The Florida Senate

CHAPTER 627

INSURANCE RATES AND CONTRACTS

PART I

RATES AND RATING ORGANIZATIONS (ss. 627.011-627.381)

PART II

THE INSURANCE CONTRACT (ss. 627.401-627.441)

PART III

LIFE INSURANCE AND ANNUITY CONTRACTS (ss. 627.451-627.482)

PART IV

INDUSTRIAL LIFE INSURANCE POLICIES (ss. 627.501-627.522)

PART V

GROUP LIFE INSURANCE POLICIES (ss. 627.551-627.575)

PART VI

HEALTH INSURANCE POLICIES (ss. 627.601-627.6499)

PART VII

GROUP, BLANKET, AND FRANCHISE HEALTH INSURANCE POLICIES
(ss. 627.651-627.6699)

PART VIII

MEDICARE SUPPLEMENT POLICIES (ss. 627.671-627.675)

PART IX

CREDIT LIFE AND DISABILITY INSURANCES (ss. 627.676-627.6845)

PART X

PROPERTY INSURANCE CONTRACTS (ss. 627.701-627.7077)

PART XI

MOTOR VEHICLE AND CASUALTY INSURANCE CONTRACTS
(ss. 627.7261-627.746)

PART XII

SURETY INSURANCE CONTRACTS (ss. 627.751-627.759)

PART XIII

TITLE INSURANCE CONTRACTS (ss. 627.7711-627.798)

PART XIV

VARIABLE OR INDETERMINATE VALUE CONTRACTS (ss. 627.801-627.807)

PART XV

PREMIUM FINANCE COMPANIES AND AGREEMENTS (ss. 627.826-627.849)

PART XVI

PREMIUM FINANCING (ss. 627.901-627.904)

PART XVII

INSURER REPORTING (ss. 627.911-627.919)

PART XVIII

LONG-TERM CARE INSURANCE POLICIES (ss. 627.9401-627.9408)

PART XIX

PURCHASING GROUPS AND RISK RETENTION GROUPS
(ss. 627.941-627.955)

PART XX

FINANCIAL GUARANTY INSURANCE (ss. 627.971-627.975)

PART XXI

MORTGAGE INSURANCE CONSOLIDATIONS (ss. 627.981-627.987)

PART I

RATES AND RATING ORGANIZATIONS

627.011  Short title.

627.021  Scope of this part.

627.031  Purposes of this part; interpretation.

627.041  Definitions.

627.0612  Administrative proceedings in rating determinations.

627.0613  Consumer advocate.

627.062  Rate standards.

627.0625  Commercial property and casualty risk management plans.

627.0628  Florida Commission on Hurricane Loss Projection Methodology.

627.0629  Residential property insurance; rate filings.

627.0645  Annual filings.

627.06501  Insurance discounts for certain persons completing driver improvement course.

627.0651  Making and use of rates for motor vehicle insurance.

627.0652  Insurance discounts for certain persons completing safety course.

627.0653  Insurance discounts for specified motor vehicle equipment.

627.06535  Electric vehicles; restrictions on imposing surcharges.

627.0654  Insurance discounts for buildings with fire sprinklers.

627.066  Excessive profits for motor vehicle insurance prohibited.

627.0665  Automatic bank withdrawal agreements; notification required.

627.072  Making and use of rates.

627.091  Rate filings; workers' compensation and employer's liability insurances.

627.0915  Rate filings; workers' compensation, drug-free workplace, and safe employers.

627.0916  Agricultural horse farms.

627.092  Workers' Compensation Administrator.

627.093  Application of s. 286.011 to workers' compensation and employer's liability insurances.

627.096  Workers' Compensation Rating Bureau.

627.101  When filing becomes effective; workers' compensation and employer's liability insurances.

627.111  Effective date of filing.

627.141  Subsequent disapproval of filing; workers' compensation and employer's liability insurances.

627.151  Basis of approval or disapproval of workers' compensation or employer's liability insurance filing; scope of disapproval power.

627.1615  Workers' compensation applicant discrimination.

627.162  Requirements for premium installments; delinquency, collection, and check return charges; attorney's fees.

627.171  Excess rates.

627.191  Adherence to filings; workers' compensation and employer's liability insurances.

627.192  Workers' compensation insurance; employee leasing arrangements.

627.211  Deviations; workers' compensation and employer's liability insurances.

627.212  Workplace safety program surcharge.

627.215  Excessive profits for workers' compensation, employer's liability, commercial property, and commercial casualty insurance prohibited.

627.221  Rating organizations; licensing; fee.

627.231  Subscribers to rating organizations.

627.241  Notice of changes.

627.251  Bureau rules not to affect dividends.

627.261  Actuarial and technical services.

627.281  Appeal from rating organization; workers' compensation and employer's liability insurance filings.

627.285  Independent actuarial peer review of workers' compensation rating organization.

627.291  Information to be furnished insureds; appeal by insureds; workers' compensation and employer's liability insurances.

627.301  Advisory organizations.

627.311  Joint underwriters and joint reinsurers; public records and public meetings exemptions.

627.312  Transitional provisions.

627.313  Workers' Compensation Joint Underwriting Plan; audit requirements.

627.314  Concerted action by two or more insurers.

627.318  Records.

627.331  Recording and reporting of loss, expense, and claims experience; rating information.

627.351  Insurance risk apportionment plans.

627.3511  Depopulation of Citizens Property Insurance Corporation.

627.3512  Recoupment of residual market deficit assessments.

627.3513  Standards for sale of bonds by Citizens Property Insurance Corporation.

627.3515  Market assistance plan; property and casualty risks.

627.3517  Consumer choice.

627.357  Medical malpractice self-insurance.

627.361  False or misleading information.

627.371  Hearings.

627.381  Penalty for violation.

627.011  Short title.--This part of this chapter may be referred to as the "Rating Law."

History.--s. 412, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318.

627.021  Scope of this part.--

(1)  This part of this chapter applies only to property, casualty, and surety insurances on subjects of insurance resident, located, or to be performed in this state.

(2)  This chapter does not apply to:

(a)  Reinsurance, except joint reinsurance as provided in s. 627.311.

(b)  Insurance against loss of or damage to aircraft, their hulls, accessories, or equipment, or against liability, other than workers' compensation and employer's liability, arising out of the ownership, maintenance, or use of aircraft.

(c)  Insurance of vessels or craft, their cargoes, marine builders' risks, marine protection and indemnity, or other risks commonly insured under marine insurance policies.

(d)  Commercial inland marine insurance.

(e)  Surplus lines insurance placed under the provisions of ss. 626.913-626.937.

(3)  For the purposes of this chapter, all motor vehicle insurance shall be deemed to be casualty insurance only.

(4)  This part does not apply to health insurance.

History.--s. 413, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 92, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 337, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 2, ch. 88-166; s. 114, ch. 92-318; s. 1, ch. 98-173.

627.031  Purposes of this part; interpretation.--

(1)  The purposes of this part are:

(a)  To promote the public welfare by regulating insurance rates as herein provided to the end that they shall not be excessive, inadequate, or unfairly discriminatory;

(b)  To encourage independent action by, and reasonable price competition among, insurers;

(c)  To authorize the existence and operation of qualified rating organizations and advisory organizations and to require that specified rating services of such rating organizations be generally available to all authorized insurers; and

(d)  To authorize cooperation between insurers in ratemaking and other related matters.

(2)  It is the purpose of this part to protect policyholders and the public against the adverse effects of excessive, inadequate, or unfairly discriminatory insurance rates, and to authorize the office to regulate such rates. If at any time the office has reason to believe any such rate is excessive, inadequate, or unfairly discriminatory under the law, it is directed to take the necessary action to cause such rate to comply with the laws of this state.

(3)  Nothing in this part shall be construed to repeal or modify the provisions of part IX of chapter 626, relating to unfair trade practices.

History.--s. 411, ch. 59-205; s. 1, ch. 67-9; ss. 13, 35, ch. 69-106; s. 1, ch. 71-3(B); s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 338, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 28, ch. 87-228; s. 114, ch. 92-318; s. 54, ch. 2001-63; s. 1061, ch. 2003-261.

627.041  Definitions.--As used in this part:

(1)  "Rate" means the unit charge by which the measure of exposure or the amount of insurance specified in a policy of insurance or covered thereunder is multiplied to determine the premium.

(2)  "Premium" means the consideration paid or to be paid to an insurer for the issuance and delivery of any binder or policy of insurance.

(3)  "Rating organization" means every person, other than an authorized insurer, whether located within or outside this state, who has as his or her object or purpose the making of rates, rating plans, or rating systems. Two or more authorized insurers that act in concert for the purpose of making rates, rating plans, or rating systems, and that do not operate within the specific authorizations contained in ss. 627.311, 627.314(2), (4), and 627.351, shall be deemed to be a rating organization. No single insurer shall be deemed to be a rating organization.

(4)  "Advisory organization" means every group, association, or other organization of insurers, whether located within or outside this state, which prepares policy forms or makes underwriting rules incident to but not including the making of rates, rating plans, or rating systems or which collects and furnishes to authorized insurers or rating organizations loss or expense statistics or other statistical information and data and acts in an advisory, as distinguished from a ratemaking, capacity.

(5)  "Member" means an insurer who participates in or is entitled to participate in the management of a rating, advisory, or other organization.

(6)  "Subscriber" means an insurer which is furnished at its request:

(a)  With rates and rating manuals by a rating organization of which it is not a member; or

(b)  With advisory services by an advisory organization of which it is not a member.

(7)  "Willful" or "willfully" in relation to an act or omission which constitutes a violation of this part means with actual knowledge or belief that such act or omission constitutes such violation and with specific intent nevertheless to commit such act or omission.

(8)  "Motor vehicle insurance" means a policy of motor vehicle insurance delivered or issued for delivery in the state by an authorized insurer:

(a)  Insuring a natural person as the named insured or one or more related individuals resident of the same household, or both; and

(b)  Insuring a motor vehicle of the private passenger type or station wagon type, which motor vehicle is not used as public or livery conveyance for passengers or rented to others, or insuring any other four-wheeled motor vehicle having a capacity of 1,500 pounds or less which is not used in the occupation, profession, or business of the insured, other than farming;

other than any policy issued under an automobile insurance risk apportionment plan; or other than any policy insuring more than four automobiles; or other than any policy covering garage, automobile sales agency, repair shop, service station, or public parking place operation hazards.

(9)  "Insurer," for purposes of ss. 627.091, 627.096, 627.101, 627.111, 627.141, 627.171, 627.191, 627.211, and 627.291, includes a commercial self-insurance fund as defined in s. 624.462 and a group self-insurance fund as defined in s. 624.4621.

History.--s. 414, ch. 59-205; s. 2, ch. 67-9; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 340, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 3, ch. 87-124; s. 114, ch. 92-318; s. 93, ch. 93-415; s. 315, ch. 97-102.

627.0612  Administrative proceedings in rating determinations.--In any proceeding to determine whether rates, rating plans, or other matters governed by this part comply with the law, the appellate court shall set aside a final order of the office if the office has violated s. 120.57(1)(k) by substituting its findings of fact for findings of an administrative law judge which were supported by competent substantial evidence.

History.--s. 7, ch. 86-160; s. 2, ch. 87-50; s. 114, ch. 92-318; s. 272, ch. 96-410; s. 27, ch. 99-3; s. 1062, ch. 2003-261.

627.0613  Consumer advocate.--The Chief Financial Officer must appoint a consumer advocate who must represent the general public of the state before the department and the office. The consumer advocate must report directly to the Chief Financial Officer, but is not otherwise under the authority of the department or of any employee of the department. The consumer advocate has such powers as are necessary to carry out the duties of the office of consumer advocate, including, but not limited to, the powers to:

(1)  Recommend to the department or office, by petition, the commencement of any proceeding or action; appear in any proceeding or action before the department or office; or appear in any proceeding before the Division of Administrative Hearings relating to subject matter under the jurisdiction of the department or office.

(2)  Have access to and use of all files, records, and data of the department or office.

(3)  Examine rate and form filings submitted to the office, hire consultants as necessary to aid in the review process, and recommend to the department or office any position deemed by the consumer advocate to be in the public interest.

(4)  Prepare an annual budget for presentation to the Legislature by the department, which budget must be adequate to carry out the duties of the office of consumer advocate.

History.--s. 18, ch. 92-318; s. 1063, ch. 2003-261.

627.062  Rate standards.--

(1)  The rates for all classes of insurance to which the provisions of this part are applicable shall not be excessive, inadequate, or unfairly discriminatory.

(2)  As to all such classes of insurance:

(a)  Insurers or rating organizations shall establish and use rates, rating schedules, or rating manuals to allow the insurer a reasonable rate of return on such classes of insurance written in this state. A copy of rates, rating schedules, rating manuals, premium credits or discount schedules, and surcharge schedules, and changes thereto, shall be filed with the office under one of the following procedures:

1.  If the filing is made at least 90 days before the proposed effective date and the filing is not implemented during the office's review of the filing and any proceeding and judicial review, then such filing shall be considered a "file and use" filing. In such case, the office shall finalize its review by issuance of a notice of intent to approve or a notice of intent to disapprove within 90 days after receipt of the filing. The notice of intent to approve and the notice of intent to disapprove constitute agency action for purposes of the Administrative Procedure Act. Requests for supporting information, requests for mathematical or mechanical corrections, or notification to the insurer by the office of its preliminary findings shall not toll the 90-day period during any such proceedings and subsequent judicial review. The rate shall be deemed approved if the office does not issue a notice of intent to approve or a notice of intent to disapprove within 90 days after receipt of the filing.

2.  If the filing is not made in accordance with the provisions of subparagraph 1., such filing shall be made as soon as practicable, but no later than 30 days after the effective date, and shall be considered a "use and file" filing. An insurer making a "use and file" filing is potentially subject to an order by the office to return to policyholders portions of rates found to be excessive, as provided in paragraph (h).

(b)  Upon receiving a rate filing, the office shall review the rate filing to determine if a rate is excessive, inadequate, or unfairly discriminatory. In making that determination, the office shall, in accordance with generally accepted and reasonable actuarial techniques, consider the following factors:

1.  Past and prospective loss experience within and without this state.

2.  Past and prospective expenses.

3.  The degree of competition among insurers for the risk insured.

4.  Investment income reasonably expected by the insurer, consistent with the insurer's investment practices, from investable premiums anticipated in the filing, plus any other expected income from currently invested assets representing the amount expected on unearned premium reserves and loss reserves. The commission may adopt rules utilizing reasonable techniques of actuarial science and economics to specify the manner in which insurers shall calculate investment income attributable to such classes of insurance written in this state and the manner in which such investment income shall be used in the calculation of insurance rates. Such manner shall contemplate allowances for an underwriting profit factor and full consideration of investment income which produce a reasonable rate of return; however, investment income from invested surplus shall not be considered.

