Florida Senate - 2025                              CS for SB 794
       
       
        
       By the Committee on Banking and Insurance; and Senator Bradley
       
       
       
       
       
       597-02813-25                                           2025794c1
    1                        A bill to be entitled                      
    2         An act relating to mandatory human reviews of
    3         insurance claim denials; creating s. 627.4263, F.S.;
    4         defining terms; requiring that insurers’ decisions to
    5         deny claims or any portion of a claim be made by
    6         qualified human professionals; specifying the duties
    7         of qualified human professionals; requiring an insurer
    8         to maintain certain records; prohibiting using
    9         algorithms, artificial intelligence, or machine
   10         learning systems as the sole basis for determining
   11         whether to adjust or deny a claim; requiring insurers
   12         to include certain information in denial
   13         communications to claimants; requiring that certain
   14         insurers detail certain information in their claims
   15         handling manual; authorizing the Office of Insurance
   16         Regulation to conduct market conduct examinations and
   17         investigations under certain circumstances;
   18         authorizing the Financial Services Commission to adopt
   19         rules; providing an effective date.
   20          
   21  Be It Enacted by the Legislature of the State of Florida:
   22  
   23         Section 1. Section 627.4263, Florida Statutes, is created
   24  to read:
   25         627.4263Mandatory human reviews of claim denials.—
   26         (1) As used in this section, the term:
   27         (a) “Algorithm” means a clearly specified mathematical
   28  process for computation which uses rules designed to give
   29  prescribed results.
   30         (b) “Artificial intelligence system” means a machine-based
   31  system that may have varying levels of autonomy and that can,
   32  for a given set of objectives, generate outputs, such as
   33  predictions, recommendations, or content, influencing decisions
   34  made in real or virtual environments.
   35         (c) “Machine learning system” means an artificial
   36  intelligence system that has the ability to learn from provided
   37  data without being explicitly programmed.
   38         (d) “Qualified human professional” means an individual who,
   39  under the Florida Insurance Code, has the authority to adjust or
   40  deny a claim or a portion of a claim and may exercise such
   41  authority over a particular claim.
   42         (2) An insurer’s decision to deny a claim or any portion of
   43  a claim must be made by a qualified human professional.
   44         (3) A qualified human professional shall, before
   45  determining whether to adjust or deny a claim or a portion of a
   46  claim, do all of the following:
   47         (a) Analyze the facts of the claim and the terms of the
   48  insurance policy independently of any system or algorithm.
   49         (b) Review the accuracy of any output generated by such a
   50  system or algorithm.
   51         (c) Conduct any review of a claim adjustment or claim
   52  decision that was made by another qualified human professional.
   53         (4) An insurer shall maintain detailed records of the
   54  actions of qualified human professionals who are required to
   55  perform the actions under subsection (3), including:
   56         (a) The name and title of the qualified human professional
   57  who made the decision to deny a claim or a portion of a claim
   58  and of any qualified human professional who reviewed a claim
   59  adjustment or claim decision.
   60         (b) The date and time of the claim decision and of any
   61  review of the claim adjustment.
   62         (c) Documentation of the basis for the denial of the claim
   63  or a portion of the claim, including any information provided by
   64  an algorithm, an artificial intelligence system, or a machine
   65  learning system.
   66         (5) An algorithm, an artificial intelligence system, or a
   67  machine learning system may not serve as the sole basis for
   68  determining whether to adjust or deny a claim.
   69         (6) In all denial communications to a claimant, an insurer
   70  shall:
   71         (a) Clearly identify the qualified human professional who
   72  made the decision to deny the claim or a portion of the claim;
   73  and
   74         (b) Include a statement affirming that an algorithm, an
   75  artificial intelligence system, or a machine learning system did
   76  not serve as the sole basis for determining whether to deny the
   77  claim or a portion of the claim.
   78         (7) An insurer that uses an algorithm, an artificial
   79  intelligence system, or a machine learning system as part of its
   80  claims handling process shall detail in its claims handling
   81  manual the manner in which such systems are to be used and the
   82  manner in which the insurer complies with this section.
   83         (8) The office may conduct market conduct examinations and
   84  investigations or use any method it deems necessary to verify
   85  compliance with this section.
   86         (9)The commission may adopt rules to implement this
   87  section.
   88         Section 2. This act shall take effect January 1, 2026.