November 14, 2023 – UnitedHealthcare, the largest health insurer in the United States, has become the subject of a significant lawsuit. The legal action accuses the company of using an artificial intelligence algorithm, named nH Predict, which is allegedly responsible for systematically denying extended healthcare coverage to severely ill and elderly patients. This lawsuit, representing a potential class of thousands, could have far-reaching implications in the intersection of healthcare and technology.

The Lawsuit’s Basis

Filed in the US District Court of Minnesota, the lawsuit originates from the estate of two deceased individuals who were denied coverage by UnitedHealth. The plaintiffs claim the insurer knew about the inaccuracy of its AI algorithm and breached its contract by relying on it. The algorithm, developed by NaviHealth Inc, a company acquired by UnitedHealth in 2020, is accused of “prematurely and in bad faith discontinuing payment for healthcare services.”

The Impact of nH Predict

The nH Predict algorithm’s decisions have reportedly resulted in inadequate care for patients, including severe cases like stroke victims and those with multiple health issues. For instance, one older woman who suffered a stroke was allocated only 20 days of rehab, just half the average for similar patients. The algorithm bases its projections on the length of stays of previous patients in the company’s database, thereby inheriting past errors and cost-cutting measures, and failing to consider individual clinical and practical exigencies.

The Financial Motivation

An investigation by Stat News into UnitedHealth’s practices at subsidiary NaviHealth revealed that employees were forced to adhere strictly to the AI algorithm’s predictions. This adherence reportedly saved the company hundreds of millions of dollars, highlighting a potential financial incentive behind the use of nH Predict.

The Legal Claims

The lawsuit alleges that UnitedHealth’s use of nH Predict violates contracts with patients and several state insurance laws by deciding claims without proper evaluation. It seeks to stop the practice and award monetary damages. Additionally, when these coverage denials are appealed, about 90% are reversed, further demonstrating the algorithm’s inaccuracy.

The Response

UnitedHealth, in a statement to Stat, denied the allegations, asserting that care denial decisions are made by medical directors based on Medicare coverage criteria, not solely on the AI tool.

The Larger Context

This lawsuit points to broader concerns regarding the use of AI in healthcare, especially when it comes to decisions that significantly impact patient care. The case may set a precedent for how AI is regulated and used ethically in the healthcare industry.

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