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: 25 627.4263 Mandatory 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.