Security Health Plan uses NaviHealth AI to deny elderly patient medical coverage
An AI length-of-stay prediction led Security Health Plan to terminate medical coverage for an elderly patient. The insurer relied on a recovery estimate from NaviHealth's algorithm despite the patient's continued severe symptoms.
The insurer replaced clinical judgment with a probabilistic recovery estimate to justify denying necessary medical care.
Key facts
- What
- An AI length-of-stay prediction led Security Health Plan to terminate medical coverage for an elderly patient.
- Incident date
- Jun 3, 2019
- Who
- Security Health Plan and NaviHealth
- Failure mode
- Brand & Safety Incident
- AI surface
- Algorithmic Decision
- Severity
- High
What happened
Frances Walter, an 85-year-old woman with a shattered shoulder, had her medical coverage terminated by Security Health Plan on the 17th day of treatment. This decision was based on a length-of-stay prediction from a NaviHealth algorithm that estimated her recovery would take 16.6 days. A federal judge later found the denial of care was improper despite her ongoing severe pain.
What broke inside the model
- 01 · TriggerA user prompts the model in public view.
- 02 · Model stepThe model produces unsafe or off-brand output.
- 03 · Control gapNo filter holds the line before publish.
- 04 · FailureThe output goes public unchecked.
- 05 · ConsequenceA reputational or safety incident lands.
A contained signal crosses into output that goes public.
The system utilized a predictive AI model to establish a rigid administrative cutoff for payment rather than a clinical guide. The failure occurred when the insurer substituted a probabilistic average recovery time for a physician's medical necessity determination.
What it cost
Sources
- PressHow Medicare Advantage plans use AI to cut off care for seniorsstatnews.com
- PressHow insurance companies use AI to deny claimswbur.org
Cite this entry
https://failureindex.ai/failures/security-health-plan-uses-navihealth-denyAI Failure Index. "Security Health Plan uses NaviHealth AI to deny elderly patient medical coverage" (FI-0596). Realm Labs. https://failureindex.ai/failures/security-health-plan-uses-navihealth-deny (indexed Jun 22, 2026).Data fields CC-BY 4.0, prose citation permitted. Incident ID FI-0596. Full dataset at /data.
Note from Realm Labs, the Index steward
How Realm would have caught this
- Prism
- OmniGuard
- AI Detection & Response (AIDR)
Realm watches the model's internal state for the signature of unsafe or off-brand generation and can block or reroute the output before it becomes public, in real time rather than after it has been screenshotted.