5.  The reasonableness of the judgment reflected in the filing.

6.  Dividends, savings, or unabsorbed premium deposits allowed or returned to Florida policyholders, members, or subscribers.

7.  The adequacy of loss reserves.

8.  The cost of reinsurance.

9.  Trend factors, including trends in actual losses per insured unit for the insurer making the filing.

10.  Conflagration and catastrophe hazards, if applicable.

11.  A reasonable margin for underwriting profit and contingencies.

12.  The cost of medical services, if applicable.

13.  Other relevant factors which impact upon the frequency or severity of claims or upon expenses.

(c)  In the case of fire insurance rates, consideration shall be given to the availability of water supplies and the experience of the fire insurance business during a period of not less than the most recent 5-year period for which such experience is available.

(d)  If conflagration or catastrophe hazards are given consideration by an insurer in its rates or rating plan, including surcharges and discounts, the insurer shall establish a reserve for that portion of the premium allocated to such hazard and shall maintain the premium in a catastrophe reserve. Any removal of such premiums from the reserve for purposes other than paying claims associated with a catastrophe or purchasing reinsurance for catastrophes shall be subject to approval of the office. Any ceding commission received by an insurer purchasing reinsurance for catastrophes shall be placed in the catastrophe reserve.

(e)  After consideration of the rate factors provided in paragraphs (b), (c), and (d), a rate may be found by the office to be excessive, inadequate, or unfairly discriminatory based upon the following standards:

1.  Rates shall be deemed excessive if they are likely to produce a profit from Florida business that is unreasonably high in relation to the risk involved in the class of business or if expenses are unreasonably high in relation to services rendered.

2.  Rates shall be deemed excessive if, among other things, the rate structure established by a stock insurance company provides for replenishment of surpluses from premiums, when the replenishment is attributable to investment losses.

3.  Rates shall be deemed inadequate if they are clearly insufficient, together with the investment income attributable to them, to sustain projected losses and expenses in the class of business to which they apply.

4.  A rating plan, including discounts, credits, or surcharges, shall be deemed unfairly discriminatory if it fails to clearly and equitably reflect consideration of the policyholder's participation in a risk management program adopted pursuant to s. 627.0625.

5.  A rate shall be deemed inadequate as to the premium charged to a risk or group of risks if discounts or credits are allowed which exceed a reasonable reflection of expense savings and reasonably expected loss experience from the risk or group of risks.

6.  A rate shall be deemed unfairly discriminatory as to a risk or group of risks if the application of premium discounts, credits, or surcharges among such risks does not bear a reasonable relationship to the expected loss and expense experience among the various risks.

(f)  In reviewing a rate filing, the office may require the insurer to provide at the insurer's expense all information necessary to evaluate the condition of the company and the reasonableness of the filing according to the criteria enumerated in this section.

(g)  The office may at any time review a rate, rating schedule, rating manual, or rate change; the pertinent records of the insurer; and market conditions. If the office finds on a preliminary basis that a rate may be excessive, inadequate, or unfairly discriminatory, the office shall initiate proceedings to disapprove the rate and shall so notify the insurer. However, the office may not disapprove as excessive any rate for which it has given final approval or which has been deemed approved for a period of 1 year after the effective date of the filing unless the office finds that a material misrepresentation or material error was made by the insurer or was contained in the filing. Upon being so notified, the insurer or rating organization shall, within 60 days, file with the office all information which, in the belief of the insurer or organization, proves the reasonableness, adequacy, and fairness of the rate or rate change. The office shall issue a notice of intent to approve or a notice of intent to disapprove pursuant to the procedures of paragraph (a) within 90 days after receipt of the insurer's initial response. In such instances and in any administrative proceeding relating to the legality of the rate, the insurer or rating organization shall carry the burden of proof by a preponderance of the evidence to show that the rate is not excessive, inadequate, or unfairly discriminatory. After the office notifies an insurer that a rate may be excessive, inadequate, or unfairly discriminatory, unless the office withdraws the notification, the insurer shall not alter the rate except to conform with the office's notice until the earlier of 120 days after the date the notification was provided or 180 days after the date of the implementation of the rate. The office may, subject to chapter 120, disapprove without the 60-day notification any rate increase filed by an insurer within the prohibited time period or during the time that the legality of the increased rate is being contested.

(h)  In the event the office finds that a rate or rate change is excessive, inadequate, or unfairly discriminatory, the office shall issue an order of disapproval specifying that a new rate or rate schedule which responds to the findings of the office be filed by the insurer. The office shall further order, for any "use and file" filing made in accordance with subparagraph (a)2., that premiums charged each policyholder constituting the portion of the rate above that which was actuarially justified be returned to such policyholder in the form of a credit or refund. If the office finds that an insurer's rate or rate change is inadequate, the new rate or rate schedule filed with the office in response to such a finding shall be applicable only to new or renewal business of the insurer written on or after the effective date of the responsive filing.

(i)  Except as otherwise specifically provided in this chapter, the office shall not prohibit any insurer, including any residual market plan or joint underwriting association, from paying acquisition costs based on the full amount of premium, as defined in s. 627.403, applicable to any policy, or prohibit any such insurer from including the full amount of acquisition costs in a rate filing.

The provisions of this subsection shall not apply to workers' compensation and employer's liability insurance and to motor vehicle insurance.

(3)(a)  For individual risks that are not rated in accordance with the insurer's rates, rating schedules, rating manuals, and underwriting rules filed with the office and which have been submitted to the insurer for individual rating, the insurer must maintain documentation on each risk subject to individual risk rating. The documentation must identify the named insured and specify the characteristics and classification of the risk supporting the reason for the risk being individually risk rated, including any modifications to existing approved forms to be used on the risk. The insurer must maintain these records for a period of at least 5 years after the effective date of the policy.

(b)  Individual risk rates and modifications to existing approved forms are not subject to this part or part II, except for paragraph (a) and ss. 627.402, 627.403, 627.4035, 627.404, 627.405, 627.406, 627.407, 627.4085, 627.409, 627.4132, 627.4133, 627.415, 627.416, 627.417, 627.419, 627.425, 627.426, 627.4265, 627.427, and 627.428, but are subject to all other applicable provisions of this code and rules adopted thereunder.

(c)  This subsection does not apply to private passenger motor vehicle insurance.

(4)  The establishment of any rate, rating classification, rating plan or schedule, or variation thereof in violation of part IX of chapter 626 is also in violation of this section.

(5)  With respect to a rate filing involving coverage of the type for which the insurer is required to pay a reimbursement premium to the Florida Hurricane Catastrophe Fund, the insurer may fully recoup in its property insurance premiums any reimbursement premiums paid to the Florida Hurricane Catastrophe Fund, together with reasonable costs of other reinsurance, but may not recoup reinsurance costs that duplicate coverage provided by the Florida Hurricane Catastrophe Fund.

(6)(a)  After any action with respect to a rate filing that constitutes agency action for purposes of the Administrative Procedure Act, except for a rate filing for medical malpractice, an insurer may, in lieu of demanding a hearing under s. 120.57, require arbitration of the rate filing. Arbitration shall be conducted by a board of arbitrators consisting of an arbitrator selected by the ¹office, an arbitrator selected by the insurer, and an arbitrator selected jointly by the other two arbitrators. Each arbitrator must be certified by the American Arbitration Association. A decision is valid only upon the affirmative vote of at least two of the arbitrators. No arbitrator may be an employee of any insurance regulator or regulatory body or of any insurer, regardless of whether or not the employing insurer does business in this state. The ¹office and the insurer must treat the decision of the arbitrators as the final approval of a rate filing. Costs of arbitration shall be paid by the insurer.

(b)  Arbitration under this subsection shall be conducted pursuant to the procedures specified in ss. 682.06-682.10. Either party may apply to the circuit court to vacate or modify the decision pursuant to s. 682.13 or s. 682.14. The commission shall adopt rules for arbitration under this subsection, which rules may not be inconsistent with the arbitration rules of the American Arbitration Association as of January 1, 1996.

(c)  Upon initiation of the arbitration process, the insurer waives all rights to challenge the action of the office under the Administrative Procedure Act or any other provision of law; however, such rights are restored to the insurer if the arbitrators fail to render a decision within 90 days after initiation of the arbitration process.

(7)(a)  The provisions of this subsection apply only with respect to rates for medical malpractice insurance and shall control to the extent of any conflict with other provisions of this section.

(b)  Any portion of a judgment entered or settlement paid as a result of a statutory or common-law bad faith action and any portion of a judgment entered which awards punitive damages against an insurer may not be included in the insurer's rate base, and shall not be used to justify a rate or rate change. Any common-law bad faith action identified as such, any portion of a settlement entered as a result of a statutory or common-law action, or any portion of a settlement wherein an insurer agrees to pay specific punitive damages may not be used to justify a rate or rate change. The portion of the taxable costs and attorney's fees which is identified as being related to the bad faith and punitive damages in these judgments and settlements may not be included in the insurer's rate base and may not be utilized to justify a rate or rate change.

(c)  Upon reviewing a rate filing and determining whether the rate is excessive, inadequate, or unfairly discriminatory, the office shall consider, in accordance with generally accepted and reasonable actuarial techniques, past and present prospective loss experience, either using loss experience solely for this state or giving greater credibility to this state's loss data after applying actuarially sound methods of assigning credibility to such data.

(d)  Rates shall be deemed excessive if, among other standards established by this section, the rate structure provides for replenishment of reserves or surpluses from premiums when the replenishment is attributable to investment losses.

(e)  The insurer must apply a discount or surcharge based on the health care provider's loss experience or shall establish an alternative method giving due consideration to the provider's loss experience. The insurer must include in the filing a copy of the surcharge or discount schedule or a description of the alternative method used, and must provide a copy of such schedule or description, as approved by the office, to policyholders at the time of renewal and to prospective policyholders at the time of application for coverage.

(f)  Each medical malpractice insurer must make a rate filing under this section, sworn to by at least two executive officers of the insurer, at least once each calendar year.

(8)(a)1.  No later than 60 days after the effective date of medical malpractice legislation enacted during the 2003 Special Session D of the Florida Legislature, the office shall calculate a presumed factor that reflects the impact that the changes contained in such legislation will have on rates for medical malpractice insurance and shall issue a notice informing all insurers writing medical malpractice coverage of such presumed factor. In determining the presumed factor, the office shall use generally accepted actuarial techniques and standards provided in this section in determining the expected impact on losses, expenses, and investment income of the insurer. To the extent that the operation of a provision of medical malpractice legislation enacted during the 2003 Special Session D of the Florida Legislature is stayed pending a constitutional challenge, the impact of that provision shall not be included in the calculation of a presumed factor under this subparagraph.

2.  No later than 60 days after the office issues its notice of the presumed rate change factor under subparagraph 1., each insurer writing medical malpractice coverage in this state shall submit to the office a rate filing for medical malpractice insurance, which will take effect no later than January 1, 2004, and apply retroactively to policies issued or renewed on or after the effective date of medical malpractice legislation enacted during the 2003 Special Session D of the Florida Legislature. Except as authorized under paragraph (b), the filing shall reflect an overall rate reduction at least as great as the presumed factor determined under subparagraph 1. With respect to policies issued on or after the effective date of such legislation and prior to the effective date of the rate filing required by this subsection, the office shall order the insurer to make a refund of the amount that was charged in excess of the rate that is approved.

(b)  Any insurer or rating organization that contends that the rate provided for in paragraph (a) is excessive, inadequate, or unfairly discriminatory shall separately state in its filing the rate it contends is appropriate and shall state with specificity the factors or data that it contends should be considered in order to produce such appropriate rate. The insurer or rating organization shall be permitted to use all of the generally accepted actuarial techniques provided in this section in making any filing pursuant to this subsection. The office shall review each such exception and approve or disapprove it prior to use. It shall be the insurer's burden to actuarially justify any deviations from the rates required to be filed under paragraph (a). The insurer making a filing under this paragraph shall include in the filing the expected impact of medical malpractice legislation enacted during the 2003 Special Session D of the Florida Legislature on losses, expenses, and rates.

(c)  If any provision of medical malpractice legislation enacted during the 2003 Special Session D of the Florida Legislature is held invalid by a court of competent jurisdiction, the office shall permit an adjustment of all medical malpractice rates filed under this section to reflect the impact of such holding on such rates so as to ensure that the rates are not excessive, inadequate, or unfairly discriminatory.

(d)  Rates approved on or before July 1, 2003, for medical malpractice insurance shall remain in effect until the effective date of a new rate filing approved under this subsection.

(e)  The calculation and notice by the office of the presumed factor pursuant to paragraph (a) is not an order or rule that is subject to chapter 120. If the office enters into a contract with an independent consultant to assist the office in calculating the presumed factor, such contract shall not be subject to the competitive solicitation requirements of s. 287.057.

History.--s. 3, ch. 67-9; s. 3, ch. 71-3(B); s. 3, ch. 76-168; s. 21, ch. 77-468; s. 1, ch. 77-457; s. 93, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 341, 357, 809(2nd), ch. 82-243; ss. 45, 49, 79, ch. 82-386; s. 93, ch. 83-216; s. 9, ch. 86-160; ss. 19, 114, ch. 92-318; s. 8, ch. 92-328; s. 5, ch. 95-276; s. 4, ch. 96-194; s. 7, ch. 96-377; s. 8, ch. 2000-370; s. 55, ch. 2001-63; s. 1064, ch. 2003-261; ss. 40, 84, ch. 2003-416.

¹Note.--

A.  As amended by s. 1064, ch. 2003-261, enacted at the 2003 Regular Session. Section 40, ch. 2003-416, enacted at Special Session D, 2003, failed to incorporate the amendment by s. 1064, ch. 2003-261, which substituted the word "office" for the word "department."

B.  Section 84, ch. 2003-416, provides that "[i]f any law that is amended by this act was also amended by a law enacted at the 2003 Regular Session or a 2003 special session of the Legislature, such laws shall be construed as if they had been enacted during the same session of the Legislature, and full effect should be given to each if that is possible."

627.0625  Commercial property and casualty risk management plans.--

(1)  For the purposes of this section, the term:

(a)  "Commercial property insurance" means insurance as defined in s. 624.604, but limited to coverage of commercial risks, excluding windstorm coverage, flood insurance, federal crop insurance, crop hail insurance, the Pollution Liability Insurance Association, and other federal governmental pools and associations. If separate rates and supporting experience data are not filed and justified for windstorm coverage, the insurer shall, using generally accepted actuarial and economic principles and techniques, identify and justify the premiums, losses, reserves, and associated data for the windstorm coverage excluded from commercial property insurance.

(b)  "Commercial casualty insurance" means insurance as defined in s. 624.605, other than workers' compensation and employer's liability insurance, but limited to coverage of commercial risks.

(c)  "Commercial umbrella liability insurance" means insurance as defined in s. 624.605 but limited to any policy or endorsement which provides coverage in the amount of $300,000 or more in excess of an underlying policy providing $300,000 liability or equivalent limits of insurance, on a specific insured vehicle, location, business operation, or other specific commercial risk.

