Humana has joined the list of health insurance companies facing accusations of using artificial intelligence tools to systematically deny care.
The same plaintiffs' law firms that sued Cigna and UnitedHealth Group on similar charges filed a complaint against Humana Tuesday in the U.S. District Court for the Western District of Kentucky and seek to represent all affected Humana members in a class-action case. Humana's use of AI to review claims constitutes a breach of contract that resulted in unjust enrichment under federal law and violated insurance laws in 22 states, the lawsuit alleges.
Related: Are insurers using tech to automate claims denials?
Lockridge Grindal Nauen PLLC and Clarkson Law Firm are representing JoAnne Barrows of Minnesota and Susan Hagood of North Carolina, a pair of Humana Medicare Advantage policyholders who allege the insurer did not provide appropriate coverage following major medical incidents. The plaintiffs seek monetary relief and an injunction to force Humana to stop using the AI tool.
"The elderly are prematurely kicked out of care facilities nationwide, forced to deplete family savings to continue receiving necessary medical care, or forced to forgo care altogether, all because an AI model 'disagrees' with their real live doctors’ determinations," the complaint says.
A Humana spokesperson said in an email, "We do not comment on pending litigation, but I can confirm that at Humana, we use various tools, including augmented intelligence, to expedite and approve utilization management requests and ensure that patients receive high-quality, safe and efficient care.
"By definition, augmented intelligence maintains a 'human in the loop' decision-making whenever AI is utilized. Coverage decisions are made based on the healthcare needs of patients, medical judgment from doctors and clinicians, and guidelines put in place by [the Centers for Medicare and Medicaid Services]. It’s important to note that adverse coverage decisions are only made by physician medical directors."
The insurer has used an AI tool called nH Predict to review Medicare Advantage post-acute care claims since at least 2019, the plaintiffs assert. Less than 1% of post-acute care denials were appealed, but 90% of appeals have been successful, according to the lawsuit. NaviHealth, a unit of UnitedHealth Group subsidiary Optum, developed the AI utility.
After a fall that resulted in a fractured leg and hospitalization in November 2021, the then-86-year-old Barrows checked in to a rehabilitation facility to recover, the complaint alleges. Humana notified Barrows that it would cover only two weeks of care, despite her doctor's recommendation she stay another four weeks, the lawsuit alleges.
Barrows and her family appealed, but Humana rejected their claim, according to the complaint. The family could not afford to continue her treatment at the rehabilitation facility and paid out-of-pocket for Barrows to be transferred to an assisted living facility, where she received sub-standard care, the lawsuit says.
In September 2022, Hagood was admitted to a hospital with a urinary tract infection, sepsis and a spinal infection, the complaint says. After being discharged the following month and transferred to a skilled nursing facility to receive treatment for eleven conditions, Hagood subsequently contracted pneumonia at the facility, according to the lawsuit. She was hospitalized again in November, and doctors diagnosed three additional conditions, the lawsui says.
Hagood's doctors referred her to the skilled nursing facility for treatment, but Humana denied to cover the stay and advised that she recover at home, the complaint says. Hagood's family has since spent $24,000 for her nursing home care, according to the lawsuit.
