is contested.
[89]
[109]
In
considering what is just and equitable, I take the view that this is
one of those exceptional cases where this Court will not
be usurping
the functions of the decision maker, the Appeal Board, and that
substitution is warranted. A remittal will
only run up costs
unnecessarily for the deceased estate and cause further delay.
The matter has already been before the three
Appeal Bodies, and
this is the fourth court that has been seized with the case.
[90]
Costs
[110]
Costs
must follow the outcome. An aspect that bears consideration in
relation to costs is
the
conduct of the attorney/executor, Mr Swanepoel, in the
substitution application. The timeline set out earlier speaks
for itself insofar as the laxity on the part of Mr Swanepoel is
concerned. The most disturbing aspect is that on
22 August 2023,
in response to this Court’s
directives, written submissions were filed, citing the late Ms Steyn
as applicant at a time
when Mr Swanepoel had already been
appointed as the executor of her deceased estate. As stated,
the only explanation
for this lapse is that Mr Swanepoel was
under the
bona
fide
impression
that in terms of this Court’s rule 7, substitution
followed as a matter of course. At best for Mr Swanepoel,
that displays a disturbing lack of insight into what the rule
unambiguously provides.
[91]
[111]
I am prepared to
give Mr Swanepoel the benefit of the doubt on this aspect.
His conduct does not fall into the category
of egregiousness that
would warrant a personal costs order.
[92]
Conclusion
[112]
The substitution application must succeed, leave to appeal
ought to be granted and the appeal must be upheld with costs.
The
costs of two counsel is warranted. I make the following
order:
1.
The late filing of the application for leave
to appeal is condoned.
2.
The application for substitution is granted
and the executor of the
deceased estate is substituted for Ms Mignon Adelia Steyn
as applicant.
3.
Leave to appeal is granted.
4.
The appeal is upheld.
5.
The order of the Full Court is set aside
and substituted with
the following:
“
The appeal is
dismissed with costs, including costs of two counsel where so
employed.”
6.
The respondent must pay the costs, including
costs of two counsel.
For the Applicant:
RF van Rooyen
SC, JP Steenkamp and D Murote instructed by
Carlo Swanepoel Attorneys
For the Respondent:
AR Sholto Douglas SC; DM Smith,
B Dhladhla and T Skosana instructed by
Knowles Husain Lindsay
Incorporated
[1]
10
of 2013.
[2]
131
of 1998.
[3]
Section 47 reads:
“
(1)
The Registrar shall, where a written complaint in relation to any
matter provided for
in this Act has been lodged with the Council,
furnish the party complained against with full particulars of the
complaint and
request such party to furnish the Registrar with his
or her written comments thereon within 30 days or such further
period as
the Registrar may allow.
(2)
The Registrar shall, as soon as possible stir receipt of any
comments furnished to him
or her as contemplated in subsection (1),
either resolve the matter or submit the complaint together with such
comments,
if any, to the Council, and the Council shall thereupon
take all such steps as it may deem necessary to resolve the
complaint.”
[4]
Enumerated in the preceding paragraph.
[5]
Mahomed
v Genesis Medical Scheme
,
unreported judgment of the High Court of South Africa, Western
Cape Division, Cape Town, 649 17351/2010 (15 September 2010).
[6]
Mahadeo
v Dial Direct Insurance Limited
2008
(4) SA 80
(W) (
Mahadeo
)
at para 17.
[7]
A diagnostic procedure where a surgeon uses a device with a small
camera to see inside the hip joint.
[8]
A
chronic health condition that causes musculoskeletal pain, fatigue,
and insomnia.
[9]
Section 50(3) reads:
“
Any
person aggrieved by a decision of the Registrar acting with the
concurrence of the Council or by a decision of the Council
under a
power conferred or a duty imposed upon it by or under this Act, may
within a period of 60 days after the date on which
such decision was
given and upon payment to the Registrar of the prescribed fee,
appeal against such decision to the Appeal Board.”
[10]
Section 29A(2)(a) reads:
“
(2)
A medical scheme may impose upon any person in respect of whom an
application is made
for membership or admission as a dependant, and
who was previously a beneficiary of a medical scheme for a
continuous period
of up to 24 months, terminating less than 90 days
immediately prior to the date of application—
(a)
a condition specific waiting period of up to 12 months, except in
respect
of any treatment or diagnostic procedures covered within the
prescribed minimum benefits.”
[11]
3
of 2000.
[12]
That section provides:
“
(2)
A court or tribunal has the power to judicially review an
administrative action
if—
. . .
(e)
the action was taken—
. . .
