HUMAN vs. AI - Does Artificial Intelligence Unfairly Favor Insurers?

Imagine the increased profits to insurers if there were no more claims by injured workers. Imagine if all claims were successfully denied and there were no more payments to injured workers. Now you can imagine the money incentive for insurers to find the intelligence needed to deny more claims.

Artificial intelligence is being used more and more by insurers to deny your worker’s compensation case.

That’s because workers’ compensation insurers are not human. They have no intelligence of their own. Their goal is money profit, and insurers need intelligence.

Even before computers existed, workers’ compensation insurance companies found a method of intelligence to deny claims and leave injured workers impoverished. They did so by training and paying intelligent persons to become the company’s artificial intelligence, such as adjusters, defense attorneys, nurse case managers, and so-called independent medical examiners and physicians.

There are many abuses made by workers’ compensation insurers by their intelligent adjusters. Here is a list of unfair claim practices posted by Amax dedicated to saving costs for insurers. The list includes

  • Failing to contact the injured employee (hoping the employee will not pursue the claim)
  • Failing to investigate the claim properly
  • Denying compensability without a valid reason
  • Failing to file all necessary state forms
  • Recording the employee’s statement when the employee is under the influence of medications or distracted by pain
  • Failing to provide a copy of a recorded statement or written statement when one is requested
  • Recording telephone calls without the other party’s knowledge of the call being recorded
  • Knowingly documenting the file notes with inaccurate information
  • Intentionally not returning phone calls of the employee or medical provider in an effort to discourage the claim
  • Failing to pay indemnity benefits timely trying to coerce the employee in to returning to work prematurely
  • Failing to authorize needed diagnostic testing without reason to not authorize
  • Paying less than the workers comp statute calls for when settling a permanent partial disability
  • Offering to settle and close out future benefits for an amount significantly less than what the adjuster knows to be fair
  • Advising the employee not to hire an attorney
  • Threatening to reduce the settlement of the claim if the employee hires an attorney
  • Discussing any aspect of the claim with an employee known to be represented by an attorney
  • Settling the claim before the extent of disability is known
  • Overstating the damages and exposures so that the adjuster’s supervisor will extend excessive settlement authority, allowing the adjuster to make a quick (but overpaid) settlement
  • Providing the employee’s personal information to parties who do not have a legitimate need to know
  • Having a financial interest in any vendor utilized on the claim

There are many known misuses and abuses by insurers who hire and pay money to so-called independent medical examiners. Some are summarily described by the Center of Justice and Democracy at New York Law School.

Vermont examples are from actual cases I have taken to trial. They are highlighted in my book, "Injured Workers’ Guide to Vermont Workers’ Compensation."

The modern use of computer-generated Artificial Intelligence programs, algorithms, and bots offers insurers the potential to strengthen the insurer pattern and practice of tracking and categorizing injured workers as merely claim numbers, treating human tragedies as merely money things, and seeing disabling injuries of human beings as merely claim categories. Use of AI offers more power to control information, more resources to exploit human disability, more techniques to develop to the detriment of injured worker and to the financial benefit of the insurance company.

A 2023 investigative report revealed health insurers denied 49 million claims in 2021 and the number of appeals by humans occurred only 2 per cent of the time. The denials were partly based on artificial intelligence and computer algorithms that cause the insurer to deny a claim in 2 seconds.

What kind of intelligence denies a claim in 2 seconds? What kind of intelligence considers an injured and disabled worker for less time than it takes to say hello and ask what is your name? Artificial intelligence for the workers’ compensation insurer is the synergistic utilization of human beings as its employees and contractors, together with ever enhanced artificial intelligence powers from computers.

Predictions are that Artificial Intelligence is soon to replace adjusters. “For example, AI can be programmed to mimic senior underwriters & adjusters who can intuitively pick up fraud based on voice & text analytics, a skill which takes years to develop.”

AI is even predicted to replace lawyers.

For now, it is important for injured workers to know that not all arguments made by an insurer are true. Some may be relying on artificial intelligence generated by a computer program. Some of those arguments may be completely false.

A recent example of completely false intelligence is from the case of the attorney who cited 10 cases in a brief. He used research and citations that were generated by the AI program called ChatGPT. But not one of the attorney’s 10 cases were real: “The lawyer who created the brief, Steven A. Schwartz of the firm Levidow, Levidow & Oberman, threw himself on the mercy of the court on Thursday, saying in an affidavit that he had used the artificial intelligence program to do his legal research — ‘a source that has revealed itself to be unreliable.’”

Intelligence used by insurers - by the combined resources of employees, contractors and the enhanced speed of artificial intelligence programming through computers - is all the intelligence an insurance company has to deny claims. It is powerful. It is intimidating.

However, the injured worker remains the more important and more intelligent and more powerful person in the workers’ compensation system. That is because of two very important facts. First, the workers’ compensation system was originally designed to help the injured worker, not to harm the injured worker. Second, the injured worker has a legal right to be represented by a Vermont workers’ compensation attorney. An experience workers’ compensation attorney is familiar with the insurer’s denials of claims, and the techniques, pretexts, misimpressions, and other games insurers play.

A Vermont Worker’s Compensation attorney is a warrior against insurers. He is human. He studies. He reads. He observes. He is trained in the law. More than this, he understands the human experience, he embraces the life of the injured worker, and he knows the truth and needs of the injured worker. He treats the injured worker as his own family. He gives more than two seconds, more than two hours, far more than is ever necessary to unstoppably represent the injured worker and bring justice.

When represented by an experienced Vermont workers’ compensation attorney, the injured and disabled worker is even more powerful than artificial intelligence.

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