(2)  This section shall apply only to commercial property insurance and to commercial casualty insurance as those terms are defined in subsection (1), or any combination thereof.

(3)  Each insurer or insurer group offering commercial casualty insurance or commercial property insurance covering risks located in this state shall develop and make available to insureds guidelines for risk management plans. The risk management program shall include the following:

(a)  Safety measures, including, as applicable, the following areas:

1.  Pollution and environmental hazards;

2.  Disease hazards;

3.  Accidental occurrences;

4.  Fire hazards and fire prevention and detection;

5.  Liability for acts from the course of business;

6.  Slip and fall hazards;

7.  Product injury; and

8.  Hazards unique to a particular class or category of insureds.

(b)  Training to insureds in safety management techniques.

(c)  Safety management counseling services.

There shall be no civil cause of action against any insurer or its agents or employees for acts or omissions in any way connected with the requirements of this subsection. This shall not limit the authority for the office to enforce the provisions of this subsection.

History.--s. 10, ch. 86-160; s. 2, ch. 87-50; s. 2, ch. 88-390; s. 18, ch. 89-167; s. 1, ch. 89-225; s. 114, ch. 92-318; s. 1065, ch. 2003-261.

627.0628  Florida Commission on Hurricane Loss Projection Methodology.--

(1)  LEGISLATIVE FINDINGS AND INTENT.--

(a)  Reliable projections of hurricane losses are necessary in order to assure that rates for residential property insurance meet the statutory requirement that rates be neither excessive nor inadequate. The ability to accurately project hurricane losses has been enhanced greatly in recent years through the use of computer modeling. It is the public policy of this state to encourage the use of the most sophisticated actuarial methods to assure that consumers are charged lawful rates for residential property insurance coverage.

(b)  The Legislature recognizes the need for expert evaluation of computer models and other recently developed or improved actuarial methodologies for projecting hurricane losses, in order to resolve conflicts among actuarial professionals, and in order to provide both immediate and continuing improvement in the sophistication of actuarial methods used to set rates charged to consumers.

(c)  It is the intent of the Legislature to create the Florida Commission on Hurricane Loss Projection Methodology as a panel of experts to provide the most actuarially sophisticated guidelines and standards for projection of hurricane losses possible, given the current state of actuarial science. It is the further intent of the Legislature that such standards and guidelines must be used by the State Board of Administration in developing reimbursement premium rates for the Florida Hurricane Catastrophe Fund, and may be used by insurers in rate filings under s. 627.062 unless the way in which such standards and guidelines were applied by the insurer was erroneous, as shown by a preponderance of the evidence.

(d)  It is the intent of the Legislature that such standards and guidelines be employed as soon as possible, and that they be subject to continuing review thereafter.

(2)  COMMISSION CREATED.--

(a)  There is created the Florida Commission on Hurricane Loss Projection Methodology, which is assigned to the State Board of Administration. For the purposes of this section, the term "commission" means the Florida Commission on Hurricane Loss Projection Methodology. The commission shall be administratively housed within the State Board of Administration, but it shall independently exercise the powers and duties specified in this section.

(b)  The commission shall consist of the following 11 members:

1.  The insurance consumer advocate.

2.  The senior employee of the State Board of Administration responsible for operations of the Florida Hurricane Catastrophe Fund.

3.  The Executive Director of the Citizens Property Insurance Corporation.

4.  The Director of the Division of Emergency Management of the Department of Community Affairs.

5.  The actuary member of the Florida Hurricane Catastrophe Fund Advisory Council.

6.  An employee of the office who is an actuary responsible for property insurance rate filings and who is appointed by the director of the office.

7.  Five members appointed by the Chief Financial Officer, as follows:

a.  An actuary who is employed full time by a property and casualty insurer which was responsible for at least 1 percent of the aggregate statewide direct written premium for homeowner's insurance in the calendar year preceding the member's appointment to the commission.

b.  An expert in insurance finance who is a full-time member of the faculty of the State University System and who has a background in actuarial science.

c.  An expert in statistics who is a full-time member of the faculty of the State University System and who has a background in insurance.

d.  An expert in computer system design who is a full-time member of the faculty of the State University System.

e.  An expert in meteorology who is a full-time member of the faculty of the State University System and who specializes in hurricanes.

(c)  Members designated under subparagraphs (b)1.-5. shall serve on the commission as long as they maintain the respective offices designated in subparagraphs (b)1.-5. The member appointed by the director of the office under subparagraph (b)6. shall serve on the commission until the end of the term of office of the director who appointed him or her, unless removed earlier by the director for cause. Members appointed by the Chief Financial Officer under subparagraph (b)7. shall serve on the commission until the end of the term of office of the Chief Financial Officer who appointed them, unless earlier removed by the Chief Financial Officer for cause. Vacancies on the commission shall be filled in the same manner as the original appointment.

(d)  The State Board of Administration shall annually appoint one of the members of the commission to serve as chair.

(e)  Members of the commission shall serve without compensation, but shall be reimbursed for per diem and travel expenses pursuant to s. 112.061.

(f)  The State Board of Administration shall, as a cost of administration of the Florida Hurricane Catastrophe Fund, provide for travel, expenses, and staff support for the commission.

(g)  There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member of the commission, any member of the State Board of Administration, or any employee of the State Board of Administration for any action taken in the performance of their duties under this section. In addition, the commission may, in writing, waive any potential cause of action for negligence of a consultant, contractor, or contract employee engaged to assist the commission.

(3)  ADOPTION AND EFFECT OF STANDARDS AND GUIDELINES.--

(a)  The commission shall consider any actuarial methods, principles, standards, models, or output ranges that have the potential for improving the accuracy of or reliability of the hurricane loss projections used in residential property insurance rate filings. The commission shall, from time to time, adopt findings as to the accuracy or reliability of particular methods, principles, standards, models, or output ranges.

(b)  In establishing reimbursement premiums for the Florida Hurricane Catastrophe Fund, the State Board of Administration must, to the extent feasible, employ actuarial methods, principles, standards, models, or output ranges found by the commission to be accurate or reliable.

(c)  With respect to a rate filing under s. 627.062, an insurer may employ actuarial methods, principles, standards, models, or output ranges found by the commission to be accurate or reliable to determine hurricane loss factors for use in a rate filing under s. 627.062, which findings and factors are admissible and relevant in consideration of a rate filing by the office or in any arbitration or administrative or judicial review.

(d)  The commission shall adopt revisions to previously adopted actuarial methods, principles, standards, models, or output ranges at least annually.

History.--s. 6, ch. 95-276; s. 6, ch. 96-194; s. 3, ch. 97-55; s. 4, ch. 2000-333; s. 1066, ch. 2003-261; s. 79, ch. 2004-390.

627.0629  Residential property insurance; rate filings.--

(1)  Effective June 1, 2002, a rate filing for residential property insurance must include actuarially reasonable discounts, credits, or other rate differentials, or appropriate reductions in deductibles, for properties on which fixtures or construction techniques demonstrated to reduce the amount of loss in a windstorm have been installed or implemented. The fixtures or construction techniques shall include, but not be limited to, fixtures or construction techniques which enhance roof strength, roof covering performance, roof-to-wall strength, wall-to-floor-to-foundation strength, opening protection, and window, door, and skylight strength. Credits, discounts, or other rate differentials for fixtures and construction techniques which meet the minimum requirements of the Florida Building Code must be included in the rate filing. All insurance companies must make a rate filing which includes the credits, discounts, or other rate differentials by February 28, 2003.

(2)(a)  A rate filing for residential property insurance made on or before the implementation of paragraph (b) may include rate factors that reflect the manner in which building code enforcement in a particular jurisdiction addresses the risk of wind damage; however, such a rate filing must also provide for variations from such rate factors on an individual basis based on an inspection of a particular structure by a licensed home inspector, which inspection may be at the cost of the insured.

(b)  A rate filing for residential property insurance made more than 150 days after approval by the office of a building code rating factor plan submitted by a statewide rating organization shall include positive and negative rate factors that reflect the manner in which building code enforcement in a particular jurisdiction addresses risk of wind damage. The rate filing shall include variations from standard rate factors on an individual basis based on inspection of a particular structure by a licensed home inspector. If an inspection is requested by the insured, the insurer may require the insured to pay the reasonable cost of the inspection. This paragraph applies to structures constructed or renovated after the implementation of this paragraph.

(c)  The premium notice shall specify the amount by which the rate has been adjusted as a result of this subsection and shall also specify the maximum possible positive and negative adjustments that are approved for use by the insurer under this subsection.

(3)  A rate filing made on or after July 1, 1995, for mobile home owner's insurance must include appropriate discounts, credits, or other rate differentials for mobile homes constructed to comply with American Society of Civil Engineers Standard ANSI/ASCE 7-88, adopted by the United States Department of Housing and Urban Development on July 13, 1994, and that also comply with all applicable tie-down requirements provided by state law.

(4)  The Legislature finds that separate consideration and notice of hurricane insurance premiums will assist consumers by providing greater assurance that hurricane premiums are lawful and by providing more complete information regarding the components of property insurance premiums. Effective January 1, 1997, a rate filing for residential property insurance shall be separated into two components, rates for hurricane coverage and rates for all other coverages. A premium notice reflecting a rate implemented on the basis of such a filing shall separately indicate the premium for hurricane coverage and the premium for all other coverages.

(5)  In order to provide an appropriate transition period, an insurer may, in its sole discretion, implement an approved rate filing for residential property insurance over a period of years. An insurer electing to phase in its rate filing must provide an informational notice to the office setting out its schedule for implementation of the phased-in rate filing.

(6)  An insurer may not write a residential property insurance policy without providing windstorm coverage or hurricane coverage as defined in s. 627.4025. This subsection does not apply with respect to risks located in an area eligible for coverage under the high-risk account of the Citizens Property Insurance Corporation pursuant to s. 627.351(6).

(7)  Any rate filing that is based in whole or part on data from a computer model may not exceed 25 percent unless there is a public hearing.

(8)  An insurer may implement appropriate discounts or other rate differentials of up to 10 percent of the annual premium to mobile home owners who provide to the insurer evidence of a current inspection of tie-downs for the mobile home, certifying that the tie-downs have been properly installed and are in good condition.

(9)  EVALUATION OF RESIDENTIAL PROPERTY STRUCTURAL SOUNDNESS.--

(a)  It is the intent of the Legislature to provide a program whereby homeowners may obtain an evaluation of the wind resistance of their homes with respect to preventing damage from hurricanes, together with a recommendation of reasonable steps that may be taken to upgrade their homes to better withstand hurricane force winds.

(b)  To the extent that funds are provided for this purpose in the General Appropriations Act, the Legislature hereby authorizes the establishment of a program to be administered by the Citizens Property Insurance Corporation for homeowners insured in the high-risk account.

(c)  The program shall provide grants to homeowners, for the purpose of providing homeowner applicants with funds to conduct an evaluation of the integrity of their homes with respect to withstanding hurricane force winds, recommendations to retrofit the homes to better withstand damage from such winds, and the estimated cost to make the recommended retrofits.

(d)  The Department of Community Affairs shall establish by rule standards to govern the quality of the evaluation, the quality of the recommendations for retrofitting, the eligibility of the persons conducting the evaluation, and the selection of applicants under the program. In establishing the rule, the Department of Community Affairs shall consult with the advisory committee to minimize the possibility of fraud or abuse in the evaluation and retrofitting process, and to ensure that funds spent by homeowners acting on the recommendations achieve positive results.

(e)  The Citizens Property Insurance Corporation shall identify areas of this state with the greatest wind risk to residential properties and recommend annually to the Department of Community Affairs priority target areas for such evaluations and inclusion with the associated residential construction mitigation program.

(10)  A property insurance rate filing that includes any adjustments related to premiums paid to the Florida Hurricane Catastrophe Fund must include a complete calculation of the insurer's catastrophe load, and the information in the filing may not be limited solely to recovery of moneys paid to the fund.

History.--s. 13, ch. 93-410; s. 7, ch. 95-276; s. 7, ch. 96-194; s. 4, ch. 97-55; s. 99, ch. 2000-141; ss. 34, 42, ch. 2001-186; ss. 3, 9, ch. 2001-372; s. 20, ch. 2002-293; s. 1067, ch. 2003-261.

627.0645  Annual filings.--

(1)  Each rating organization filing rates for, and each insurer writing, any line of property or casualty insurance to which this part applies, except:

(a)  Workers' compensation and employer's liability insurance; or

(b)  Commercial property and casualty insurance as defined in s. 627.0625(1) other than commercial multiple line and commercial motor vehicle,

shall make an annual base rate filing for each such line with the office no later than 12 months after its previous base rate filing, demonstrating that its rates are not inadequate.

(2)(a)  Deviations filed by an insurer to any rating organization's base rate filing are not subject to this section.

(b)  The office, after receiving a request to be exempted from the provisions of this section, may, for good cause due to insignificant numbers of policies in force or insignificant premium volume, exempt a company, by line of coverage, from filing rates or rate certification as required by this section.

(3)  The filing requirements of this section shall be satisfied by one of the following methods:

(a)  A rate filing prepared by an actuary which contains documentation demonstrating that the proposed rates are not excessive, inadequate, or unfairly discriminatory pursuant to the applicable rating laws and pursuant to rules of the commission.

(b)  If no rate change is proposed, a filing which consists of a certification by an actuary that the existing rate level produces rates which are actuarially sound and which are not inadequate, as defined in s. 627.062.

(4)  An insurer may satisfy the annual filing requirements of this section by being a member or subscriber of a licensed rating organization which complies with the requirements of this section.

(5)  If an insurer does not employ or otherwise retain the services of an actuary, the insurer's rate filing or certification that rates are actuarially sound shall be prepared by insurer personnel or consultants with a minimum of 5 years' experience in insurance ratemaking. A rate filing or certification prepared by a consultant must be reviewed and signed by an employee of the insurer who is authorized to approve rate filings.

(6)  If at the time a filing is required under this section an insurer is in the process of completing a rate review, the insurer may apply to the office for an extension of up to an additional 30 days in which to make the filing. The request for extension must be received by the office no later than the date the filing is due.

(7)  Nothing in this section limits the office's authority to review rates at any time or to find that a rate or rate change is excessive, inadequate, or unfairly discriminatory pursuant to s. 627.062.

(8)  As used in this section, the term "actuary" means an individual who is a member of the Casualty Actuarial Society.

(9)  If an insurer fails to meet the filing requirements of this section and does not submit the filing within 60 days after the date the filing is due, the office may, in addition to any other penalty authorized by law, order the insurer to discontinue the issuance of policies for the line of insurance for which the required filing was not made until such time as the office determines that the required filing is properly submitted.

History.--s. 2, ch. 89-360; s. 1, ch. 90-192; s. 19, ch. 90-249; s. 11, ch. 90-366; ss. 21, 114, ch. 92-318; s. 1068, ch. 2003-261.