(iii)
because irrelevant considerations were taken into account or
relevant considerations
were not considered”.
[13]
Steyn v
Registrar of Medical Schemes
2021
(3) SA 551
(WCC) (High Court Judgment).
[14]
High Court Judgment above n 13 at para 14.
[15]
High Court
Judgment above n 13 at para 36.
Section 6(2)(c)
of PAJA provides:
“
(2)
A court or tribunal has the power to judicially review an
administrative action
if—
. . .
(c)
the action was procedurally unfair.”
[16]
High Court
Judgment above n 13 at para 40.
[17]
Regent Insurance Company Ltd
v King’s Property
[2014]
ZASCA 176
;
2015 (3) SA 85
(SCA) (
Regent Insurance
).
[18]
Mutual and Federal Insurance Co Ltd
v Oudtshoorn Municipality
[1984]
ZASCA 129
;
1985 (1) SA 419
(A) (
Oudtshoorn Municipality
)
at 435G-I.
[19]
Qilingele
v South African Mutual Life Assurance Society
[1992] ZASCA 189
;
1993
(1) SA 69
(A) (
Qilingele
)
at 75B-D.
[20]
High Court
Judgment above n 13 at para 46.
[21]
Id
at para 47.
[22]
Id
.
[23]
Id at para 49.
[24]
Id at para 50.
[25]
Profmed
Medical Scheme v Steyn
,
unreported judgment of the High Court of South Africa, Western
Cape Division, Cape Town, 60 A 171/2021 (26 April 2022)
(Full Court
Judgment).
[26]
Id
at
para 30.
[27]
Id at
para
31.
[28]
Id at
para
32. The Court cited
Lambert
v Director of Census
1956
(3) SA 452
(T) at 455A-B.
[29]
Full Court
Judgment above n 25 at para 27.
[30]
Id at
para
25.
[31]
Id at para
26.
[32]
Id at
paras
34-5.
[33]
Tecmed
(Pty) Ltd v Nissho Iwai Corporation
[2009]
ZASCA 143
;
2011 (1) SA 35
(SCA) (
Tecmed
).
[34]
Id at para 14. See also cases cited there.
[35]
Minister
of Health v New Clicks South Africa (Pty) Ltd (Treatment Action
Campaign as Amici Curiae)
[2005]
ZACC 14
;
2006 (2) SA 311
(CC);
2006 (1) BCLR 1
(CC) at para 96.
[36]
Mkhize
N.O. v Premier of the Province of KwaZulu Natal
[2018] ZACC 50
;
2019 (3)
BCLR 360
(CC) (
Mkhize
)
at para 53.
[37]
Id at para 51.
[38]
Hofmeyr et al
The
Law of Succession in South Africa
3
ed (Juta & Co Ltd, Cape Town 2023) at para 1.9.
[39]
Gildenhuys “Wills and Succession” in
LAWSA
4 ed (2023) vol 44 at
para 231.
[40]
Mkhize
above n 36 at paras 51
and 53.
[41]
Section 1 reads:
“‘
administrative
action’ means any decision taken, or any failure to take a
decision, by—
(a)
an organ of state, when—
(i)
exercising a power in terms of the Constitution or a provincial
constitution; or
(ii)
exercising a public power or performing a public function in terms
of any legislation; or
(b)
a natural or juristic person, other than an organ of state, when
exercising
a public power or performing a public function in terms
of an empowering provision, which adversely affects the rights of
any
person and which has a direct, external legal effect, but does
not include—
(aa)
the executive powers or functions of the National Executive,
including the powers
or functions referred to in sections 79(1)
and (4), 84(2)(a), (b), (c), (d), (m), (g), (h), (i) and (k),
85(2)(b), (c),
(d) and (e), 91(2), (3), (4) and (5), 92(3), 93, 97,
98, 99 and 100 of the Constitution;
(bb)
the executive powers or functions of the Provincial Executive,
including the powers
or functions referred to in sections 121(1)
and (2), 125(2)(d), (e) and (m), 126, 127(2), 132(2),
133(3)(b), 137, 138,
139 and 145(1) of the Constitution;
(cc)
the executive powers or functions of a municipal council;
(dd)
the legislative functions of Parliament, a provincial legislature or
a municipal
council;
(ee)
the judicial functions of a judicial officer of a court referred to
in section 166
of the Constitution or of a Special Tribunal
established under section 2 of the Special Investigating Units
and Special
Tribunals Act, 1996 (Act No. 74 of 1996), and the
judicial functions of a traditional leader under customary law or
any other
law;
(ff)
a decision to institute or continue a prosecution;
(gg)
a decision relating to any aspect regarding the appointment of a
judicial officer,
by the Judicial Service Commission;
(hh)
any decision taken, or failure to take a decision, in terms of any
provision of
the
Promotion of Access to Information Act, 2000
; or
(ii)
any decision taken, or failure to take a decision, in terms of
section 4(l)
”.
