Medical Access Denied

To insure or not to insure?

For those with health insurance, the final three months of the annual calendar year may ignite a sense of urgency to schedule appointments and utilize benefits, such as a free eye exam or 100% coverage after a deductible is paid.  In the case of two now-deceased elderly insurance holders, however, conflict may arise if owed benefits are not honored.  According to a recent lawsuit filed against UnitedHealth, elderly patients were not provided the care afforded under their Medicare Advantage Plans.  An artificial intelligence (AI) algorithm is the alleged reason for the denial.

Although doctors ordered long-term care for two patients, the AI template performed an override function that did not take into consideration the doctors’ recommendations for necessary care, and instead deemed the medical assistance as unnecessary to continue payment.  These patients, as well as others that have not initiated legal action, have been forced to either leave medical care facilities early or pay portions of their medical bills out-of-pocket.  The main issue with UnitedHealth continuing to implement these technological decision-makers is that the AI system has been determined to yield a 90% error rate, of which the company is allegedly fully aware.            

Within the lawsuit, the families of the now-deceased patients accuse UnitedHealth of using the age of the patients to their advantage, reasoning that elderly policyholders may not question the AI-derived coverage denials.  If the elderly patients do not push for their owed coverage, the insurance company may continue to collect premiums and refuse to pay allowed benefits.  The plaintiffs in the lawsuit intend to escalate the claim to class action status, which may impact all individuals who acquired Medicare Advantage Plan health insurance.  While the use of an AI system may provide obvious advantages, such as quicker prior authorization, the vast number of improperly denied claims may lead patients to question whether speedy turnaround times outweigh accuracy.