How To Avoid Being The Next Victim Of The Health Insurance Industry’s Policy To Delay, Deny And Defend

The firm was recently hired by a 90-year-old woman and her family to secure health insurance benefits to which she was entitled. Unable to ambulate at all, our client had been transported via ambulance to a local hospital, where she remained for nine days. She was diagnosed with urinary tract infections (UTI), transient ischemic attacks (TIAs) and multiple falls. After a nine-day stay in the hospital, she was released, with a recommendation that she be transferred to a subacute rehabilitative care facility for further care and treatment.

The woman is insured by Humana. This is a Medicare policy, of sorts. Specifically, she had chosen Humana’s Gold Plus HMO, an alternative to standard government supported Medicare. It is an HMO or health maintenance organization. After Humana discussed the referral with our client’s in-hospital physician, the referral was denied.

It can be intimidating facing off against a large health insurer. We were hired to file an appeal. We insisted that the appeal be expedited, meaning that a decision was to be rendered within three days. We noted the woman’s history of falls and the diagnosis of UTIs and TIAs. We added that our client remained in the hospital due to Humana’s refusal to follow the treating physician’s recommendations. While awaiting the decision on the appeal, the client was discharged.

It helped our client’s case that a class action suit was brought against Humana in December 2023 in Kentucky federal court by plaintiffs whose post-acute care coverage was terminated based on Humana’s use of artificial intelligence (AI) to deny medical care under Medicaid Advantage plans.

In the Kentucky case, the plaintiffs claim that Humana wrongfully denied care that the elderly patients’ doctors recommended because Humana uses an AI algorithm, nH Predict, rather than actual doctors, to determine what care is medically necessary. Furthermore, the plaintiffs allege that Humana knew that the AI algorithm was flawed but used it anyway because Humana knew that only about 2% of policyholders would appeal the denial of their claims.

Humana insures approximately 5.8 million seniors under Medicare Advantage plans. The nH Predict model predicts unrealistically short recovery times in post-acute care. The plaintiffs alleged that Humana had a policy of disciplining and terminating employees who approved more care and departed from the AI model’s strict prediction of how much care elderly patients needed.

Similar cases are pending against Cigna and UnitedHealth Group for using AI to deny claims. By using AI, these medical insurance companies profit from policy premiums at the expense of elderly patients who must forgo necessary medical care or use their own resources and become encumbered with medical debt. Seems as though the health insurance industry’s policy of delay, deny and defend operates to swell the insurer’s coffers, while ill patients are refused required care.

Ultimately, the expedited appeal that we filed on our client’s behalf was granted. The denial of care was reversed. The client can now secure the rehabilitative services to which she is entitled. I am convinced that we succeeded in securing the reversal of this ill-advised refusal to provide necessary care because we noted Humana’s involvement in the above-noted lawsuit.

If you find that you or a loved one has been wrongfully denied health insurance benefits to which you are contractually entitled, you will have questions. You should consult with an attorney who is familiar with this area of the law and who will assist you in making informed decisions. If you need further information regarding this subject, contact the Law Office of David V. Diggs LLC, located at 8684 Veterans Highway, Suite 302, in Millersville. Call 410-244-1189 or email david@diggslaw.com.

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