Lawsuit Alleges USAA Uses Computer System to Arbitrarily Deny, Reduce Claims

USAA Insurance News

In a legal case currently gaining attention, USAA is accused of utilizing a computer program to indiscriminately deny or lessen claims for personal injury protection and medical payments. This system, provided by CCC’s Auto Injury Solutions, is at the heart of numerous lawsuits that the insurance giant has faced in recent years.

Allegations of Systematic Denials

The class-action lawsuit, which emerged from Washington Superior Court for Clark County, suggests that USAA’s reliance on Auto Injury Solutions’ (AIS) computerized system is to the detriment of policyholder claims following vehicle accidents. San Antonio Express-News reported that this is not an isolated claim, as USAA has encountered similar charges for over two decades.

USAA’s Statement

Despite the allegations raised, USAA staunchly denies the claims presented in the lawsuit and emphasizes its ongoing commitment to the computer program in question, outlining the benefits it believes such a system brings to the table in terms of efficiency and accuracy for claim reviews.

The Role of AIS

AIS, belonging to CCC Intelligent Solutions Holdings Inc., boasts a suite of products designed to provide comprehensive solutions to auto-insurance carriers nationwide. AIS touts its ability to process and analyze massive amounts of claim data, enabling faster and more informed decision-making.

However, the lawsuit contends that USAA abused the AIS Medical Bill Audit (MBA) process, allowing the system to operate without any human intervention to investigate individual claims, thus bypassing potentially crucial nuances that a manual review could reveal.USAA Insurance News(

Questionable Data Sources

Critics argue that the reliance on the Milliman Database, which purportedly uses outdated and limited data, skews results against policyholders. Specifically, the database is said to draw on a sample that does not effectively represent the demographic or geographical realities of insurance claims being processed.

Alleged “Sham Medical Reviews”

The suit further accuses AIS of enlisting healthcare professionals to produce “sham medical reviews,” using only superficial evaluations and automated processes, rather than direct consultation with the insured or their medical providers.

Past Legal Challenges

This isn’t the first time USAA has been under legal scrutiny with similar allegations. A notable case resolved in 2016 entailed claims against the insurer and AIS under the Georgia Racketeer Influenced and Corrupt Organizations Act. Although the parties denied the accusations of criminal behavior and conspiracy, the spotlight remains on the operational ethics of insurance claims processing.

Ensuring Ethical Claims Processing

As policyholders contend with insurance claims, particularly in the aftermath of distressing events such as car accidents, the fairness and ethical considerations of these processes are brought sharply into focus. The public and legal outcomes of such cases stand to have important implications for both consumer rights and the insurance industry’s operations.

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