[42]
Pennington
v Friedgood
2002
(1) SA 251
(C) (
Pennington
)
at paras 41-2; referred to with apparent approval in
Trustees
for the time being of the Legacy Body Corporate v Bae Estates and
Escapes (Pty) Ltd
[2021]
ZASCA 157; 2022 (1) SA 424 (SCA).
[43]
Mkhize
above n 36 at paras
69-70.
[44]
Section 38
reads:
“
Anyone
listed in this section has the right to approach a competent court,
alleging that a right in the Bill of Rights has been
infringed or
threatened, and the court may grant appropriate relief, including a
declaration of rights. The persons who
may approach a court
are—
(a)
anyone acting in their own interest;
(b)
anyone acting on behalf of another person who cannot act in their
own
name;
(c)
anyone acting as a member of, or in the interest of, a group or
class
of persons;
(d)
anyone acting in the public interest; and
(e)
an association acting in the interest of its members.”
[45]
G
iant
Concerts CC v Rinaldo Investments (Pty) Ltd
[2012]
ZACC 28
;
[2013] 3 BCLR 251
(CC) at paras 45 and 47.
[46]
Id.
[47]
Id at paras 28-9.
[48]
Regent Insurance
above n 17 at para 23.
[49]
Allpay
Consolidated Investments Holdings (Pty) Ltd v Chief Executive
Officer, South African Social Security Agency
[2014] ZACC 12
;
2014 (4)
SA 179
(CC);
2014 (6) BCLR 641
(CC) (
Allpay
II
).
[50]
Id at para 55.
[51]
In [23].
[52]
Oudtshoorn Municipality
above
n 18 at 435G-I.
[53]
Regent Insurance
above n 17 at para 23.
[54]
President
Versekeringsmaatskappy Bpk v Trust Bank van Afrika Bpk
[1988] ZASCA 88
;
1989
(1) SA 208
(A) (
President Versekeringmaatskappy
)
at 216F.
[55]
Clifford
v Commercial Union Insurance Co of SA Ltd
[1998]
ZASCA 37
;
1998 (4) SA 150
(SCA) at 156D-J, where the Court held:
“
If
I, as a member of this Court, were asked to interpret
section 63(3)
for the first time, I would not interpret it as Kriegler AJA
did in
Qilingele
[above n 19]. To my mind, his interpretation does not give
effect to the purpose or import of the subsection; nor does
it
differentiate clearly the concepts of materiality and inducement.
At common law an insurer relying upon being misled
must prove
both things. He must prove, in the first place, materiality.
This is, of course, also an aspect of wrongfulness
in a
delictual setting. The standard is an objective one, that of
the average prudent person or reasonable man: the
Oudtshoorn Municipality
case [above n 18] at 435H-I. The test is not, however whether
in the reasonable man’s view the evaluation of the
risk is
affected by the falsity, but whether a reasonable man would consider
that that particular information should have been
disclosed to the
insurer, so that the latter could form his own view as to its
effect:
President
Versekeringsmaatskappy
[above n 54] at 216F-G.”
[56]
Janse
van Rensburg N.O. v Minister of Trade and Industry
[2000] ZACC 18; 2001 (1)
SA 29 (CC); 2000 (11) BCLR 1235 (CC).
[57]
Id at para 24.
[58]
Section 2(1)
of PAJA;
Masethla
v President of the Republic of South Africa
[2007]
ZACC 20
;
2008 (1) SA 566
(CC);
2008 (1) BCLR 1
at para 190.
[59]
Section 3(2)(b)(ii)
of PAJA.
[60]
Turner
v Jockey Club of South Africa
1974
(3) SA 633
(A);
[1974] All SA 52
(A) (
Turner
).
[61]
Id
at 646E-G.
[62]
De
Lange v Smuts
[1998]
ZACC 6
;
1998
(3) SA 785
(CC)
[1998] ZACC 6
; ;
1998 (7) BCLR 779
(CC) (
De
Lange
).
[63]
Id
at
para 131.
[64]
Section 3(1)
and (2), read with
section 6(2)(c)
of PAJA.
[65]
Full Court Judgment above n 25 at para 32, citing
Lambert
above
n 28 at 452A-B.
[66]
Id at para 33.
[67]
Section 29A(7)
of the MSA.
