Grievance (Health Care) Law and Legal Definition

Grievance in the context of health care means a complaint about the manner in which medicare health plan gives care. According to the Managed Care Reform Act, there are two ways by which a patient can challenge decisions made by their managed care plan. All decisions except the decision denying claims for services on the grounds that the services are not "medically necessary" can be challenged by filing a grievance. A grievance can be filed against denials of referrals to specialists and denial of services on the grounds that they are not covered under a patient's insurance contract, on facing any problem on calling the plan and when a staff person at the plan behaves in an unhappy manner. A grievance cannot be filed about a treatment decision or a service that is not covered by the plan.

Grievance process is an important source of identification of healthcare delivery and access problems. It also helps to pinpoint weaknesses in the delivery network. Generally a group health plan, and a health insurance issuer establishes and maintains a system for presentation and resolution of oral and written grievances brought by beneficiaries.