Class Action Lawsuit Accuses UnitedHealthcare of Wrongfully Denying Coverage Using AI Algorithm for Elderly Patients’ Post-Acute Care Claims

MINNEAPOLIS (AP) — A recent class action lawsuit against UnitedHealthcare alleges that the health insurance provider wrongfully denied claims for post-acute care using an artificial intelligence (AI) algorithm. The plaintiffs claim that UnitedHealthcare’s use of the “nH Predict” AI algorithm led to the rejection of elderly patients’ claims for stays in skilled nursing-care facilities and in-home care. When these denials were appealed to federal administrative law judges, roughly 90% of them were overturned.

This lawsuit follows a similar case earlier this year against health insurance company Cigna, where plaintiffs accused the company of automatically denying patient claims using AI technology without reviewing their files.

The plaintiffs in the UnitedHealthcare lawsuit are the estates of deceased individuals who were previously covered by Medicare Advantage plans provided by the insurance company. UnitedHealthcare denied these plaintiffs coverage for at least part of their stay in extended care facilities, resulting in significant annual costs that had to be borne by the patients.

According to the lawsuit, the plaintiffs argue that UnitedHealthcare’s use of the nH Predict algorithm violates their contracts and the insurance laws of different states. They claim that claims are being decided without proper evaluation. The plaintiffs are seeking a court order to prohibit UnitedHealthcare from continuing this practice and are also seeking monetary damages.

On the other hand, UnitedHealthcare denies using the nH Predict tool to make claim determinations. The company states that the AI tool was employed as a guide to provide information to providers, families, and caregivers regarding the necessary assistance and care a patient might require during their time at a facility and upon returning home. UnitedHealthcare maintains that its coverage decisions are still based on Medicare coverage criteria and the terms of the insured person’s plan.

The case, known as Estate of Gene. B. Lokken v. UnitedHealth Group, Inc., is currently being heard in the District Court of Minnesota.