[68]
53 of 1998 (Short Term Insurance Act).
Section 53(1)
of that Act reads:
“
Misrepresentation
and failure to disclose material information
(1)(a)
Notwithstanding anything to the contrary contained in a short term
policy, whether entered
into before or after the commencement of
this Act, but subject to subsection (2)—
(i)
the policy shall not be invalidated;
(ii)
the obligation of the short term insurer thereunder shall not
be excluded or limited; and
(iii)
the obligations of the policyholder shall not be increased, on
account of any
representation made to the insurer which is not true,
or failure to disclose information, whether or not the
representation or
disclosure has been warranted to be true and
correct, unless that representation or non disclosure is such
as to be likely
to have materially affected the assessment of the
risk under the policy concerned at the time of its issue or at the
time of
any renewal or variation thereof.
(b)
The representation or non disclosure shall be regarded as
material if a reasonable, prudent person
would consider that the
particular information constituting the representation or which was
not disclosed, as the case may be,
should have been correctly
disclosed to the short term insurer so that the insurer could
form its own view as to the effect
of such information on the
assessment of the relevant risk.”
[69]
Ferreira
v Levin N.O.; Vryenhoek v Powell N.O.
[1995]
ZACC 13
;
1996 (1) SA 984
(CC)
;
1996
(1) BCLR 1
(CC) (
Ferreira
)
at para 266. See also
Hoban
v Absa Bank Ltd t/a United Bank
[1999]
ZASCA 12
;
1999 (2) SA 1036
(SCA) at para 20.
[70]
117 of 1991.
[71]
24 of 1936.
[72]
71 of 2008.
[73]
Ferreira
above n 69 at para 266.
[74]
Independent
Institute of Education (Pty) Limited v KwaZulu Natal Law
Society
[2019]
ZACC 47
;
2020 (2) SA 325
(CC) at para 38 with reference to
Shaik
v Minister of Justice and Constitutional Development
[2003] ZACC 24
;
2004 (3)
SA 599
(CC);
2004 (4) BCLR 333
(CC) at paras 17-8.
[75]
Arse v
Minister of Home Affairs
[2010]
ZASCA 9
;
2012 (4) SA 544
(SCA) at para 19 with reference to
Petz Products
(Pty) Ltd v Commercial Electrical Contractors (Pty) Ltd
1990
(4) SA 196
(C) at 204H-I.
[76]
Smith v
City of Jackson
[2005] USSC 2718
;
544
US 228
, 233 (2005), citing
Northcross
v Board of Ed. of Memphis City Schools
[1973] USSC 123
;
412
US 427
, 428 (1973).
[77]
United
States v Cleveland Indians Baseball Co
[2001] USSC 25
;
532
US 200
, 213 (2001).
[78]
Non disclosure in insurance contracts is governed by the
materiality test, which is set out in
section 9
of the
Long Term Insurance Act 52 of 1998
and section 53 of the
Short-Term Insurance Act above n 68, which have been consolidated in
the Insurance Act 18 of 2017.
[79]
Mahadeo
above
n 6 at paras 17-8, cited with approval in
Regent Insurance
above
n 17 at para 24.
[80]
Regent Insurance
above
n 17 at para 23.
[81]
Oudtshoorn Municipality
above n 18 at 435G-I and
Regent Insurance
above n 17 at para 23.
[82]
Rule 12.4 of Profmed Medical Scheme Rules.
[83]
Regent Insurance
above n 17 at para 27;
the Court cites
Qilingele
above
n 19 at 75C-D.
[84]
MEC for
Environmental Affairs and Development Planning v Clairison’s
CC
[2013]
ZASCA 82
;
2013 (6) SA 235
(SCA) at paras 20-2.
[85]
In terms of section 8(1)(c)(i) of PAJA.
[86]
Section 8(1)(c)(ii)(aa) of PAJA.
[87]
Trencon
Construction (Pty) Limited v Industrial Development Corporation of
South Africa Limited
[2015]
ZACC 22
;
2015 (5) SA 245
(CC);
2015 (10) BCLR 1199
(CC) (
Trencon
).
[88]
Id at para 47.
[89]
Compare
Trencon
above n 87 at para 48.
[90]
I add in this count the Supreme Court of Appeal,
which has refused both the applications for leave to appeal and
for
reconsideration.
[91]
As set out in [40].
[92]
Ex
parte Minister of Home Affairs: In re Lawyers for Human Rights v
Minister of Home Affairs
[2023]
ZACC 34
;
2024 (2) SA 58
(CC);
2024 (1) BCLR 70
(CC).
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