627.06501  Insurance discounts for certain persons completing driver improvement course.--

(1)  Any rate, rating schedule, or rating manual for the liability, personal injury protection, and collision coverages of a motor vehicle insurance policy filed with the office may provide for an appropriate reduction in premium charges as to such coverages when the principal operator on the covered vehicle has successfully completed a driver improvement course approved and certified by the Department of Highway Safety and Motor Vehicles which is effective in reducing crash or violation rates, or both, as determined pursuant to ¹s. 318.1451(5). Any discount, not to exceed 10 percent, used by an insurer is presumed to be appropriate unless credible data demonstrates otherwise.

(2)  The premium reduction authorized by this section shall be effective for an insured for a 3-year period after successful completion of the approved course, except that the insurer may require, as a condition of maintaining the reduction, that the insured:

(a)  Not be involved in an accident for which the insured is at fault; and

(b)  Not be convicted of or plead guilty or nolo contendere to a moving traffic violation.

(3)  The organization offering the course shall, upon a person's successful completion of the course, issue the person a certificate that the person may use to qualify for the premium discount authorized by this section.

(4)  This section does not apply if the driver improvement course is taken in lieu of a court appearance for a traffic infraction as provided for in s. 318.14(9). However, the five-election restriction enumerated in that section is not applicable to taking the course for the purposes of receiving insurance premium reductions.

History.--s. 1, ch. 97-178; s. 1069, ch. 2003-261.

¹Note.--Repealed by s. 14, ch. 99-5.

627.0651  Making and use of rates for motor vehicle insurance.--

(1)  Insurers shall establish and use rates, rating schedules, or rating manuals to allow the insurer a reasonable rate of return on motor vehicle insurance written in this state. A copy of rates, rating schedules, and rating manuals, and changes therein, shall be filed with the office under one of the following procedures:

(a)  If the filing is made at least 60 days before the proposed effective date and the filing is not implemented during the office's review of the filing and any proceeding and judicial review, such filing shall be considered a "file and use" filing. In such case, the office shall initiate proceedings to disapprove the rate and so notify the insurer or shall finalize its review within 60 days after receipt of the filing. Notification to the insurer by the office of its preliminary findings shall toll the 60-day period during any such proceedings and subsequent judicial review. The rate shall be deemed approved if the office does not issue notice to the insurer of its preliminary findings within 60 days after the filing.

(b)  If the filing is not made in accordance with the provisions of paragraph (a), such filing shall be made as soon as practicable, but no later than 30 days after the effective date, and shall be considered a "use and file" filing. An insurer making a "use and file" filing is potentially subject to an order by the office to return to policyholders portions of rates found to be excessive, as provided in subsection (11).

(2)  Upon receiving notice of a rate filing or rate change, the office shall review the rate or rate change to determine if the rate is excessive, inadequate, or unfairly discriminatory. In making that determination, the office shall in accordance with generally accepted and reasonable actuarial techniques consider the following factors:

(a)  Past and prospective loss experience within and outside this state.

(b)  The past and prospective expenses.

(c)  The degree of competition among insurers for the risk insured.

(d)  Investment income reasonably expected by the insurer, consistent with the insurer's investment practices, from investable premiums anticipated in the filing, plus any other expected income from currently invested assets representing the amount expected on unearned premium reserves and loss reserves. Such investment income shall not include income from invested surplus. The commission may adopt rules utilizing reasonable techniques of actuarial science and economics to specify the manner in which insurers shall calculate investment income attributable to motor vehicle insurance policies written in this state and the manner in which such investment income is used in the calculation of insurance rates. Such manner shall contemplate the use of a positive underwriting profit allowance in the rates that will be compatible with a reasonable rate of return plus provisions for contingencies. The total of the profit and contingency factor as specified in the filing shall be utilized in computing excess profits in conjunction with s. 627.066. In adopting such rules, the commission shall in all instances adhere to and implement the provisions of this paragraph.

(e)  The reasonableness of the judgment reflected in the filing.

(f)  Dividends, savings, or unabsorbed premium deposits allowed or returned to Florida policyholders, members, or subscribers.

(g)  The cost of repairs to motor vehicles.

(h)  The cost of medical services, if applicable.

(i)  The adequacy of loss reserves.

(j)  The cost of reinsurance.

(k)  Trend factors, including trends in actual losses per insured unit for the insurer making the filing.

(l)  Other relevant factors which impact upon the frequency or severity of claims or upon expenses.

(3)  Rates shall be deemed excessive if they are likely to produce a profit from Florida business that is unreasonably high in relation to the risk involved in the class of business or if expenses are unreasonably high in relation to services rendered.

(4)  Rates shall be deemed excessive if, among other things, the rate structure established by a stock insurance company provides for replenishment of surpluses from premiums, when such replenishment is attributable to investment losses.

(5)(a)  Rates shall be deemed inadequate if they are clearly insufficient, together with the investment income attributable to them, to sustain projected losses and expenses in the class of business to which they apply.

(b)  The office has the responsibility to ensure that rates for private passenger vehicle insurance are adequate. To that end, the commission shall adopt rules establishing standards defining inadequate rates on private passenger vehicle insurance as defined in s. 627.041(8). In the event that the office finds that a rate or rate change is inadequate, the office shall order that a new rate or rate schedule be thereafter filed by the insurer and shall further provide information as to the manner in which noncompliance of the standards may be corrected. When a violation of this provision occurs, the office shall impose an administrative fine pursuant to s. 624.4211.

(6)  One rate shall be deemed unfairly discriminatory in relation to another in the same class if it clearly fails to reflect equitably the difference in expected losses and expenses.

(7)  Rates are not unfairly discriminatory because different premiums result for policyholders with like loss exposures but different expense factors, or like expense factors but different loss exposures, so long as rates reflect the differences with reasonable accuracy.

(8)  Rates are not unfairly discriminatory if averaged broadly among members of a group; nor are rates unfairly discriminatory even though they are lower than rates for nonmembers of the group. However, such rates are unfairly discriminatory if they are not actuarially measurable and credible and sufficiently related to actual or expected loss and expense experience of the group so as to assure that nonmembers of the group are not unfairly discriminated against. Use of a single United States Postal Service zip code as a rating territory shall be deemed unfairly discriminatory.

(9)  In reviewing the rate or rate change filed, the office may require the insurer to provide at the insurer's expense all information necessary to evaluate the condition of the company and the reasonableness of the filing according to the criteria enumerated herein.

(10)  The office may, at any time, review a rate or rate change, the pertinent records of the insurer, and market conditions; and, if the office finds on a preliminary basis that the rate or rate change may be excessive, inadequate, or unfairly discriminatory, the office shall so notify the insurer. However, the office may not disapprove as excessive any rate for which it has given final approval or which has been deemed approved for a period of 1 year after the effective date of the filing unless the office finds that a material misrepresentation or material error was made by the insurer or was contained in the filing. Upon being so notified, the insurer or rating organization shall, within 60 days, file with the office all information which, in the belief of the insurer or organization, proves the reasonableness, adequacy, and fairness of the rate or rate change. In such instances and in any administrative proceeding relating to the legality of the rate, the insurer or rating organization shall carry the burden of proof by a preponderance of the evidence to show that the rate is not excessive, inadequate, or unfairly discriminatory. After the office notifies an insurer that a rate may be excessive, inadequate, or unfairly discriminatory, unless the office withdraws the notification, the insurer shall not increase the rate until the earlier of 120 days after the date the notification was provided or 180 days after the date of the implementation of the rate. The office may, subject to chapter 120, disapprove without the 60-day notification any rate increase filed by an insurer within the prohibited time period or during the time that the legality of the increased rate is being contested.

(11)  In the event the office finds that a rate or rate change is excessive, inadequate, or unfairly discriminatory, the office shall issue an order of disapproval specifying that a new rate or rate schedule which responds to the findings of the office be filed by the insurer. The office shall further order for any "use and file" filing made in accordance with paragraph (1)(b), that premiums charged each policyholder constituting the portion of the rate above that which was actuarially justified be returned to such policyholder in the form of a credit or refund. If the office finds that an insurer's rate or rate change is inadequate, the new rate or rate schedule filed with the office in response to such a finding shall be applicable only to new or renewal business of the insurer written on or after the effective date of the responsive filing.

(12)  Any portion of a judgment entered as a result of a statutory or common-law bad faith action and any portion of a judgment entered which awards punitive damages against an insurer shall not be included in the insurer's rate base, and shall not be used to justify a rate or rate change. Any portion of a settlement entered as a result of a statutory or common-law bad faith action identified as such and any portion of a settlement wherein an insurer agrees to pay specific punitive damages shall not be used to justify a rate or rate change. The portion of the taxable costs and attorney's fees which is identified as being related to the bad faith and punitive damages in these judgments and settlements shall not be included in the insurer's rate base and shall not be utilized to justify a rate or rate change.

(13)(a)  Underwriting rules not contained in rating manuals shall be filed for private passenger automobile insurance and homeowners' insurance.

(b)  The submission of rates, rating schedules, and rating manuals to the office by a licensed rating organization of which an insurer is a member or subscriber will be sufficient compliance with this subsection for any insurer maintaining membership or subscribership in such organization, to the extent that the insurer uses the rates, rating schedules, and rating manuals of such organization. All such information shall be available for public inspection, upon receipt by the office, during usual business hours.

History.--s. 22, ch. 77-468; s. 8, ch. 78-374; s. 2, ch. 81-318; ss. 343, 357, 809(2nd), ch. 82-243; ss. 46, 47, 49, 79, ch. 82-386; s. 94, ch. 83-216; s. 16, ch. 85-245; s. 34, ch. 90-119; s. 114, ch. 92-318; s. 2, ch. 98-173; s. 1070, ch. 2003-261.

627.0652  Insurance discounts for certain persons completing safety course.--

(1)  Any rates, rating schedules, or rating manuals for the liability, personal injury protection, and collision coverages of a motor vehicle insurance policy filed with the office shall provide for an appropriate reduction in premium charges as to such coverages when the principal operator on the covered vehicle is an insured 55 years of age or older who has successfully completed a motor vehicle accident prevention course approved by the Department of Highway Safety and Motor Vehicles. Any discount used by an insurer is presumed to be appropriate unless credible data demonstrates otherwise.

(2)  The premium reduction required by this section shall be effective for an insured for a 3-year period after successful completion of the approved course, except that the insurer may require, as a condition of maintaining the discount, that the insured:

(a)  Not be involved in an accident for which the insured is at fault; and

(b)  Not be convicted of or plead guilty or nolo contendere to a moving traffic violation.

(3)  The Department of Highway Safety and Motor Vehicles shall approve motor vehicle accident prevention courses for the purposes of this section. The Department of Highway Safety and Motor Vehicles shall consider the competency of the personnel offering the course, the quality of the content and activities of the course with respect to its capability to prevent accidents by persons age 55 or older who complete the course, and the reasonableness of the fee for the course. The Department of Highway Safety and Motor Vehicles shall establish the minimum number of hours necessary for completion of a course. A course approved by the Department of Highway Safety and Motor Vehicles shall require each person completing the course to pass a written test given by the course evaluating the person's knowledge of the content of the course.

(4)  The organization offering the course shall, upon a person's successful completion of the course, issue the person a certificate that the person may use to qualify for the premium discount required by this section.

(5)  This section does not apply if the approved course is taken as punishment specified by a court or other governmental entity resulting from a moving traffic violation.

History.--s. 1, ch. 85-244; s. 1, ch. 86-286; s. 1, ch. 88-250; ss. 22, 114, ch. 92-318; s. 1071, ch. 2003-261.

627.0653  Insurance discounts for specified motor vehicle equipment.--

(1)  Any rates, rating schedules, or rating manuals for the liability, personal injury protection, and collision coverages of a motor vehicle insurance policy filed with the office shall provide a premium discount if the insured vehicle is equipped with factory-installed, four-wheel antilock brakes.

(2)  Each insurer writing motor vehicle comprehensive coverage in this state shall include in its rating manual discount provisions for comprehensive coverage which specifically relate to an antitheft device or vehicle recovery system utilized in the insured vehicle which are factory installed or approved by the office. The commission shall adopt, by rule, procedures under which manufacturers, distributors, or sellers may apply to the office for approval of non-factory-installed devices under this subsection. The rules must include, at a minimum, the test results that must accompany the application and the standards for approval.

(3)  Any rates, rating schedules, or rating manuals for personal injury protection coverage and medical payments coverage, if offered, of a motor vehicle insurance policy filed with the office shall provide a premium discount if the insured vehicle is equipped with one or more air bags which are factory installed.

(4)  The removal of a discount or credit does not constitute the imposition of, or request for, additional premium or a surcharge if the basis for the discount or credit no longer exists or is substantially eliminated.

(5)  Each insurer writing motor vehicle comprehensive coverage in this state may provide a premium discount for this coverage if the insured vehicle has the complete manufacturer's vehicle identification number permanently etched on the windshield and all windows of the vehicle. The etching must be by a tool or process that does not destroy the integrity of the glass or visibility for the operator of the motor vehicle. The identification numbers and letters must be at least ¹/₄ inch in height. A sticker may identify the presence of this identification system. The commission may, by rule, set forth appropriate guidelines to implement this subsection.

History.--ss. 37, 52, ch. 90-119; ss. 23, 109, 114, ch. 92-318; s. 1072, ch. 2003-261.

627.06535  Electric vehicles; restrictions on imposing surcharges.--An insurer may not impose a surcharge on the premium for motor vehicle insurance written on an electric vehicle, as defined in s. 320.01, if the surcharge is based on a factor such as new technology, passenger payload, weight-to-horsepower ratio, or types of materials, including composite materials or aluminum, used to manufacture the vehicle, unless the office determines from actuarial data submitted to it that the surcharge is justified.

History.--s. 13, ch. 95-333; s. 1073, ch. 2003-261.

627.0654  Insurance discounts for buildings with fire sprinklers.--

(1)  Any rates, rating schedules, or rating manuals for a new or renewal fire insurance policy for an existing or newly constructed building, whether used for commercial or residential purposes, must provide for a premium discount if a fire sprinkler system has been installed in the building in accordance with nationally accepted fire sprinkler design standards, as adopted by the department, and if the fire sprinkler system is maintained in accordance with nationally accepted standards.

(2)  The discount required by this section must provide a premium rate that is lower than that for a building in which a fire sprinkler system has not been installed. A discount used by an insurer is presumed appropriate unless credible data demonstrates otherwise.

History.--s. 4, ch. 95-379.

627.066  Excessive profits for motor vehicle insurance prohibited.--

(1)  As used herein:

(a)  "Private passenger automobile business" means that insurance business that is written on a family automobile policy, standard automobile policy, or personal automobile or similar private passenger automobile policy written for personal use, as opposed to commercial automobile insurance business.

(b)  "Cash" means coins, currency, checks, drafts, or money orders.

