The Blubber

UnitedHealthcare, $UNH, has been accused of using AI that denies critical medical care coverage, per TechSpot

Two families, whose former beneficiaries with UnitedHealth have passed away, have filed a lawsuit against the healthcare giant. The suit alleges that UnitedHealth knowingly employed a faulty artificial intelligence algorithm to reject coverage for essential extended care recommended by physicians for elderly patients.

Filed last Tuesday in federal court in Minnesota, the lawsuit asserts that UnitedHealth unlawfully refused "care owed to elderly patients under Medicare Advantage Plans" by using an AI model, known by the company to have a 90% error rate. This model overruled decisions made by the patients' doctors regarding the medical necessity of expenses.

The complaint states that "the elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth's] AI model 'disagrees' with their real live doctors' determinations."

Medicare Advantage plans, administered by private health insurers like UnitedHealth, offer Medicare-approved insurance plans to elderly individuals as an alternative to traditional federal health insurance plans, as per the U.S. Centers for Medicare and Medicaid Services.

The lawsuit contends that the allegedly flawed AI model, developed by NaviHealth and named "nH Predict," allowed the insurance company to "prematurely and in bad faith discontinue payment" to elderly beneficiaries, causing them medical or financial hardships.

NaviHealth's spokesperson, Aaron Albright, stated to CBS MoneyWatch that the AI tool is not utilized for coverage determinations but rather as "a guide to help [UnitedHealth] inform providers about what sort of assistance and care the patient may need." Albright emphasized that coverage decisions are ultimately made "based on CMS coverage criteria and the terms of the member's plan" and declared that the lawsuit "has no merit."

However, the families in their complaint accuse UnitedHealth of leveraging faulty AI to reject claims as part of a financial strategy to collect premiums without covering elderly beneficiaries. The lawsuit alleges that UnitedHealth believes these individuals lack the knowledge and resources "to appeal the erroneous AI-powered decisions."

UnitedHealth persists in "systemically denying claims using their flawed AI model because they know that only a tiny minority of policyholders (roughly 0.2%)1 will appeal denied claims, and the vast majority will either pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care."

The family's legal representation aims to include "All persons who purchased Medicare Advantage Plan health insurance from Defendants in the United States during the period of four years prior to the filing of the complaint through the present."