# PIR-2026-0005 - Estate of Lokken v. UnitedHealth: nH Predict model alleged de facto denier of post-acute care

- `id`: PIR-2026-0005
- `title`: Class action alleges UnitedHealth's nH Predict model cut off Medicare Advantage post-acute care against physician judgment
- `date_occurred`: 2022-2023 (named plaintiffs' coverage cutoffs; practice alleged to be ongoing)
- `date_detected`: unknown (families experienced cutoffs directly; litigation followed investigative reporting)
- `date_disclosed`: 2023-11-14 (complaint filed, D. Minn., 0:23-cv-03514); motion to dismiss partially denied 2025-02-13
- `status`: disputed (core mechanism is plaintiff allegation; UnitedHealth contests; no judgment)

### The agent
- `agent_description`: nH Predict (NaviHealth/UnitedHealth), a predictive model applied to Medicare Advantage post-acute care claims, generating length-of-stay predictions alleged to function as de facto coverage-termination decisions.
- `operator_type`: enterprise
- `autonomy_level`: human-on-the-loop nominally (human sign-off formally required); alleged de facto autonomous-within-policy (predictions alleged to override treating physicians)
- `model_stack`: unknown (proprietary predictive model; internals subject to ongoing discovery)
- `harness`: NaviHealth utilization-management pipeline
- `failure_locus`: operator-config (alleged: rigid targets imposed on model output; the model did what it was deployed to do)

### Authority
- `authority_scope`: decision authority over insurance coverage (effective control of care funding for elderly patients); data access (claims and clinical records)
- `funds_at_risk_usd`: unknown at class scale; named plaintiffs allege tens of thousands of dollars each in out-of-pocket costs
- `blast_radius`: customers/third parties (Medicare Advantage members across the plan)

### The failure
- `root_cause`: policy-violation - primary: alleged breach of contract and of good-faith coverage obligations. Contributing: operator-error (deployment of predictions as rigid cutoffs)
- `mechanism`: Per the complaint: nH Predict generated length-of-stay targets, and coverage was cut when the prediction was reached regardless of treating physicians' assessments. Plaintiffs allege the model's denials were reversed on appeal over 90% of the time, that UnitedHealth knew this, and that it relied on most patients not appealing. Named plaintiffs' families paid out of pocket; two named patients died during or after the coverage cutoffs. The court (Judge Tunheim, 2025-02-13) dismissed several Medicare-preempted counts with prejudice but allowed breach-of-contract and implied-covenant claims to proceed, with broad discovery following.
- `adversary_present`: no
- `exploitation_status`: in-wild-malfunction (real coverage denials in production; no attacker - reclassified from in-wild-exploited, which implies an adversary)

### Impact
- `severity`: loss (named plaintiffs' realized out-of-pocket costs; alleged patient harm up to death) - class-scale loss unknown and unadjudicated
- `direct_loss_usd`: unknown (no judgment; named-plaintiff allegations in the tens of thousands each)
- `indirect_loss_usd`: unknown
- `downtime`: n/a
- `data_exposure`: none

### Detection and recovery
- `detected_by`: third-party (affected families and counsel; investigative reporting preceding the suit)
- `time_to_detect`: unknown
- `time_to_recover`: ongoing (litigation active as of Aug 2026)
- `remediation`: none by operator to date on the public record
- `structural_fix`: none disclosed
- `controls_that_worked`: the appeals process - the alleged >90% reversal rate is itself evidence the human appellate layer caught errors, but only for patients who invoked it

### Legal
- `liability_holder`: contested (UnitedHealth Group/NaviHealth as operator; no adjudication)
- `precedent_set`: 2025-02-13 ruling lets contract and good-faith claims over AI-driven coverage denial proceed past dismissal, with broad discovery into the model's use
- `sealed_material`: unknown (discovery ongoing)

### Evidence
- `telemetry_grade`: operator-logs (claims-system records in the operator's custody, now subject to discovery)
- `sources`:
  - https://www.courtlistener.com/docket/68006832/estate-of-gene-b-lokken-the-v-unitedhealth-group-inc/
  - https://law.justia.com/cases/federal/district-courts/minnesota/mndce/0:2023cv03514/211721/91/
  - https://litigationtracker.law.georgetown.edu/litigation/estate-of-gene-b-lokken-the-et-al-v-unitedhealth-group-inc-et-al/
  - https://minnlawyer.com/2025/02/18/lawsuit-over-unitedhealth-claim-denials-continues/
  - `independence`: court record + academic tracker + independent legal press - strong on procedure.
- `aiid_incident_id`: 608 (https://incidentdatabase.ai/cite/608/) - cross-reference; primaries verified independently
- `confidence`: medium - procedural facts high (documented rulings); the 90% reversal rate and rigid-cutoff mechanics are plaintiff allegations not yet proven.

### Verification notes
Filing date, case number, and the 2025-02-13 partial denial verified against the docket and coverage; allegations kept clearly labeled as such throughout. Boundary case (alleged de facto autonomy) recorded under the v0.1 legal block.

### Corrections

- 2026-08-19: Added `aiid_incident_id` cross-reference (AIID 608), matched against the AIID weekly database export (2026-08-17). A cross-reference, not a re-verification; no claim changed.