How Insurers Use AI to Deny Your Claims — And How to Fight Back

The Rise of Automated Claim Denials

Health insurers have increasingly adopted AI and automated decision-making tools to process and adjudicate claims. These systems analyse billing codes, clinical documentation, and historical patterns to flag or automatically deny claims without physician review. This allows insurers to process millions of claims faster and at lower cost — but it creates a new category of unjust denials.

In 2023, an investigative report by ProPublica documented how one major US insurer used an algorithm to deny thousands of claims in seconds, with one physician reportedly reviewing claims for just 1.2 seconds each. Similar practices have been identified in the UK and Gulf markets.

How to Identify an AI or Automated Denial

Indicators of automated denial include:

• The denial letter uses generic language without addressing the specific clinical details of your case
• The denial references a denial code rather than a policy clause
• The response time was extremely rapid (hours rather than days)
• Multiple claims for similar services have been denied simultaneously
• The denial reason does not match your actual clinical circumstances

How to Challenge an AI-Driven Denial

1. Request a human review — explicitly state in your appeal that you require a physician-level review of your case, not an automated reassessment. Most markets with regulated insurance provide for this right.
2. Request the clinical criteria applied — ask the insurer to disclose the specific clinical guideline or algorithm used to assess your claim. If they cannot or will not provide this, it weakens their denial.
3. Provide granular clinical documentation — automated systems score against pattern matches; detailed, specific clinical notes that address the denial criteria directly are harder for algorithms to dismiss.
4. Escalate immediately to the regulator — regulatory bodies in the UAE (SANADAK) and UK (FOS) take a dim view of automated denials that bypass clinical judgment. An escalation complaint with evidence of automated decision-making is treated seriously.