MP
Merle P
1 reviews | Active since Feb 2013
16 Apr 2026, 12:10
NON PAYMENT OF PRODUCT USED IN THEATRE
I had a second hand operation to repair my median nerve in my hand. Genesis are refusing to pay for a product called TISSEEL which the doctor used to repair the nerve in my hand and which costs R8000 I sent a motivation letter from the hand specialist as well. I am paralysed in my left hand, I cannot work or do any daily functions that im used to for the last 5 months. I have no control what a specialist uses in theatre. I am a pensioner as well. I received an email regarding this product saying its not registered in SA and its biological drug used for experiments. There should be a ruling as to how and why certain drugs/products are used. If its cosmetic fair enough but in my case it was a crucial element of repairing my nerve so that hopefully one day i can use my hand again. Please Genesis re-consider this decision of non payment. thanks and regards ,
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Replies (5)
Genesis Medical Scheme's replyOfficial
16 Apr 2026, 14:37Dear Mrs Piner We are very sorry to hear that your accident from a few months ago continues to impact your quality of life. With regard to Tisseel, it is classified as a biological product (drug) and is therefore excluded from cover under the Scheme Rules. With the exception of a limited number of high-end benefit options, most medical schemes in South Africa do not provide cover for biological products. While we do not have control over the specific drugs or products selected for use during a procedure, it is important to note that alternative, non-biological options were / are available. Based on the above, the Scheme is unfortunately unable to fund this biological product. Yours sincerely The GENESIS Team
Best regards,
Genesis Medical Scheme's reply16 Apr 2026, 14:37
Official
Dear Mrs Piner We are very sorry to hear that your accident from a few months ago continues to impact your quality of life. With regard to Tisseel, it is classified as a biological product (drug) and is therefore excluded from cover under the Scheme Rules. With the exception of a limited number of high-end benefit options, most medical schemes in South Africa do not provide cover for biological products. While we do not have control over the specific drugs or products selected for use during a procedure, it is important to note that alternative, non-biological options were / are available. Based on the above, the Scheme is unfortunately unable to fund this biological product. Yours sincerely The GENESIS Team
Best regards,
MP
Merle P's updateReviewer Update
16 Apr 2026, 15:54thank you for your reply. I as the patient also do not have control over what a surgeon uses in theatre. Surely discretion should be used in cases and app**** accordingly as to what the product was used for. As part of your rule is as follows and I copy and paste from a Genesis email
Unless otherwise expressly stated to the contrary in these Rules and the Annexures and Appendices or as otherwise determined by the Board, expenses incurred in respect of any of the following conditions, procedures, and services shall not be covered by the Scheme. Please refer to the scheme rules: ANNEXURE C Number 7. Medical treatment in a research environment and all drugs, medication, substances, appliances and the like that is experimental and/or not registered in terms of appropriately recognised law in the Republic of South Africa or any of the above that are authorised in terms of section 21 of the Medicines and Related Substances Control Act 101 of 1965 or the off-label use of any medical treatment. Number 30. Medication and injection material referred to as biological or specialised drugs or medication.
IT IS EXPRESSLEY STATED TO THE CONTRARY AS THE SUBSTANCE WAS NOT USED IN A RESEARCH ENVIRONMENT NOR AN EXPERIMENTAL ENVIRONMENT. IT IS NOT A MEDICATION OR A SPECIALISED DRUG.
Is this item which is registered in the country, does have an authorised code for use in hospitals. Are you rejecting it because its expensive? and what product do you suggest as mentioned should the surgeon have used, Surely he is the best judge of what a patient needs in theatre and not a medical insurance company.
Unless otherwise expressly stated to the contrary in these Rules and the Annexures and Appendices or as otherwise determined by the Board, expenses incurred in respect of any of the following conditions, procedures, and services shall not be covered by the Scheme. Please refer to the scheme rules: ANNEXURE C Number 7. Medical treatment in a research environment and all drugs, medication, substances, appliances and the like that is experimental and/or not registered in terms of appropriately recognised law in the Republic of South Africa or any of the above that are authorised in terms of section 21 of the Medicines and Related Substances Control Act 101 of 1965 or the off-label use of any medical treatment. Number 30. Medication and injection material referred to as biological or specialised drugs or medication.
IT IS EXPRESSLEY STATED TO THE CONTRARY AS THE SUBSTANCE WAS NOT USED IN A RESEARCH ENVIRONMENT NOR AN EXPERIMENTAL ENVIRONMENT. IT IS NOT A MEDICATION OR A SPECIALISED DRUG.
Is this item which is registered in the country, does have an authorised code for use in hospitals. Are you rejecting it because its expensive? and what product do you suggest as mentioned should the surgeon have used, Surely he is the best judge of what a patient needs in theatre and not a medical insurance company.
MP
Merle P's update16 Apr 2026, 15:54
Reviewer Update
thank you for your reply. I as the patient also do not have control over what a surgeon uses in theatre. Surely discretion should be used in cases and app**** accordingly as to what the product was used for. As part of your rule is as follows and I copy and paste from a Genesis email
Unless otherwise expressly stated to the contrary in these Rules and the Annexures and Appendices or as otherwise determined by the Board, expenses incurred in respect of any of the following conditions, procedures, and services shall not be covered by the Scheme. Please refer to the scheme rules: ANNEXURE C Number 7. Medical treatment in a research environment and all drugs, medication, substances, appliances and the like that is experimental and/or not registered in terms of appropriately recognised law in the Republic of South Africa or any of the above that are authorised in terms of section 21 of the Medicines and Related Substances Control Act 101 of 1965 or the off-label use of any medical treatment. Number 30. Medication and injection material referred to as biological or specialised drugs or medication.
