AI's Role in Medical Care Decisions Under Scrutiny Amid Lawsuits Against Insurers

<figure> <img alt="an illustrated silhouette of a woman’s face being digitally scanned with a bright red stamp on top reading “Denied”" src="https://platform.vox.com/wp-content/uploads/sites/2/2026/09/GettyImages-1478421122.jpg?quality=90&amp;strip=all&amp;crop=0,0,100,100" /> <figcaption> </figcaption> </figure> <p class="wp-block-paragraph"><a href="https://www.vox.com/politics/502717/ai-freakout-mainstream-openai-anthropic-humans">Recent discussions about AI</a> have focused on existential risks, but AI is already impacting healthcare decisions. UnitedHealth Group, the largest health insurer in the US, faces a class-action lawsuit for allegedly using AI to deny necessary medical payments, despite doctors' recommendations.</p> <p class="wp-block-paragraph"><a href="https://litigationtracker.law.georgetown.edu/litigation/barrows-et-al-v-humana-inc/">Humana</a> and <a href="https://litigationtracker.law.georgetown.edu/litigation/kisting-leung-et-al-v-cigna-corporation-et-al/">Cigna</a> are also involved in litigation over similar claims. Medicare has introduced an AI tool to assist in prior authorization decisions, prompting reports from doctors about patients distressed over denied medications for chronic pain.</p> <p class="wp-block-paragraph">Legal complaints detail troubling scenarios, such as families fighting to keep elderly relatives in nursing homes after falls, and doctors confused when patients needing extended rehabilitation are cut off by algorithms.</p> <p class="wp-block-paragraph">The current discourse may be focused on broader AI implications, but private insurers and the previous administration have already implemented AI to evaluate health insurance claims. Evidence suggests these systems may not always function effectively, potentially jeopardizing patient health. Until legal cases are resolved or regulations are established, individuals must remain vigilant against potential denials of entitled benefits.</p> <p class="wp-block-paragraph">Mika Hamer, a health services researcher at the University of Maryland, stated, “The type of care that clinicians deliver is very sensitive to the patient’s unique circumstances. That may not really show up as a number.” She emphasized that many factors cannot be quantified and may not be suitable for AI models, warning that reliance on these systems could diminish the human aspect of care.</p> <h2 class="wp-block-heading">Claims of AI Denials by Insurers</h2> <p class="wp-block-paragraph">Disputes between insurers and patients over medical claims are longstanding, with policyholders seeking maximum coverage and insurers aiming to minimize payouts. Insurers have historically used algorithms to estimate medical care needs based on factors like age and weight. However, current AI programs can make specific predictions about future health, which are now influencing claim approvals and denials.</p> <p class="wp-block-paragraph">Daniel Schwarcz, a law professor at the University of Minnesota, noted that distinguishing between AI supporting human decision-making and replacing it is challenging, particularly in regulatory contexts.</p> <p class="wp-block-paragraph">Experts recommend patients appeal denied claims, as many are overturned upon review. They also advise looking out for vulnerable individuals who may not understand their rights in the face of AI-driven decisions and advocating for regulatory oversight of AI in healthcare.</p> <p class="wp-block-paragraph">The lawsuits against major insurers highlight the use of AI in decision-making processes. In May 2022, Gene Lokken, 91, fell and was treated for a broken leg and ankle. After initial coverage from UnitedHealth for rehabilitation, the insurer denied further nursing home services, claiming they were no longer medically necessary, which left Lokken's family to pay significant out-of-pocket costs.</p> <p class="wp-block-paragraph">The lawsuit alleges that the denial was influenced by an AI algorithm, nH Predict, which reportedly led to claims being denied after two weeks of care. Similar cases involving other patients demonstrate a pattern of denials based on AI assessments.</p> <p class="wp-block-paragraph">UnitedHealth has responded to the lawsuits by asserting that federal regulations require human doctors to make final claims decisions, although plaintiffs argue that employees are pressured to adhere to AI recommendations.</p> <p class="wp-block-paragraph">Humana and Cigna are also facing lawsuits for their AI practices, with allegations that their systems allow for mass denial of claims without proper review. Many affected patients were unaware that AI influenced their coverage decisions until it was too late.</p> <h2 class="wp-block-heading">AI's Expansion into Traditional Medicare</h2> <p class="wp-block-paragraph">The use of AI is not limited to private insurers; traditional Medicare is also adopting AI for claims adjudication. In June 2025, the Department of Health and Human Services announced the WISeR model, which utilizes AI to make prior authorization decisions for certain procedures in traditional Medicare.</p> <p class="wp-block-paragraph">Concerns have been raised about the potential negative effects of the WISeR program, with reports indicating that it has led to delays and denials of necessary care since its implementation.</p> <p class="wp-block-paragraph">Internal documents reveal that one company using the AI model denied more prior authorization requests than it approved, with significant delays in care even when approvals were granted. Feedback from healthcare providers indicates that patients are experiencing distress due to these delays.</p> <p class="wp-block-paragraph">Despite concerns from medical professionals and patient advocates, the administration appears committed to expanding the WISeR program.</p> <h2 class="wp-block-heading">Ensuring Responsible AI Use in Healthcare</h2> <p class="wp-block-paragraph">While AI has the potential to improve healthcare efficiency, its rapid deployment in decision-making roles has raised significant issues. The lack of regulatory oversight means that the full extent of AI's use in healthcare remains unclear.</p> <p class="wp-block-paragraph">Some states are beginning to implement rules for AI transparency in insurance claims, and Congress is considering proposals to ensure human involvement in decision-making processes. However, the challenge remains to create effective regulations that balance innovation with patient protection.</p> <p class="wp-block-paragraph">Until comprehensive policies are established, patients are encouraged to appeal denied claims and remain proactive in understanding their rights regarding insurance coverage.</p>