Grievance — in plain language

Plain language

a complaint you make to your health insurer or plan

• complaint
• member complaint
• plan complaint

What to watch for

• A grievance is a complaint, distinct from an appeal, which challenges a denied benefit; the plain rewrite should keep the two apart.
• It is about dissatisfaction with the plan, a provider, or care, not about a coverage decision; the plain version should keep that focus visible.
• Plans must have a grievance process; the plain version should keep that right visible.

Distinct From an Appeal. A grievance is a complaint, distinct from an appeal, which challenges a denied benefit. The plain rewrite should keep the two apart, because the processes and the remedies differ.

About Dissatisfaction, Not a Coverage Decision. A grievance is about dissatisfaction with the plan, a provider, or the way care was given, not about a coverage decision. The plain version should keep that focus visible, because a reader with a denied claim needs an appeal, not a grievance.

Plans Must Have a Process. Plans must have a grievance process. The plain version should keep that right visible, because a member who knows the process exists can use it.

Common Misunderstandings by Non-Lawyers.

• "A grievance and an appeal are the same thing." (No — a grievance is a complaint about the plan, a provider, or care; an appeal challenges a denied benefit.)
• "I file a grievance to overturn a denied claim." (No — that's an appeal; a grievance is for dissatisfaction with the plan, a provider, or care.)
• "The plan doesn't have to respond to my grievance." (Generally no — plans must have a process for handling grievances.)

Legal definition

A grievance is a complaint that you communicate to your health insurer or plan. It is distinct from an appeal, which is a request to reconsider a denied benefit; a grievance is about dissatisfaction with the plan, a provider, or the way care was given, rather than a challenge to a coverage decision. Plans must have a process for handling grievances.

Examples

Where you'll see it

• member complaint processes
• dissatisfaction with a provider or plan
• claimant questions about how to complain
• quality-of-care complaints

Related terms

• appeal
• provider
• network

Word details

Pronunciation

GREE-vuns

Part of speech

noun

Origin

Old French via English — a cause for complaint, from 'grever' — to burden or aggrieve

Domains

insurance law, administrative law

Frequency

common

Formality

moderate