A lawsuit against UnitedHealth Group over its wrongful denials of post-acute care under Medicare Advantage plans, including nursing home services, advanced following a court ruling on Thursday.

The lawsuit filed in the U.S. District Court for the District of Minnesota claims that UnitedHealth’s use of an AI tool called nH Predict led to arbitrary coverage denials without consideration of the patients’ health status or the involvement of a physician.

The latest court decision could reopen the discovery process and allow attorneys representing the aggrieved Medicare Advantage enrollees and their families to seek documents from UnitedHealth, especially pertaining to its use of AI tools.

Last summer, the health insurance giant tried to dismiss the case, which was filed in late 2023, by arguing that plaintiffs did not properly complete the process of appealing their denied claims.

The judge refused to dismiss the case, but allowed it to proceed with a reduced number of claims brought on by the plaintiffs.

“The Court will grant in part and deny in part UnitedHealth’s motion to dismiss, allowing Plaintiffs’ breach of contract and breach of the implied covenant of good faith and fair dealing claims to proceed,” U.S. District Judge for the John Tunheim said in his ruling.

The plaintiffs argue that UnitedHealth’s policies prioritize profits over patients’ well-being. They claim that UnitedHealth was aware of the inaccuracies in nH Predict, as more than 90% of claim denials and over 80% of preauthorization denials are overturned on appeal, although UnitedHealth denies using nH Predict, the court ruling noted.

Plaintiffs also accuse UnitedHealth of approving any appeals that reach the late stages so that administrative remedies are never exhausted, the ruling stated.

Moreover, the plaintiffs state that the appeals process, entailing repeated denials, is so arduous that “plaintiffs suffered worsening injury, illness, or death as a result of the denials,” the ruling notes.

Death was the outcome for Robby Martin, one of several plaintiffs whose father was allegedly denied rehab care multiple times under UnitedHealth’s Medicare Advantage plan. His father was forced to return home where he died from a fall.

Martin’s father was an 82-year-old retiree recovering from a back fracture, and had his rehab coverage cut multiple times by UnitedHealth, despite his ongoing need for care, with the company internally citing a cost-saving strategy that left him exhausted from the appeal process, Martin said in an interview with the Guardian newspaper.

Despite the company’s claims that its decisions follow Medicare guidelines, the Martin family’s legal team argues that UnitedHealth’s actions show a disregard for the needs of older adult enrollees such as his father.
This case highlights broader concerns about Medicare Advantage plans and the practices of health insurance providers, including Cigna and Humana, over their use of AI tools to deny post-acute care in nursing homes.