IT IS EXPRESSLEY STATED TO THE CONTRARY AS THE SUBSTANCE WAS NOT USED IN A RESEARCH ENVIRONMENT NOR AN EXPERIMENTAL ENVIRONMENT. IT IS NOT A MEDICATION OR A SPECIALISED DRUG.
Is this item which is registered in the country, does have an authorised code for use in hospitals. Are you rejecting it because its expensive? and what product do you suggest as mentioned should the surgeon have used, Surely he is the best judge of what a patient needs in theatre and not a medical insurance company.
Unless otherwise expressly stated to the contrary in these Rules and the Annexures and Appendices or as otherwise determined by the Board, expenses incurred in respect of any of the following conditions, procedures, and services shall not be covered by the Scheme. Please refer to the scheme rules: ANNEXURE C Number 7. Medical treatment in a research environment and all drugs, medication, substances, appliances and the like that is experimental and/or not registered in terms of appropriately recognised law in the Republic of South Africa or any of the above that are authorised in terms of section 21 of the Medicines and Related Substances Control Act 101 of 1965 or the off-label use of any medical treatment. Number 30. Medication and injection material referred to as biological or specialised drugs or medication.
IT IS EXPRESSLEY STATED TO THE CONTRARY AS THE SUBSTANCE WAS NOT USED IN A RESEARCH ENVIRONMENT NOR AN EXPERIMENTAL ENVIRONMENT. IT IS NOT A MEDICATION OR A SPECIALISED DRUG.
Is this item which is registered in the country, does have an authorised code for use in hospitals. Are you rejecting it because its expensive? and what product do you suggest as mentioned should the surgeon have used, Surely he is the best judge of what a patient needs in theatre and not a medical insurance company.
MP
Merle P's updateReviewer Update
17 Apr 2026, 08:38Genesis, please reply to my comment of yesterday. The product was not a drug or a medication it was a sealant for nerve repair as the surgeon cannot SUTURE a nerve. How can you not use your discretion???? What was according to you he supposed to use...I would like to know as I intend telling him about this and this surgeon is also on the medical council. Please reply, thank you.
MP
Merle P's update17 Apr 2026, 08:38
Reviewer Update
Genesis, please reply to my comment of yesterday. The product was not a drug or a medication it was a sealant for nerve repair as the surgeon cannot SUTURE a nerve. How can you not use your discretion???? What was according to you he supposed to use...I would like to know as I intend telling him about this and this surgeon is also on the medical council. Please reply, thank you.
MP
Merle P's updateReviewer Update
17 Apr 2026, 08:59There are many products under the TISSEELL HEADING. THE PRODUCT USED WAS A FIBRIN SEALANT
MP
Merle P's update17 Apr 2026, 08:59
Reviewer Update
There are many products under the TISSEELL HEADING. THE PRODUCT USED WAS A FIBRIN SEALANT
Genesis Medical Scheme's replyOfficial
17 Apr 2026, 09:28Mrs Piner, thank you for your ongoing engagement on this matter. We appreciate the opportunity to again clarify our position. All relevant information and explanations have already been provided in our previous email correspondence, and unfortunately there is no further information we are able to add on this platform. As advised, Tisseel is classified as a biological product and is therefore a Scheme exclusion, irrespective of the purpose for which it was used. Genesis does not interfere with the clinical decisions made regarding a member’s treatment. Decisions around how and with what a member is treated remain entirely between the member and their healthcare provider. The Scheme’s role is limited to funding medically appropriate treatment in accordance with the selected benefit option and the Scheme Rules. In addition to being an exclusion, Tisseel would not qualify for funding under Rule 4.39 of the Main Rules, which defines the criteria for “medically appropriate” treatment. We do understand that this outcome may be disappointing, and we empathise with your frustration. However, based on the Scheme Rules, the benefit requested is unfortunately not funded. Yours sincerely The GENESIS Team
Best regards,
Genesis Medical Scheme's reply17 Apr 2026, 09:28
Official
Mrs Piner, thank you for your ongoing engagement on this matter. We appreciate the opportunity to again clarify our position. All relevant information and explanations have already been provided in our previous email correspondence, and unfortunately there is no further information we are able to add on this platform. As advised, Tisseel is classified as a biological product and is therefore a Scheme exclusion, irrespective of the purpose for which it was used. Genesis does not interfere with the clinical decisions made regarding a member’s treatment. Decisions around how and with what a member is treated remain entirely between the member and their healthcare provider. The Scheme’s role is limited to funding medically appropriate treatment in accordance with the selected benefit option and the Scheme Rules. In addition to being an exclusion, Tisseel would not qualify for funding under Rule 4.39 of the Main Rules, which defines the criteria for “medically appropriate” treatment. We do understand that this outcome may be disappointing, and we empathise with your frustration. However, based on the Scheme Rules, the benefit requested is unfortunately not funded. Yours sincerely The GENESIS Team
Best regards,