Insurance Giant UnitedHealth Group Faces Lawsuit Over AI Denying Rehab Stays for Elderly Patients
UnitedHealth Group, one of the largest insurance companies in the United States, is facing a lawsuit over its alleged use of artificial intelligence (AI) to deny or shorten rehabilitation stays for elderly patients. The lawsuit claims that the company’s AI program is making rigid and unrealistic determinations about patients’ recovery needs, overriding doctors’ recommendations for care. The families of two elderly patients from Wisconsin have filed the lawsuit in Minnesota, seeking class-action status.
According to the lawsuit, UnitedHealth’s AI program is denying coverage for skilled nursing and rehab centers that should be covered under Medicare Advantage plans. The families argue that these assessments should be made by medical professionals, not AI algorithms. They also claim that the insurance company is taking advantage of elderly patients who are less likely to fight back.
The lawsuit alleges that UnitedHealth’s AI program has a high error rate and that more than 90% of patient claim denials were later overturned through internal appeals or a federal administrative law judge. However, few patients actually challenge the algorithm’s determinations, with only a tiny percentage choosing to fight claim denials through the appeals process. As a result, many insured individuals either have to pay out-of-pocket costs or forgo the remainder of their prescribed post-acute care.
Attorneys representing the families argue that the high rate of denials is a result of the insurance company prioritizing profits over patient care. They believe that UnitedHealth is placing its financial interests above the well-being of the individuals it is contracted to cover.
In response to the lawsuit, UnitedHealth stated that its AI program, called naviHealth, is used as a guide to inform providers, families, and caregivers about the care a patient may need. The company claims that coverage decisions are based on the criteria set by the Centers for Medicare & Medicaid Services and the consumer’s insurance plan.
This lawsuit is part of a growing trend of legal action against the use of AI in healthcare. In July, the Lawson law firm filed a case against CIGNA Healthcare, accusing the insurer of using AI to automate claims rejections. Similar cases have been pursued against OpenAI and Google.
Concerns about the routine use of AI technology to deny or reduce care for older adults on private Medicare plans have been raised by Medicare advocates. The Center for Medicare Advocacy examined the use of AI programs by multiple insurers and found that they often made coverage decisions that were more restrictive than what Medicare would have allowed. The decisions lacked the necessary nuance to evaluate each case’s unique circumstances.
Legal experts emphasize the importance of including human decision-making in the AI process. While AI systems can be efficient, they can also make mistakes and lack common sense. Companies that use AI in their decision-making should ensure that there is an opportunity for human intervention and override of the algorithm’s decisions.
As the lawsuit against UnitedHealth Group unfolds, it highlights the concerns surrounding the use of AI in healthcare and the need for a careful balance between technology and human judgment. The outcome of the case could have significant implications for the use of AI in insurance coverage decisions and may lead to further regulations in the field.