(2)  Each Florida private passenger automobile insurer group shall file with the office, prior to July 1 of each year on forms prescribed by the commission, the following data for Florida private passenger automobile business. The data filed for the group shall be a consolidation of the data of the individual insurers of the group. The data shall include both voluntary and joint underwriting association business, as follows:

(a)  Calendar-year total limits earned premium.

(b)  Accident-year incurred losses and loss adjustment expenses.

(c)  The administrative and selling expenses incurred in this state or allocated to this state for the calendar year.

(d)  Policyholder dividends incurred during the applicable calendar year.

(3)(a)  Excessive profit has been realized if there has been an underwriting gain for the 3 most recent calendar-accident years combined which is greater than the anticipated underwriting profit plus 5 percent of earned premiums for those calendar-accident years.

(b)  As used herein with respect to any 3-year period, "anticipated underwriting profit" means the sum of the dollar amounts obtained by multiplying, for each rate filing of the insurer group in effect during such period, the earned premiums applicable to such rate filing during such period by the percentage factor included in such rate filing for profit and contingencies, such percentage factor having been determined with due recognition to investment income from funds generated by Florida business. Separate calculations need not be made for consecutive rate filings containing the same percentage factor for profits and contingencies.

(4)  Each insurer group shall also file a schedule of Florida private passenger automobile loss and loss adjustment experience for each of the 3 most recent accident years. The incurred losses and loss adjustment expenses shall be valued as of March 31 of the year following the close of the accident year, developed to an ultimate basis, and at two 12-month intervals thereafter, each developed to an ultimate basis, so that a total of three evaluations will be provided for each accident year. The first year to be so reported shall be accident year 1976, so that the reporting of 3 accident years will not take place until accident years 1977 and 1978 have become available.

(5)  Each insurer group's underwriting gain or loss for each calendar-accident year shall be computed as follows: The sum of the accident-year incurred losses and loss adjustment expenses as of March 31 of the following year, developed to an ultimate basis, plus the administrative and selling expenses incurred in the calendar year, plus policyholder dividends applicable to the calendar year, will be subtracted from the calendar-year earned premium to determine the underwriting gain or loss.

(6)  For the 3 most recent calendar-accident years, the underwriting gain or loss will be compared to the anticipated underwriting profit.

(7)  If the insurer group has realized an excessive profit, the office shall order a return of the excessive amounts after affording the insurer group an opportunity for hearing and otherwise complying with the requirements of chapter 120. Such excessive amounts shall be refunded in all instances unless the insurer group affirmatively demonstrates to the office that the refund of the excessive amounts will render a member of the insurer group financially impaired or will render it insolvent under the provisions of the Florida Insurance Code.

(8)  The excessive amount shall be refunded on a pro rata basis in relation to the final compilation year earned premiums to the voluntary private passenger automobile policyholders of record of the insurer group on December 31 of the final compilation year.

(9)  Any excess profit of an insurance company offering motor vehicle insurance shall be returned to policyholders in the form of a cash refund or a credit towards the future purchase of insurance.

(10)(a)  Cash refunds to policyholders may be rounded to the nearest dollar.

(b)  Data in required reports to the office may be rounded to the nearest dollar.

(c)  Rounding, if elected by the insurer group, shall be applied consistently.

(11)(a)  Refunds shall be completed in one of the following ways:

1.  If the insurer group elects to make a cash refund, the refund shall be completed within 60 days of entry of a final order indicating that excessive profits have been realized.

2.  If the insurer group elects to make refunds in the form of a credit to renewal policies, such credits shall be applied to policy renewal premium notices which are forwarded to insureds more than 60 calendar days after entry of a final order indicating that excessive profits have been realized. If an insurer group has made this election but an insured thereafter cancels his or her policy or otherwise allows the policy to terminate, the insurer group shall make a cash refund not later than 60 days after termination of such coverage.

(b)  Upon completion of the renewal credits or refund payments, the insurer group shall immediately certify to the office that the refunds have been made.

(12)  Any refund or renewal credit made pursuant to this section shall be treated as a policyholder dividend applicable to the year in which it is incurred, for purposes of reporting under this section for subsequent years.

History.--s. 23, ch. 77-468; ss. 26, 27, ch. 80-236; s. 424, ch. 81-259; s. 2, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 2, ch. 90-366; s. 114, ch. 92-318; s. 316, ch. 97-102; s. 1074, ch. 2003-261.

627.0665  Automatic bank withdrawal agreements; notification required.--Any insurer licensed to issue insurance in the state who has an automatic bank withdrawal agreement with an insured party for the payment of insurance premiums for any type of insurance shall give the named insured at least 15 days advance written notice of any increase in policy premiums prior to any automatic bank withdrawal of an increased premium.

History.--ss. 1, 2, ch. 88-320; s. 114, ch. 92-318.

627.072  Making and use of rates.--

(1)  As to workers' compensation and employer's liability insurance, the following factors shall be used in the determination and fixing of rates:

(a)  The past loss experience and prospective loss experience within and outside this state;

(b)  The conflagration and catastrophe hazards;

(c)  A reasonable margin for underwriting profit and contingencies;

(d)  Dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers;

(e)  Investment income on unearned premium reserves and loss reserves;

(f)  Past expenses and prospective expenses, both those countrywide and those specifically applicable to this state; and

(g)  All other relevant factors, including judgment factors, within and outside this state.

(2)  As to all rates which are subject to this part, the systems of expense provisions included in the rates for use by an insurer or group of insurers may differ from those of other insurers or groups of insurers to reflect the requirements of the operating methods of any such insurer or group with respect to any kind of insurance or with respect to any subdivision or combination thereof for which subdivision or combination separate expense provisions are applicable.

(3)  As to all rates which are subject to this part, risks may be grouped by classifications for the establishment of rates and minimum premiums. Classification rates may be modified to produce rates for individual risks in accordance with rating plans which establish standards for measuring variations in hazards or expense provisions, or both. Such standards may measure any difference among risks that can be demonstrated to have a probable effect upon losses or expenses. Such classifications and modifications shall apply to all risks under the same or substantially the same circumstances or conditions.

(4)(a)  In the case of workers' compensation and employer's liability insurance, the office shall consider utilizing the following methodology in rate determinations: Premiums, expenses, and expected claim costs would be discounted to a common point of time, such as the initial point of a policy year, in the determination of rates; the cash-flow pattern of premiums, expenses, and claim costs would be determined initially by using data from 8 to 10 of the largest insurers writing workers' compensation insurance in the state; such insurers may be selected for their statistical ability to report the data on an accident-year basis and in accordance with subparagraphs (b)1., 2., and 3., for at least 2¹/₂ years; such a cash-flow pattern would be modified when necessary in accordance with the data and whenever a radical change in the payout pattern is expected in the policy year under consideration.

(b)  If the methodology set forth in paragraph (a) is utilized, to facilitate the determination of such a cash-flow pattern methodology:

1.  Each insurer shall include in its statistical reporting to the rating bureau and the office the accident year by calendar quarter data for paid-claim costs;

2.  Each insurer shall submit financial reports to the rating bureau and the office which shall include total incurred claim amounts and paid-claim amounts by policy year and by injury types as of December 31 of each calendar year; and

3.  Each insurer shall submit to the rating bureau and the office paid-premium data on an individual risk basis in which risks are to be subdivided by premium size as follows:


Number of Risks in
  Premium Range

Standard Premium Size

 (to be filled in by carrier) 

$300--999

 (to be filled in by carrier) 

1,000--4,999

 (to be filled in by carrier) 

5,000--49,999

 (to be filled in by carrier) 

50,000--99,999

 (to be filled in by carrier) 

100,000 or more

Total:

History.--s. 4, ch. 67-9; s. 1, ch. 70-179; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 24, ch. 77-468; s. 94, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 344, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 11, ch. 86-160; s. 114, ch. 92-318; s. 317, ch. 97-102; s. 5, ch. 2000-333; s. 94, ch. 2002-1; s. 1075, ch. 2003-261.

627.091  Rate filings; workers' compensation and employer's liability insurances.--

(1)  As to workers' compensation and employer's liability insurances, every insurer shall file with the office every manual of classifications, rules, and rates, every rating plan, and every modification of any of the foregoing which it proposes to use. Every insurer is authorized to include deductible provisions in its manual of classifications, rules, and rates. Such deductibles shall in all cases be in a form and manner which is consistent with the underlying purpose of chapter 440.

(2)  Every such filing shall state the proposed effective date thereof, and shall indicate the character and extent of the coverage contemplated. When a filing is not accompanied by the information upon which the insurer supports the filing and the office does not have sufficient information to determine whether the filing meets the applicable requirements of this part, it shall within 15 days after the date of filing require the insurer to furnish the information upon which it supports the filing. The information furnished in support of a filing may include:

(a)  The experience or judgment of the insurer or rating organization making the filing;

(b)  Its interpretation of any statistical data it relies upon;

(c)  The experience of other insurers or rating organizations; or

(d)  Any other factors which the insurer or rating organization deems relevant.

(3)  A filing and any supporting information shall be open to public inspection as provided in s. 119.07(1).

(4)  An insurer may satisfy its obligation to make such filings by becoming a member of, or a subscriber to, a licensed rating organization which makes such filings and by authorizing the office to accept such filings in its behalf; but nothing contained in this chapter shall be construed as requiring any insurer to become a member or a subscriber to any rating organization.

(5)  Pursuant to the provisions of s. 624.3161, the office may examine the underlying statistical data used in such filings.

(6)  Whenever the committee of a recognized rating organization with responsibility for workers' compensation and employer's liability insurance rates in this state meets to discuss the necessity for, or a request for, Florida rate increases or decreases, the determination of Florida rates, the rates to be requested, and any other matters pertaining specifically and directly to such Florida rates, such meetings shall be held in this state and shall be subject to s. 286.011. The committee of such a rating organization shall provide at least 3 weeks' prior notice of such meetings to the office and shall provide at least 14 days' prior notice of such meetings to the public by publication in the Florida Administrative Weekly.

History.--s. 419, ch. 59-205; s. 5, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 20, ch. 78-300; s. 95, ch. 79-40; ss. 20, 22, ch. 80-236; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 4, 9, 10, ch. 87-124; s. 63, ch. 91-108; s. 4, ch. 91-429; s. 1, ch. 93-289; s. 1076, ch. 2003-261.

627.0915  Rate filings; workers' compensation, drug-free workplace, and safe employers.--

(1)  The office shall approve rating plans for workers' compensation and employer's liability insurance that give specific identifiable consideration in the setting of rates to employers that either implement a drug-free workplace program pursuant to s. 440.102 and rules adopted under such section or implement a safety program pursuant to provisions of the rating plan or implement both a drug-free workplace program and a safety program. The plans must be actuarially sound and must state the savings anticipated to result from such drug-testing and safety programs.

(2)  An insurer offering a rate plan approved under this section shall notify the employer at the time of the initial quote for the policy and at the time of each renewal of the policy of the availability of the premium discount where a drug-free workplace plan is used by the employer pursuant to s. 440.102 and rules adopted under such section. The Financial Services Commission may adopt rules to implement the provisions of this subsection.

History.--s. 51, ch. 90-201; s. 49, ch. 91-1; s. 17, ch. 91-201; s. 4, ch. 91-429; s. 94, ch. 93-415; s. 5, ch. 98-126; s. 34, ch. 2001-91; s. 67, ch. 2002-194; s. 1077, ch. 2003-261; s. 26, ch. 2004-374.

627.0916  Agricultural horse farms.--Notwithstanding any other provision of this chapter to the contrary, any rates, rating schedules, or rating manuals for workers' compensation and employer's liability insurance filed with the office shall provide for the rates of an agricultural horse farm engaged in breeding or training to be separated into the following three rate classifications and the premium paid shall be applied proportionately according to payroll: breeding activity involving stallions; breeding activity not involving stallions, including but not limited to boarding and foaling; and training.

History.--s. 96, ch. 93-415; s. 2, ch. 95-219; s. 1078, ch. 2003-261.

627.092  Workers' Compensation Administrator.--There is created within the office the position of Workers' Compensation Administrator to monitor carrier practices in the field of workers' compensation.

History.--s. 21, ch. 78-300; s. 96, ch. 79-40; s. 2, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 6, ch. 97-93; s. 1079, ch. 2003-261.

627.093  Application of s. 286.011 to workers' compensation and employer's liability insurances.--Section 286.011 shall be applicable to every rate filing, approval or disapproval of filing, rating deviation from filing, or appeal from any of these regarding workers' compensation and employer's liability insurances.

History.--s. 97, ch. 79-40; s. 2, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429.

627.096  Workers' Compensation Rating Bureau.--

(1)  There is created within the office a Workers' Compensation Rating Bureau, which shall make an investigation and study of all insurers authorized to issue workers' compensation and employer's liability coverage in this state. Such bureau shall study the data, statistics, schedules, or other information as it may deem necessary to assist and advise the office in its review of filings made by or on behalf of workers' compensation and employer's liability insurers. The commission may adopt rules requiring all workers' compensation and employer's liability insurers to submit to the rating bureau any data, statistics, schedules, and other information deemed necessary to the rating bureau's study and advisement.

(2)  The acquisition by the Department of Management Services of data processing software, hardware, and services necessary to carry out the provisions of this act for the department or office shall be exempt from the provisions of part I of chapter 287.

History.--s. 98, ch. 79-40; s. 2, ch. 81-318; ss. 345, 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 5, 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 313, ch. 92-279; s. 55, ch. 92-326; s. 1080, ch. 2003-261.

627.101  When filing becomes effective; workers' compensation and employer's liability insurances.--

(1)  The office shall review filings as to workers' compensation and employer's liability insurances as soon as reasonably possible after they have been made in order to determine whether they meet the applicable requirements of this part. If the office determines that part of a rate filing does not meet the applicable requirements of this part, it may reject so much of the filing as does not meet these requirements, and approve the remainder of the filing.

(2)  The office shall specifically approve the filing before it becomes effective, unless the office has concluded it to be in the public interest to hold a public hearing to determine whether the filing meets the requirements of this chapter and has given notice of such hearing to the insurer or rating organization that made the filing, and in which case the effectiveness of the filing shall be subject to the further order of the office made as provided in s. 627.111. If the office specifically disapproves the filing, the provisions of subsection (4) shall apply.

(3)  An insurer or rating organization may, at the time it makes a filing with the office, request a public hearing thereon. In such event, the office shall give notice of the hearing.

(4)  If the office disapproves a filing, it shall promptly give notice of such disapproval to the insurer or rating organization that made the filing, stating the respects in which it finds that the filing does not meet the requirements of this chapter. If the office approves a filing, it shall give prompt notice thereof to the insurer or rating organization that made the filing, and in which case the filing shall become effective upon such approval or upon such subsequent date as may be satisfactory to the office and the insurer or rating organization that made the filing.

History.--s. 420, ch. 59-205; s. 6, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; s. 22, ch. 78-300; s. 99, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 2, ch. 93-289; s. 1081, ch. 2003-261.

