関連インシデント
- COURT: D. Minn.
- TRACK DOCKET: 23-cv-03514
Health insurer UnitedHealthcare is facing a class action alleging it used an artificial intelligence algorithm to wrongfully deny coverage to elderly people for care under their Medicare Advantage health policies.
Filed Tuesday in the US District Court for the District of Minnesota, the lawsuit alleges UnitedHealthcare made health-care determinations via its “nH Predict” algorithm, overrode physician recommendations, and denied elderly patients’ claims for stays in extended care facilities. Doing so “resulted in a significant increase in the number of post-acute care coverage denials,” the lawsuit said.
The lawsuit follows a class action brought earlier this year against health insurer Cigna. That lawsuit, filed in the US District Court for the Eastern District of California, accuses Cigna of illegally using advanced technology to automatically deny patient claims without opening their files.
Public interest law firm Clarkson Law Firm PC is behind both lawsuits. Ryan Clarkson, managing partner at Clarkson Law, said in a statement that UnitedHealthcare was “effectively using AI to throw the elderly—our parents or grandparents—out onto the street.”
A spokesperson for naviHealth, the UnitedHealth Group outfit behind the algorithm, said in a statement that its tool wasn’t for making coverage determinations.
Instead, the spokesperson said it “is used as a guide to help us inform providers, families and other caregivers about what sort of assistance and care the patient may need both in the facility and after returning home.”
Coverage decisions are based on Medicare agency “coverage criteria and the terms of the member’s plan. This lawsuit has no merit and we will defend ourselves vigorously,” they said.
According to the complaint, UnitedHealthcare’s use of the technology is “illegal.” The plaintiffs also alleged the technology lets the company “aggressively deny coverage because they know they will not be held accountable for wrongful denials.”
“Defendants bank on the patients’ impaired conditions, lack of knowledge, and lack of resources to appeal the erroneous AI-powered decisions,” the complaint said.
The plaintiffs named in the lawsuit are estates for deceased people who were covered by Medicare Advantage plans provided by UnitedHealthcare but denied coverage for at least some of their time in extended care.
The family of one of those patients, Gene B. Lokken, had continued paying for Lokken’s care at a skilled nursing facility after UnitedHealthcare allegedly stopped covering it. That amounted to between $12,000 to $14,000 for about a year.
Another patient, Dale Henry Tetzloff, had contacted UnitedHealthcare to see why he had been denied coverage, though he was told such information was confidential, the complaint said. The complaint also noted that Tetzloff’s out-of-pocket expenses for care were over $70,000.
The case is Estate of Gene. B. Lokken v. UnitedHealth Group, Inc., D. Minn., No. 23-cv-03514, complaint filed 11/14/23.
(Updated with naviHealth comment starting in fifth paragraph.)