A lawsuit is filed alleging that an insurance company used AI to unfairly deny medical coverage.
The family of a deceased insured person filed a lawsuit alleging that United Health, the largest health insurance company in the United States, used a ``seriously flawed AI algorithm'' to deny coverage.
UnitedHealth uses AI model with 90% error rate to deny care, lawsuit alleges | Ars Technica
According to the complaint filed in the U.S. District Court for the District of Minnesota, United Health used flawed AI, endorsed the AI's results, and denied coverage. In addition to paying insurance claims, United Health provides medical services such as drug prescriptions and dental treatment services at hospitals affiliated with United Health.
The AI ``nH Predict'' used by United Health was designed to predict how long patients in an insurance plan would need to stay in the hospital and receive medical attention after suffering an acute injury or illness, such as a fall or stroke. It was an estimate of what would happen. It is unclear how accurately this AI will work, but it is said to be estimated by referring to a database containing medical cases of approximately 6 million patients, and United Health is based on the results produced by the AI. We decided on the coverage, such as the period of rehabilitation programs and the period of use of nursing care facilities.
nH Predict was created by NaviHealth, a subsidiary of United Health, but some NaviHealth employees said they were skeptical about nH Predict. This lawsuit was carried out in parallel with
Cases in which insurance companies prematurely stop paying medical expenses to elderly people due to ``AI predictions'' have become a social problem - GIGAZINE
According to Amber Lynch, a former NaviHealth employee interviewed by Stat News, nH Predict does not take into account many other relevant factors, such as whether a patient has comorbidities or developed the disease while hospitalized. That's what he said. nH Predict's estimates were extremely harsh, such as concluding that coverage for at most 14 days would be sufficient, whereas existing plans should provide 100 days of care.
It has been pointed out that the reason behind the creation of this AI is that United Health has changed its policy to ``make the care provided to insured patients as short and efficient as possible.'' According to testimony from former employees, since United Health acquired NaviHealth in 2020, efforts have been made to provide the shortest possible care to patients and streamline care after an illness or injury. This was so important that executives at the company even said things like, ``What can we do to get patients discharged from nursing homes as quickly as possible?''
As patients, we would like to receive coverage for as long as possible, but some patients were only able to receive the minimum level of care based on AI predictions and were forced to use their savings.
However, patients can appeal their insurance coverage. The plaintiffs in this case argue that if all insured persons filed a complaint, more than 90% of the complaints would be granted, stating, ``United Health has proven that the AI has come up with clearly inaccurate values. 'I should have understood that. It is clear that the algorithm is incorrectly denying insurance coverage.'
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