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Estate of Lokken v. UnitedHealth: nH Predict model alleged de facto denier of post-acute…
PIR-2026-0005PIR-2026-0005id: PIR-2026-0005title: Class action alleges UnitedHealth's nH Predict model cut off Medicare Advantage post-acute care against physician judgmentdate_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 2025-02-13status: disputed (core mechanism is plaintiff allegation; UnitedHealth contests; no judgment)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: enterpriseautonomy_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 pipelinefailure_locus: operator-config (alleged: rigid targets imposed on model output; the model did what it was deployed to do)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 costsblast_radius: customers/third parties (Medicare Advantage members across the plan)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: noexploitation_status: in-wild-malfunction (real coverage denials in production; no attacker - reclassified from in-wild-exploited, which implies an adversary)severity: loss (named plaintiffs' realized out-of-pocket costs; alleged patient harm up to death) - class-scale loss unknown and unadjudicateddirect_loss_usd: unknown (no judgment; named-plaintiff allegations in the tens of thousands each)indirect_loss_usd: unknowndowntime: n/adata_exposure: nonedetected_by: third-party (affected families and counsel; investigative reporting preceding the suit)time_to_detect: unknowntime_to_recover: ongoing (litigation active as of Aug 2026)remediation: none by operator to date on the public recordstructural_fix: none disclosedcontrols_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 itliability_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 usesealed_material: unknown (discovery ongoing)telemetry_grade: operator-logs (claims-system records in the operator's custody, now subject to discovery)sources:independence: court record + academic tracker + independent legal press - strong on procedure.aiid_incident_id: 608 (https://incidentdatabase.ai/cite/608/) - cross-reference; primaries verified independentlyconfidence: medium - procedural facts high (documented rulings); the 90% reversal rate and rigid-cutoff mechanics are plaintiff allegations not yet proven.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.
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.See also - this event in the AI Incident Database: incident 608.