627.111  Effective date of filing.--

(1)  If, pursuant to s. 627.101(2), the office determines to hold a public hearing as to a filing, or it holds such a public hearing pursuant to request therefor under s. 627.101(3), it shall give written notice thereof to the rating organization or insurer that made the filing and shall hold such hearing within 30 days, and not less than 10 days prior to the date of the hearing, it shall give written notice of the hearing to the insurer or rating organization that made the filing. The office may also, in its discretion, give advance public notice of such hearing by publication of notice in one or more daily newspapers of general circulation in this state.

(2)  If the order of the office disapproves the filing, the filing shall not become effective during the effectiveness of such order. If the order of the office approves the filing, the filing shall become effective upon the date of the order or upon such subsequent date as may be satisfactory to the insurer or rating organization that made the filing.

History.--s. 421, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 3, ch. 93-289; s. 1082, ch. 2003-261.

627.141  Subsequent disapproval of filing; workers' compensation and employer's liability insurances.--If at any time after a filing has been approved by it or has otherwise become effective the office finds that the filing no longer meets the requirements of this chapter, it shall issue an order specifying in what respects it finds that such filing fails to meet such requirements and stating when, within a reasonable period thereafter, such filing shall be deemed no longer effective. The order shall not affect any insurance contract or policy made or issued prior to the expiration of the period set forth in the order.

History.--s. 424, ch. 59-205; s. 7, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; s. 100, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 1083, ch. 2003-261.

627.151  Basis of approval or disapproval of workers' compensation or employer's liability insurance filing; scope of disapproval power.--

(1)  In determining at any time whether to approve or disapprove a filing as to workers' compensation or employer's liability insurance, or to permit the filing otherwise to become effective, the office shall give consideration only to the applicable standards and factors referred to in ss. 627.062 and 627.072.

(2)  As to workers' compensation and employer's liability insurances, no manual of classifications, rule, rating plan, rating system, plan of operation, or any modification of any of the foregoing which establishes standards for measuring variations in hazards or expense provisions, or both, shall be disapproved if the rates thereby produced meet the applicable requirements of this part.

History.--s. 425, ch. 59-205; s. 8, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 101, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 1084, ch. 2003-261.

627.1615  Workers' compensation applicant discrimination.--Insurers shall not refuse to provide workers' compensation coverage on the basis of the applicant's premium volume.

History.--s. 52, ch. 90-201; s. 50, ch. 91-1; s. 17, ch. 91-201; s. 4, ch. 91-429.

627.162  Requirements for premium installments; delinquency, collection, and check return charges; attorney's fees.--

(1)  Insurers providing workers' compensation coverage under chapter 440 shall provide, upon request of the employer, policies providing for the payment of premiums by installment for policies with annual premiums exceeding $1,000.

(2)  Insurers providing workers' compensation coverage under chapter 440 may charge the insured a delinquency and collection fee on each installment in default for a period of not less than 5 days in an amount not to exceed $25 or 5 percent of the delinquent installment, whichever is greater. Only one such delinquency and collection fee may be collected on any such installment regardless of the period during which it remains in default.

(3)  If an installment in default under this section is referred for collection to an attorney, the insured is liable for the payment of attorney's fees not exceeding 25 percent of the sum of the installment and any delinquency and collection fee charged by the insurer.

(4)  Notwithstanding other provisions of this section, an insurer may not take or receive from or charge an insured any collection fee or attorney's fee unless the insurer has mailed a notice of the default to the insured at his or her address as shown on the records of the insurer, giving the insured at least 5 days within which to make the payment in default. A notice of cancellation sent by the insurer to the insured in accordance with s. 440.42 is legally sufficient notice of the default for purposes of this section.

(5)  If a payment is made to an insurer by check or draft and the instrument is returned because of insufficient funds, the insurer may impose a charge of $20 or 5 percent of the check amount, whichever is greater.

(6)  The term "insurer," for purposes of this section, includes a commercial self-insurance fund as defined in s. 624.462, an assessable mutual insurer as defined in s. 628.6011, and a group self-insurer's fund as defined in s. 624.4621.

History.--s. 53, ch. 90-201; s. 51, ch. 91-1; s. 17, ch. 91-201; s. 4, ch. 91-429; s. 24, ch. 92-318; s. 318, ch. 97-102; s. 28, ch. 99-3; s. 33, ch. 2003-412.

627.171  Excess rates.--

(1)  With written consent of the insured signed prior to the policy inception date and filed with the insurer, the insurer may use a rate in excess of the otherwise applicable filed rate on any specific risk. The signed consent form must include the filed rate as well as the excess rate for the risk insured, and a copy of the form must be maintained by the insurer for 3 years and be available for review by the office.

(2)  An insurer may not use excess rates pursuant to this section for more than 10 percent of its commercial insurance policies written or renewed in each calendar year for any line of commercial insurance or for more than 5 percent of its personal lines insurance policies written or renewed in each calendar year for any line of personal insurance. In determining the 10-percent limitation for commercial insurance policies, the insurer shall exclude any workers' compensation policy that was written for an employer who had coverage in the joint underwriting plan created by s. 627.311(5) immediately prior to the writing of the policy by the insurer and any workers' compensation policy that was written for an employer who had been offered coverage in the joint underwriting plan but who was written a policy by the insurer in lieu of accepting the joint underwriting plan policy. These workers' compensation policies shall be excluded from the 10-percent limitation for the first 3 years of coverage.

History.--s. 427, ch. 59-205; s. 9, ch. 67-9; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 53, ch. 89-360; s. 4, ch. 91-429; s. 1085, ch. 2003-261; s. 2, ch. 2004-82.

627.191  Adherence to filings; workers' compensation and employer's liability insurances.--No insurer or employee thereof, and no agent, shall make or issue a contract or policy of workers' compensation or employer's liability insurance except in accordance with the filings which are in effect for such insurer, as provided in the applicable provisions of this part, or in accordance with s. 627.171.

History.--s. 429, ch. 59-205; s. 11, ch. 67-9; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 102, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429.

627.192  Workers' compensation insurance; employee leasing arrangements.--

(1)  The purpose of this section is to ensure that an employer who leases some or all of its workers properly obtains workers' compensation insurance coverage for all of its employees, including those leased from or coemployed with another entity, and that premium paid by an employee leasing company is commensurate with exposure and anticipated claim experience for all employees.

(2)  For purposes of the Florida Insurance Code:

(a)  "Employee leasing" shall have the same meaning as set forth in s. 468.520(4).

(b)  "Experience rating modification" means a factor applied to a premium to reflect a risk's variation from the average risk. The experience modification is determined by comparing actual losses to expected losses, using the risk's own past experience.

(c)  "Leased employee" means a person performing services for a lessee under an employee leasing arrangement.

(d)  "Lessee" means an entity which obtains all or part of its workforce from another entity through an employee leasing arrangement or which employs the services of an entity through an employee leasing arrangement.

(e)  "Lessor" means an employee leasing company, as set forth in part XI of chapter 468, engaged in the business of or holding itself out as being in the business of employee leasing. A lessor may also be referred to as an employee leasing company.

(f)  "Premium subject to dispute" means that the insured has provided a written notice of dispute to the insurer or service carrier, has initiated any applicable proceeding for resolving such disputes as prescribed by law or rating organization procedures approved by the office, or has initiated litigation regarding the premium dispute. The insured must have detailed the specific areas of dispute and provided an estimate of the premium the insured believes to be correct. The insured must have paid any undisputed portion of the bill.

(3)  A lessor that obtains coverage in the voluntary workers' compensation market may elect, with the voluntary market insurer's knowledge and consent, to secure the coverage on leased employees through a workers' compensation policy issued to the lessor. The insurer of the lessor may, in its discretion, take all reasonable steps to ascertain exposure under the policy and collect the appropriate premium by:

(a)  Requiring the lessor to provide a complete description of lessor's operations.

(b)  Requiring periodic reporting by the lessor of covered lessees' payroll, classifications, claims information, loss data, and jurisdictions with exposure. This reporting may be supplemented by a requirement for lessees to submit to the carrier Internal Revenue Service Form 941 or its equivalent on a quarterly basis.

(c)  Auditing the lessor's operations.

(d)  Using other reasonable measures to determine the appropriate premium.

(4)  A lessor that applies for coverage or is covered through the voluntary market shall also maintain and furnish to the insurer on an annual basis, and as the insurer may otherwise reasonably require, sufficient information to permit the calculation of an experience modification factor for each lessee upon termination of the employee leasing relationship. Information accruing during the term of the leasing arrangement which is used to calculate an experience modification factor for a lessee upon termination of the leasing relationship shall continue to be used in the future experience ratings of the lessor. Such information shall include:

(a)  The lessee's corporate name.

(b)  The lessee's taxpayer or employer identification number.

(c)  Payroll summaries and class codes applicable to each lessee, and, if requested by the insurer, a listing of all leased employees associated with a given lessee.

(d)  Claims information grouped by lessee, and any other information maintained by or readily available to the lessor that is necessary for the calculation of an experience modification factor for each lessee.

(5)  In addition to any other provision of law, any material violation of this section by an employee leasing company is grounds for cancellation or nonrenewal of the lessor's insurance policy provided that the employee leasing company has been provided a reasonable opportunity to cure the violation. If an employee leasing company has received notice that its workers' compensation insurance policy will be canceled or nonrenewed, the leasing company shall notify by certified mail, within 15 days after receipt of the notice, all of the lessees for which there is an employee leasing arrangement covered under the policy to be canceled, except notice is not required if the employee leasing company has obtained another insurance policy with an effective date that is the same as the date of cancellation or nonrenewal.

(6)  If the employee leasing arrangement with a lessee is terminated, the lessee shall be assigned an experience modification factor which reflects its experience during the experience period specified by the approved experience rating plan, including, if applicable, experience incurred for leased employees under the employee leasing arrangements. The employee leasing company shall notify the insurer of its intent to terminate any lessee relationship prior to termination when feasible. When prior notice is not feasible, the employee leasing company shall notify its insurer within 5 working days following actual termination.

(7)  This section shall not have any effect on the statutory obligation, if any, of a lessee to secure workers' compensation coverage for employees that the lessee does not coemploy or lease pursuant to an employee leasing arrangement.

(8)  A lessee shall not enter into an employee leasing relationship or be eligible for workers' compensation coverage in the voluntary market if the lessee owes its current or a prior insurer any premium for workers' compensation insurance, or if the lessee owes its current or prior employee leasing company amounts due under the service agreement, except for premium or amounts due that are subject to dispute. For the purposes of this section and compliance with other laws and regulations, a lessor may rely on a sworn statement by the lessee that the lessee has met any and all prior premium or fee obligations, unless the lessor has actual knowledge to the contrary.

(9)  Insurers shall conduct annual audits of payroll and classifications of employee leasing companies in order to ensure that the appropriate premium is charged for workers' compensation coverage. The audits shall be conducted to ensure that all sources of payment by lessors to employees, subcontractors, and independent contractors have been reviewed and the accuracy of classifications of employees has been verified. Insurers may provide for more frequent audits of lessors based on such factors as amount of premium, type of business, loss ratios, or other relevant factors. Payroll and classification verification audit rules of insurers must include, but need not be limited to, use by the insurer of state and federal reports of employee income, payroll and other accounting records, certificates of insurance maintained by subcontractors, and duties of employees.

(10)  If a lessor or a lessee fails to provide reasonable access to payroll and classification records for a payroll and classification audit, the insured shall pay a premium to the insurer not to exceed three times the most recent estimated annual premium. However, the lessor is not subject to such penalty if the failure to obtain the needed records is the direct result of the acts or omissions of the lessee.

History.--s. 95, ch. 98-199; s. 95, ch. 2002-1; s. 1086, ch. 2003-261.

627.211  Deviations; workers' compensation and employer's liability insurances.--

(1)  Every member or subscriber to a rating organization shall, as to workers' compensation or employer's liability insurance, adhere to the filings made on its behalf by such organization; except that any such insurer may make written application to the office for permission to file a uniform percentage decrease or increase to be applied to the premiums produced by the rating system so filed for a kind of insurance, for a class of insurance which is found by the office to be a proper rating unit for the application of such uniform percentage decrease or increase, or for a subdivision of workers' compensation or employer's liability insurance:

(a)  Comprised of a group of manual classifications which is treated as a separate unit for ratemaking purposes; or

(b)  For which separate expense provisions are included in the filings of the rating organization.

Such application shall specify the basis for the modification and shall be accompanied by the data upon which the applicant relies. A copy of the application and data shall be sent simultaneously to the rating organization.

(2)  Every member or subscriber to a rating organization may, as to workers' compensation and employer's liability insurance, file a plan or plans to use deviations that vary according to factors present in each insured's individual risk. The insurer that files for the deviations provided in this subsection shall file the qualifications for the plans, schedules of rating factors, and the maximum deviation factors which shall be subject to the approval of the office pursuant to s. 627.091. The actual deviation which shall be used for each insured that qualifies under this subsection may not exceed the maximum filed deviation under that plan and shall be based on the merits of each insured's individual risk as determined by using schedules of rating factors which shall be applied uniformly. Insurers shall maintain statistical data in accordance with the schedule of rating factors. Such data shall be available to support the continued use of such varying deviations.

(3)  In considering an application for the deviation, the office shall give consideration to the applicable principles for ratemaking as set forth in ss. 627.062 and 627.072 and the financial condition of the insurer. In evaluating the financial condition of the insurer, the office may consider: (1) the insurer's audited financial statements and whether the statements provide unqualified opinions or contain significant qualifications or "subject to" provisions; (2) any independent or other actuarial certification of loss reserves; (3) whether workers' compensation and employer's liability reserves are above the midpoint or best estimate of the actuary's reserve range estimate; (4) the adequacy of the proposed rate; (5) historical experience demonstrating the profitability of the insurer; (6) the existence of excess or other reinsurance that contains a sufficiently low attachment point and maximums that provide adequate protection to the insurer; and (7) other factors considered relevant to the financial condition of the insurer by the office. The office shall approve the deviation if it finds it to be justified, it would not endanger the financial condition of the insurer, and it would not constitute predatory pricing. The office shall disapprove the deviation if it finds that the resulting premiums would be excessive, inadequate, or unfairly discriminatory, would endanger the financial condition of the insurer, or would result in predatory pricing. The insurer may not use a deviation unless the deviation is specifically approved by the office. An insurer may apply the premiums approved pursuant to s. 627.091 or its uniform deviation approved pursuant to this section to a particular insured according to underwriting guidelines filed with and approved by the office, such approval to be based on ss. 627.062 and 627.072.

(4)  Each deviation permitted to be filed shall be effective for a period of 1 year unless terminated, extended, or modified with the approval of the office. If at any time after a deviation has been approved the office finds that the deviation no longer meets the requirements of this code, it shall notify the insurer in what respects it finds that the deviation fails to meet such requirements and specify when, within a reasonable period thereafter, the deviation shall be deemed no longer effective. The notice shall not affect any insurance contract or policy made or issued prior to the expiration of the period set forth in the notice.

