Beneficiaries of the UMWA Health and Retirement Funds have the right to file a grievance or appeal with the Funds.
A Grievance is a complaint from a beneficiary about a specific event that is not related to payment or coverage of benefits and requires further action on part of the Funds. Grievance includes complaints about interpersonal aspect of care such as rudeness by a provider or failure to respect the rights of the beneficiary, dissatisfaction with physicians, facilities, providers, Funds’ staff or operations, or quality of care, as well as the timeliness, access, or appropriateness of a covered health care service or item. In addition, grievance includes complaints related to the involuntary disenrollment of a beneficiary initiated by the Funds.
An Appeal is a procedure for reconsidering the Funds’ decision to deny a health care service or payment that the beneficiary believes he or she is entitled to receive. This includes delay in providing, arranging for, or approving the health care services (such that a delay will jeopardize the health of the beneficiary) or any amounts that a beneficiary must pay for a service.
