Sizwe-Hosmed Medical Scheme has accused its administrator 3Sixty Health of defrauding it of nearly R71-million through submission of irregular claims.
The irregular claims were discovered after Sizwe-Hosmed was placed on curatorship in September last year, triggering a legal dispute threatening to end their working relationship.
3Sixty Health is a sister company to 3Sixty Life, the troubled underwriter of life insurance and funeral policies, which has been in a year’s long battle with the Reserve Bank’s Prudential Authority, which placed it under curatorship for failing to adhere the minimum capital requirement threshold for insurance.
Yashoda Ram, from BDO, was appointed as provisional curator in December 2021 after the Numsa-owned 3Sixty Life failed to meet minimum capital requirements, but she was removed after being accused of misrepresenting her qualifications,
The latest conflict with Sizwe is laid out in formal letters sent to 3Sixty Health in November and December 2025 by the scheme’s curator Lebogang Mpakati and its attorneys.
Now Sizwe-Hosmed Medical Scheme is accusing 3Sixty Health of breaching its service level agreement (SLA) and causing severe financial and operational harm to the scheme and its members.
According to the letter from Maluks Attorneys & Corporate Law Advisors, acting on instructions Mpakati, 3Sixty allegedly processed improper payments worth R71 894 624.
The alleged losses include stale claims worth R10 361 843, R17 022 284 in duplicated claims, higher non-healthcare expenses at R42 433 145 and fictitious claims worth R2 077 352.
The scheme has formally demanded that the money be repaid. “Our client’s position is that 3Sixty contravened its duties outlined in Annexure A of the 2019 Administration SLA and that its obligation in accordance with the Managed Care SLA was not fulfilled, which resulted in the scheme suffering prejudice.
“It has further been noted that, in certain cases, bank account details were altered to reflect another member’s cover number without the requisite letter of authority from the legitimate bank account holder.
“This constitutes a serious breach of security and illustrates that 3Sixty’s quality assurance processes were applied inconsistently,” reads the letter in part.
In a separate letter drafted by Mpakati on December 17, 2025, the scheme stated that it had already lodged a R17 022 284 claim against 3Sixty for breach of service level agreement for duplicated claims following findings in the KPMG report.
However, the letter notes that 3Sixty denied the allegations, despite being afforded an opportunity to refute claims contained in the KPMG report.
Beyond the money, the scheme paints a picture of a collapsing administration system that has directly affected members’ access to healthcare, leading to private hospital group Mediclinic refusing to accept members of the scheme.
“The scheme has received various complaints and reports from members and various hospital groups regarding short-payment, struggles with getting authorisations timeously, getting feedback from the administrator when claims are rejected or short-paid and the changing of banking details.
“Despite some improvements in communication relating to claims aging and the authorisations with Netcare and Mediclinic, Mediclinic has resolved not to accept the scheme’s members until guarantees have been issued and they have greater certainty as to the schemes financial position,” said Mpakati.
Sizwe-Hosmed also accused 3Sixty of refusing to provide proper access to data on its members, despite repeated requests.
Mpakati said the scheme is not asking for access to live systems but a copy of the backed-up information, but the request has been denied with no explanation, he added.
A security and forensic company, TFS Africa, was appointed to investigate duplicate claims and suspicious bank account changes amid fraud concerns.
“Reports have been received from TFSA confirming bank account changes, fraudulent payments made to certain service providers and fraud committed by certain 3SH employees.
“It remains a concern that when there is fraud found, [3Sixty Health] does not report same to the scheme in order for the issue to be amicably resolved and withhold effected timeously and the increasing hostility of the FWA department to the schemes service provider,” reads the letter.
In response to questions, 3Sixty CEO Khandani Msibi, denied all allegations against the administrator. He shared a letter 3Sxity wrote to the to the Council for Medical Schemes denying claims of irregular expenditure.
He noted the accusation on unpaid hospital claims, saying the scheme changed the Designated Service Provider from National Health Network to Netcare, with costs that are 40% above industry benchmark.