(5)  For purposes of this section, the office, when considering the experience of any insurer, shall consider the experience of any predecessor insurer when the business and the liabilities of the predecessor insurer were assumed by the insurer pursuant to an order of the office which approves the assumption of the business and the liabilities.

(6)  The office shall submit an annual report to the President of the Senate and the Speaker of the House of Representatives by January 1 of each year which evaluates competition in the workers' compensation insurance market in this state. The report must contain an analysis of the availability and affordability of workers' compensation coverage and whether the current market structure, conduct, and performance are conducive to competition, based upon economic analysis and tests. The purpose of this report is to aid the Legislature in determining whether changes to the workers' compensation rating laws are warranted. The report must also document that the office has complied with the provisions of s. 627.096 which require the office to investigate and study all workers' compensation insurers in the state and to study the data, statistics, schedules, or other information as it finds necessary to assist in its review of workers' compensation rate filings.

History.--s. 431, ch. 59-205; s. 12, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; s. 103, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 6, 9, 10, ch. 87-124; s. 17, ch. 90-249; s. 7, ch. 90-366; s. 4, ch. 91-429; s. 1, ch. 96-405; s. 96, ch. 2002-1; s. 1087, ch. 2003-261; s. 3, ch. 2004-82.

627.212  Workplace safety program surcharge.--The office shall approve a rating plan for workers' compensation coverage insurance that provides for carriers voluntarily to impose a surcharge of no more than 10 percent on the premium of a policyholder or fund member if that policyholder or fund member has been identified by the department as having been required to implement a safety program and having failed to establish or maintain, either in whole or in part, a safety program. The department shall adopt rules prescribing the criteria for the employee safety programs.

History.--s. 97, ch. 93-415; s. 12, ch. 99-240; s. 1088, ch. 2003-261.

627.215  Excessive profits for workers' compensation, employer's liability, commercial property, and commercial casualty insurance prohibited.--

(1)(a)  Each insurer group writing workers' compensation and employer's liability insurance as defined in s. 624.605(1)(c), commercial property insurance as defined in s. 627.0625, commercial umbrella liability insurance as defined in s. 627.0625, or commercial casualty insurance as defined in s. 627.0625 shall file with the office prior to July 1 of each year, on a form prescribed by the commission, the following data for the component types of such insurance as provided in the form:

1.  Calendar-year earned premium.

2.  Accident-year incurred losses and loss adjustment expenses.

3.  The administrative and selling expenses incurred in this state or allocated to this state for the calendar year.

4.  Policyholder dividends applicable to the calendar year.

Nothing herein is intended to prohibit an insurer from filing on a calendar-year basis.

(b)  The data filed for the group shall be a consolidation of the data of the individual insurers of the group. However, an insurer may elect to either consolidate commercial umbrella liability insurance data with commercial casualty insurance data or to separately file data for commercial umbrella liability insurance. Each insurer shall elect its method of filing commercial umbrella liability insurance at the time of filing data for accident year 1987 and shall thereafter continue filing under the same method. In the case of commercial umbrella liability insurance data reported separately, a separate excessive profits test shall be applied and the test period shall be 10 years. In the case of workers' compensation and employer's liability insurance, the final report for the test period including accident years 1984, 1985, and 1986 must be filed prior to July 1, 1988. In the case of commercial property and commercial casualty insurance, the final report for the test period including accident years 1987, 1988, and 1989 must be filed prior to July 1, 1991.

(2)  Each insurer group writing workers' compensation and employer's liability insurance shall also file a schedule of Florida loss and loss adjustment experience for each of the 3 years previous to the most recent accident year. The incurred losses and loss adjustment expenses shall be valued as of December 31 of the first year following the latest accident year to be reported, developed to an ultimate basis, and at two 12-month intervals thereafter, each developed to an ultimate basis, so that a total of three evaluations will be provided for each accident year. The first year to be so reported shall be accident year 1984, so that the reporting of 3 accident years under this revised evaluation will not take place until accident years 1985 and 1986 have become available. For reporting purposes unrelated to determining excessive profits, the loss and loss adjustment experience of each accident year shall continue to be reported until each accident year has been reported at eight stages of development.

(3)(a)  Each insurer group writing commercial property insurance or commercial casualty insurance shall also file a schedule of Florida loss and loss adjustment experience for each of the 3 years previous to the most recent accident year. The incurred losses and loss adjustment expenses shall be valued as of December 31 of the first year following the latest accident year, developed to an ultimate basis, and at two 12-month intervals thereafter, each developed to an ultimate basis, so that a total of 3 evaluations will be provided for each accident year. The first year to be so reported shall be accident year 1987, which shall first be reported on or before July 1, 1989, and the reporting of 3 accident years will not take place until accident years 1988 and 1989 have become available. For medical malpractice insurance, the first year to be so reported shall be accident year 1990, which shall first be reported on or before July 1, 1992, and the reporting of 3 accident years for full inclusion of medical malpractice experience in commercial casualty insurance will not take place until accident years 1991 and 1992 become available. Accordingly, no medical malpractice insured shall be eligible for refunds or credits until the reporting period ending with calendar-accident year 1992. For reporting purposes unrelated to determining excess profits, the loss and loss adjustment experience of each accident year shall continue to be reported until each accident year has been reported at eight stages of development.

(b)  Each insurer group writing commercial umbrella liability insurance which elects to file separate data for such insurance shall also file a schedule of Florida loss and loss adjustment experience for each of the 10 years previous to the most recent accident year. The incurred losses and loss adjustment expenses shall be valued as of December 31 of the first year following the latest accident year, developed to an ultimate basis, and at nine 12-month intervals thereafter, each developed to an ultimate basis, so that a total of 10 evaluations will be provided for each accident year. The first year to be so reported shall be accident year 1987, which shall first be reported on or before October 1, 1989, and the reporting of 10 accident years will not take place until accident year 1996 data is reported.

(4)  Each insurer group's underwriting gain or loss for each calendar-accident year shall be computed as follows: The sum of the accident-year incurred losses and loss adjustment expenses as of December 31 of the year, developed to an ultimate basis, plus the administrative and selling expenses incurred in the calendar year, plus policyholder dividends applicable to the calendar year, shall be subtracted from the calendar-year earned premium to determine the underwriting gain or loss.

(5)  For the 3 most recent calendar-accident years for which data is to be filed under this section, the underwriting gain or loss shall be compared to the anticipated underwriting profit, except in the case of separately reported commercial umbrella liability insurance for which such comparison shall be made for the 10 most recent calendar-accident years.

(6)  For those insurer groups writing workers' compensation and employer's liability insurance during the years 1984, 1985, 1986, 1987, and 1988, an excessive profit has been realized if underwriting gain is greater than the anticipated underwriting profit plus 5 percent of earned premiums for the 3 most recent calendar years for which data is to be filed under this section. Any excess profit of an insurance company offering workers' compensation or employer's liability insurance during this period of time, shall be returned to policyholders in the form of a cash refund or a credit toward future purchase of insurance. The excessive amount shall be refunded on a pro rata basis in relation to the final compilation year earned premiums to the workers' compensation policyholders of record of the insurer group on December 31 of the final compilation year.

(7)(a)  Beginning with the July 1, 1991, report for workers' compensation insurance, employer's liability insurance, commercial property insurance, and commercial casualty insurance, an excessive profit has been realized if the net aggregate underwriting gain for all these lines combined is greater than the net aggregate anticipated underwriting profit for these lines plus 5 percent of earned premiums for the 3 most recent calendar years for which data is to be filed under this section. For calculation purposes commercial property insurance and commercial casualty insurance shall be broken down into sublines in order to ascertain the anticipated underwriting profit factor versus the actual underwriting gain for the given subline.

(b)  Beginning with the July 1, 1998, report for commercial umbrella liability insurance, if an insurer has elected to file data separately for such insurance, an excessive profit has been realized if the underwriting gain for such insurance is greater than the anticipated underwriting profit for such insurance plus 5 percent of earned premiums for the 10 most recent calendar years for which data is to be filed under this section.

(8)  As used in this section with respect to any 3-year period, or with respect to any 10-year period in the case of commercial umbrella liability insurance, "anticipated underwriting profit" means the sum of the dollar amounts obtained by multiplying, for each rate filing of the insurer group in effect during such period, the earned premiums applicable to such rate filing during such period by the percentage factor included in such rate filing for profit and contingencies, such percentage factor having been determined with due recognition to investment income from funds generated by Florida business, except that the anticipated underwriting profit for the purposes of this section shall be calculated using a profit and contingencies factor that is not less than zero. Separate calculations need not be made for consecutive rate filings containing the same percentage factor for profits and contingencies.

(9)  If the insurer group has realized an excessive profit, the office shall order a return of the excessive amounts after affording the insurer group an opportunity for hearing and otherwise complying with the requirements of chapter 120. Such excessive amounts shall be refunded in all instances unless the insurer group affirmatively demonstrates to the office that the refund of the excessive amounts will render a member of the insurer group financially impaired or will render it insolvent under the provisions of the Florida Insurance Code.

(10)  Any excess profit of an insurance company as determined on July 1, 1991, and thereafter shall be returned to policyholders in the form of a cash refund or a credit toward the future purchase of insurance. The excessive amount shall be refunded on a pro rata basis in relation to the final compilation year earned premiums to the policyholders of record of the insurer group on December 31 of the final compilation year.

(11)(a)  Cash refunds to policyholders may be rounded to the nearest dollar.

(b)  Data in required reports to the office may be rounded to the nearest dollar.

(c)  Rounding, if elected by the insurer, shall be applied consistently.

(12)(a)  Refunds shall be completed in one of the following ways:

1.  If the insurer group elects to make a cash refund, the refund shall be completed within 60 days of entry of a final order indicating that excessive profits have been realized.

2.  If the insurer group elects to make refunds in the form of a credit to renewal policies, such credits shall be applied to policy renewal premium notices which are forwarded to insureds more than 60 calendar days after entry of a final order indicating that excessive profits have been realized. If an insurer group has made this election but an insured thereafter cancels her or his policy or otherwise allows the policy to terminate, the insurer group shall make a cash refund not later than 60 days after termination of such coverage.

(b)  Upon completion of the renewal credits or refund payments, the insurer group shall immediately certify to the office that the refunds have been made.

(13)  Any refund or renewal credit made pursuant to this section shall be treated as a policyholder dividend applicable to the year immediately succeeding the compilation period giving rise to the refund or credit, for purposes of reporting under this section for subsequent years.

(14)  The application of this law to commercial property and commercial casualty insurance, which includes commercial umbrella liability insurance, ceases on January 1, 1997.

History.--s. 104, ch. 79-40; ss. 21, 22, ch. 80-236; s. 425, ch. 81-259; s. 2, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 7, 9, 10, ch. 87-124; s. 3, ch. 88-390; s. 2, ch. 89-225; s. 8, ch. 90-249; ss. 1, 3, ch. 90-366; s. 4, ch. 91-429; s. 15, ch. 95-276; s. 319, ch. 97-102; ss. 1, 2, ch. 97-292; s. 6, ch. 2000-333; s. 1089, ch. 2003-261.

627.221  Rating organizations; licensing; fee.--

(1)  A person, whether located within or outside this state, may make application to the office for a license as a rating organization. As to property or inland marine insurance, the application shall be for such kinds of insurance or subdivisions thereof or classes of risk or a part or combination thereof as are specified in the application. As to casualty and surety insurances, the application shall be for such kinds of insurance or subdivisions thereof as are specified in the application. The applicant shall file with its application:

(a)  A copy of its constitution, its articles of agreement or association or its certificate of incorporation, and of its bylaws, rules, and regulations governing the conduct of its business;

(b)  A list of its members and subscribers;

(c)  The name and address of a resident of this state upon whom notices or orders of the office or process affecting such rating organization may be served; and

(d)  A statement of its qualifications as a rating organization.

If the office finds that the applicant is competent, trustworthy, and otherwise qualified to act as a rating organization and that its constitution, articles of agreement or association or certificate of incorporation, and its bylaws, rules, and regulations governing the conduct of its business conform to the requirements of law, it shall issue a license specifying (in the case of a casualty or surety rating organization) the kinds of insurance or subdivisions thereof, or (in the case of a property insurance rating organization) the kinds of insurance or subdivisions thereof or classes of risk or a part or combination thereof, for which the applicant is authorized to act as a rating organization.

(2)  Licenses issued pursuant to this section shall expire on the September 30 next following date of issuance and shall be subject to annual renewal.

(3)  The fee for the license shall be in the amount specified therefor in s. 624.501. This fee, when collected, shall be deposited to the credit of the Insurance Regulatory Trust Fund.

History.--s. 432, ch. 59-205; s. 17, ch. 65-269; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 346, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1090, ch. 2003-261.

627.231  Subscribers to rating organizations.--

(1)  Subject to rules and regulations which have been approved by the office as reasonable, each rating organization shall permit any insurer, not a member, to subscribe to its rating services. As to property and marine rating organizations, an insurer shall be so permitted to subscribe to rating services for any kind of insurance, subdivision thereof, or class of risk or a part or combination thereof for which the rating organization is authorized so to act. As to casualty and surety rating organizations, an insurer shall be so permitted to subscribe to rating services for any kind of insurance or subdivision thereof for which the rating organization is authorized so to act. The rating organization shall give notice to subscribers of proposed changes in such rules and regulations.

(2)  The reasonableness of any rule or regulation in its application to subscribers, or the refusal of any rating organization to admit an insurer as a subscriber, shall, at the request of any subscriber or any such insurer, be reviewed by the office. If the office finds that such rule or regulation is unreasonable in its application to subscribers, it shall order that such rule or regulation shall not be applicable to subscribers. If the rating organization fails to grant or reject an insurer's application for subscribership within 30 days after it was made, the insurer may request a review by the office as if the application had been rejected. If the office finds that the insurer has been refused admittance to the rating organization as a subscriber without justification, it shall order the rating organization to admit the insurer as a subscriber. If it finds that the action of the rating organization was justified, it shall make an order affirming its action.

(3)  Each rating organization shall furnish its rating services without discrimination to its members and subscribers.

History.--s. 433, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1091, ch. 2003-261.

627.241  Notice of changes.--Every rating organization shall notify the office promptly of every change in:

(1)  Its constitution, its articles of agreement or association, or its certificate of incorporation, and its bylaws, rules and regulations governing the conduct of its business;

(2)  Its list of members and subscribers; and

(3)  The name and address of the resident of this state designated by it upon whom notices or orders of the office or process affecting such rating organization may be served.

History.--s. 434, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1092, ch. 2003-261.

627.251  Bureau rules not to affect dividends.--No rating organization shall adopt any rule the effect of which would be to prohibit or regulate the payment of dividends, savings, or unabsorbed premium deposits allowed or returned by insurers to their policyholders, members, or subscribers.

History.--s. 435, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318.

627.261  Actuarial and technical services.--Any rating organization may subscribe for or purchase actuarial, technical, or other services; and such services shall be available to all members and subscribers without discrimination.

History.--s. 436, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318.

627.281  Appeal from rating organization; workers' compensation and employer's liability insurance filings.--

(1)  Any member or subscriber to a rating organization may appeal to the office from the action or decision of such rating organization in approving or rejecting any proposed change in or addition to the workers' compensation or employer's liability insurance filings of such rating organization, and the office shall issue an order approving the decision of such rating organization or directing it to give further consideration to such proposal. If such appeal is from the action or decision of the rating organization in rejecting a proposed addition to its filings, the office may, in the event it finds that such action or decision was unreasonable, issue an order directing the rating organization to make an addition to its filings, on behalf of its members and subscribers, in a manner consistent with its findings, within a reasonable time after the issuance of such order.

(2)  If such appeal is based upon the failure of the rating organization to make a filing on behalf of such member or subscriber which is based on a system of expense provisions which differs, in accordance with the right granted in s. 627.072(2), from the system of expense provisions included in a filing made by the rating organization, the office shall, if it grants the appeal, order the rating organization to make the requested filing for use by the appellant. In deciding such appeal, the office shall apply the applicable standards set forth in ss. 627.062 and 627.072.

History.--s. 438, ch. 59-205; s. 13, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; s. 105, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 1093, ch. 2003-261.

627.285  Independent actuarial peer review of workers' compensation rating organization.--The Financial Services Commission shall at least once every other year contract for an independent actuarial peer review and analysis of the ratemaking processes of any licensed rating organization that makes rate filings for workers' compensation insurance, and the rating organization shall fully cooperate in the peer review. The contract shall require submission of a final report to the commission, the President of the Senate, and the Speaker of the House of Representatives by February 1. The first report shall be submitted by February 1, 2004. The costs of the independent actuarial peer review shall be paid from the Workers' Compensation Administration Trust Fund.

History.--s. 34, ch. 2003-412.

627.291  Information to be furnished insureds; appeal by insureds; workers' compensation and employer's liability insurances.--

(1)  As to workers' compensation and employer's liability insurances, every rating organization and every insurer which makes its own rates shall, within a reasonable time after receiving written request therefor and upon payment of such reasonable charge as it may make, furnish to any insured affected by a rate made by it, or to the authorized representative of such insured, all pertinent information as to such rate.

(2)  As to workers' compensation and employer's liability insurances, every rating organization and every insurer which makes its own rates shall provide within this state reasonable means whereby any person aggrieved by the application of its rating system may be heard, in person or by his or her authorized representative, on his or her written request to review the manner in which such rating system has been applied in connection with the insurance afforded him or her. If the rating organization or insurer fails to grant or rejects such request within 30 days after it is made, the applicant may proceed in the same manner as if his or her application had been rejected. Any party affected by the action of such rating organization or insurer on such request may, within 30 days after written notice of such action, appeal to the office, which may affirm or reverse such action.

History.--s. 439, ch. 59-205; s. 14, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; s. 106, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 806, ch. 82-243; s. 49, ch. 82-386; ss. 9, 10, ch. 87-124; s. 4, ch. 91-429; s. 320, ch. 97-102; s. 1094, ch. 2003-261.

627.301  Advisory organizations.--

(1)  No advisory organization shall conduct its operations in this state unless and until it has filed with the office:

(a)  A copy of its constitution, articles of incorporation, articles of agreement or of association, and bylaws or rules and regulations governing its activities, all duly certified by the custodian of the originals thereof;

(b)  A list of its members and subscribers; and

(c)  The name and address of a resident of this state upon whom notices or orders of the office or process may be served.

(2)  Every such advisory organization shall notify the office promptly of every change in:

(a)  Its constitution;

(b)  Its articles of incorporation, agreement, or association;

(c)  Its bylaws, rules and regulations governing the conduct of its business;

(d)  The list of members and subscribers; and

(e)  The name and address of the resident of this state designated by it upon whom notices or orders of the office or process affecting such organization may be served.

(3)  No such advisory organization shall engage in any unfair or unreasonable practice with respect to such activities.

History.--s. 440, ch. 59-205; s. 15, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1095, ch. 2003-261.

¹627.311  Joint underwriters and joint reinsurers; public records and public meetings exemptions.--

(1)  Every group, association, or other organization of insurers which engages in joint underwritings or joint reinsurance shall be subject to regulation with respect thereto as herein provided, subject, however, with respect to joint underwriting, to all other provisions of this chapter and, with respect to joint reinsurance, to ss. 624.15 and 624.3161.

(2)  If the office finds that any activity or practice of any such group, association, or other organization is unfair or unreasonable or otherwise inconsistent with the provisions of this chapter, it may issue a written order specifying in what respects such activity or practice is unfair or unreasonable or otherwise inconsistent with the provisions of this chapter, and requiring the discontinuance of such activity or practice.

²(3)  The office may, after consultation with insurers licensed to write automobile insurance in this state, approve a joint underwriting plan for purposes of equitable apportionment or sharing among insurers of automobile liability insurance and other motor vehicle insurance, as an alternate to the plan required in s. 627.351(1). All insurers authorized to write automobile insurance in this state shall subscribe to the plan and participate therein. The plan shall be subject to continuous review by the office which may at any time disapprove the entire plan or any part thereof if it determines that conditions have changed since prior approval and that in view of the purposes of the plan changes are warranted. Any disapproval by the office shall be subject to the provisions of chapter 120. The Florida Automobile Joint Underwriting Association is created under the plan. The plan and the association:

(a)  Must be subject to all provisions of s. 627.351(1), except apportionment of applicants.

(b)  May provide for one or more designated insurers, able and willing to provide policy and claims service, to act on behalf of all other insurers to provide insurance for applicants who are in good faith entitled to, but unable to, procure insurance through the voluntary insurance market at standard rates.

(c)  Must provide that designated insurers will issue policies of insurance and provide policyholder and claims service on behalf of all insurers for the joint underwriting association.

(d)  Must provide for the equitable apportionment among insurers of losses and expenses incurred.

(e)  Must provide that the joint underwriting association will operate subject to the supervision and approval of a board of governors consisting of 11 individuals, including 1 who will be elected as chair. Five members of the board must be appointed by the Chief Financial Officer. Two of the Chief Financial Officer's appointees must be chosen from the insurance industry. Any board member appointed by the Chief Financial Officer may be removed and replaced by her or him at any time without cause. Six members of the board must be appointed by the participating insurers, two of whom must be from the insurance agents' associations. All board members, including the chair, must be appointed to serve for 2-year terms beginning annually on a date designated by the plan.

(f)  Must provide that an agent appointed to a servicing carrier must be a licensed general lines agent of an insurer which is authorized to write automobile liability and physical damage insurance in the state and which is actively writing such coverage in the county in which the agent is located, or the immediately adjoining counties, or an agent who places a volume of other property and casualty insurance in an amount equal to the premium volume placed with the Florida Joint Underwriting Association. The office may, however, determine that an agent may be appointed to a servicing carrier if, after public hearing, the office finds that consumers in the agent's operating area would not have adequate and reasonable access to the purchase of automobile insurance if the agent were not appointed to a servicing carrier.

(g)  Must make available noncancelable coverage as provided in s. 627.7275(2).

(h)  Must provide for the furnishing of a list of insureds and their mailing addresses upon the request of a member of the association or an insurance agent licensed to place business with an association member. The list must indicate whether the insured is currently receiving a good driver discount from the association. The plan may charge a reasonable fee to cover the cost incurred in providing the list.

(i)  Must not provide a renewal credit or discount or any other inducement designed to retain a risk.

(j)  Must not provide any other good driver credit or discount that is not actuarially sound. In addition to other criteria that the plan may specify, to be eligible for a good driver credit, an insured must not have any criminal traffic violations within the most recent 36-month period preceding the date the discount is received.

(k)1.  Shall have no liability, and no cause of action of any nature shall arise against any member insurer or its agents or employees, agents or employees of the association, members of the board of governors of the association, the Chief Financial Officer, or the office or its representatives for any action taken by them in the performance of their duties or responsibilities under this subsection. Such immunity does not apply to actions for or arising out of breach of any contract or agreement pertaining to insurance, or any willful tort.

2.  Notwithstanding the requirements of s. 624.155(3)(a), as a condition precedent to bringing an action against the plan under s. 624.155, the department and the plan must have been given 90 days' written notice of the violation. If the department returns a notice for lack of specificity, the 90-day time period shall not begin until a proper notice is filed. This notice must comply with the information requirements of s. 624.155(3)(b). Effective October 1, 2007, this subparagraph shall expire unless reenacted by the Legislature prior to that date.

(l)  May require from the insured proof that he or she has obtained the mandatory types and amounts of insurance from another admitted carrier prior to the cancellation of a policy the insured obtained from the plan and prior to the return of any unearned premium the insured paid for such coverage from the plan. This paragraph does not apply to any person who provides proof of sale or inoperability of the vehicle covered under the policy purchased from the plan or relocation outside the state.

(4)  The Florida Automobile Joint Underwriting Association:

(a)  Shall keep the following records confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution:

1.  Underwriting files, except that a policyholder or an applicant shall have access to his or her own underwriting files.

2.  Claims files, until termination of all litigation and settlement of all claims arising out of the same incident. Confidential and exempt claims files may be released to other governmental agencies in the furtherance of their duties and responsibilities. The receiving agency must maintain the confidential and exempt status of the claims files.

3.  Records obtained or generated by an internal auditor pursuant to a routine audit, until the audit is completed or, if the audit is conducted as part of an investigation, until the investigation is closed or ceases to be active. An investigation is considered "active" while the investigation is being conducted with a reasonable, good faith belief that it could lead to the filing of administrative, civil, or criminal proceedings.

4.  Proprietary information licensed to the association under contract when the contract provides for the confidentiality of such information.

5.  All information relating to the medical condition or medical status of an association employee which is not relevant to that employee's capacity to perform his or her duties, except as otherwise provided in this paragraph. Information which is confidential and exempt shall include, but is not limited to, information relating to workers' compensation, insurance benefits, and retirement or disability benefits.

6.  All records relating to an employee's participation in an employee assistance program designed to assist any employee who has a behavioral or medical disorder, substance abuse problem, or emotional difficulty which affects the employee's job performance, except as otherwise provided in s. 112.0455(11).

7.  Information relating to negotiations for financing, reinsurance, depopulation, or contractual services, until the conclusion of the negotiations.

8.  Minutes of closed meetings regarding confidential and exempt underwriting files or confidential and exempt claims files until termination of all litigation and settlement of all claims with regard to that claim, except that information otherwise made confidential or exempt by law must be redacted.

When an authorized insurer is considering underwriting a risk insured by the association, relevant confidential and exempt underwriting files and confidential and exempt claims files may be released to the insurer, provided the insurer agrees in writing, notarized and under oath, to maintain the confidential and exempt status of such files. When a file is transferred to an insurer, that file is no longer a public record because it is not held by an agency subject to the provisions of the public records law. The association may make the following information obtained from confidential and exempt underwriting files and confidential and exempt claims files available to licensed general lines insurance agents: name, address, and telephone number of the automobile owner or insured; location of the risk; rating information; loss history; and policy type. The receiving licensed general lines insurance agent must maintain the confidential and exempt status of the information received.

(b)  Shall keep portions of association meetings during which confidential and exempt underwriting files or confidential and exempt claims files are discussed exempt from the provisions of s. 286.011 and s. 24(b), Art. I of the State Constitution. All closed portions of association meetings shall be recorded by a court reporter. The court reporter shall record the times of commencement and termination of the meeting, all discussion and proceedings, the names of all persons present at any time, and the names of all persons speaking. No portion of any closed meeting shall be off the record. Subject to the provisions of this paragraph and s. 119.07(1)(b)-(d), the court reporter's notes of any closed meeting shall be retained by the association for a minimum of 5 years. A copy of the transcript, less any confidential and exempt information, of any closed meeting during which confidential and exempt claims files are discussed shall become public as to individual claims files after settlement of that claim.

(5)(a)  The office shall, after consultation with insurers, approve a joint underwriting plan of insurers which shall operate as a nonprofit entity. For the purposes of this subsection, the term "insurer" includes group self-insurance funds authorized by s. 624.4621, commercial self-insurance funds authorized by s. 624.462, assessable mutual insurers authorized under s. 628.6011, and insurers licensed to write workers' compensation and employer's liability insurance in this state. The purpose of the plan is to provide workers' compensation and employer's liability insurance to applicants who are required by law to maintain workers' compensation and employer's liability insurance and who are in good faith entitled to but who are unable to procure such insurance through the voluntary market. Except as provided herein, the plan must have actuarially sound rates that ensure that the plan is self-supporting.

³(b)  The operation of the plan is subject to the supervision of a 9-member board of governors. The board of governors shall be comprised of:

1.  Three members appointed by the Financial Services Commission. Each member appointed by the commission shall serve at the pleasure of the commission;

2.  Two of the 20 domestic insurers, as defined in s. 624.06(1), having the largest voluntary direct premiums written in this state for workers' compensation and employer's liability insurance, which shall be elected by those 20 domestic insurers;

3.  Two of the 20 foreign insurers as defined in s. 624.06(2) having the largest voluntary direct premiums written in this state for workers' compensation and employer's liability insurance, which shall be elected by those 20 foreign insurers;

4.  One person appointed by the largest property and casualty insurance agents' association in this state; and

5.  The consumer advocate appointed under s. 627.0613 or the consumer advocate's designee.

Each board member shall serve a 4-year term and may serve consecutive terms. A vacancy on the board shall be filled in the same manner as the original appointment for the unexpired portion of the term. The Financial Services Commission shall designate a member of the board to serve as chair. No board member shall be an insurer which provides services to the plan or which has an affiliate which provides services to the plan or which is serviced by a service company or third-party administrator which provides services to the plan or which has an affiliate which provides services to the plan. The minutes, audits, and procedures of the board of governors are subject to chapter 119.

(c)  The operation of the plan shall be governed by a plan of operation that is prepared at the direction of the board of governors. The plan of operation may be changed at any time by the board of governors or upon request of the office. The plan of operation and all changes thereto are subject to the approval of the office. The plan of operation shall:

1.  Authorize the board to engage in the activities necessary to implement this subsection, including, but not limited to, borrowing money.

2.  Develop criteria for eligibility for coverage by the plan, including, but not limited to, documented rejection by at least two insurers which reasonably assures that insureds covered under the plan are unable to acquire coverage in the voluntary market.

3.  Require notice from the agent to the insured at the time of the application for coverage that the application is for coverage with the plan and that coverage may be available through an insurer, group self-insurers' fund, commercial self-insurance fund, or assessable mutual insurer through another agent at a lower cost.

4.  Establish programs to encourage insurers to provide coverage to applicants of the plan in the voluntary market and to insureds of the plan, including, but not limited to:

a.  Establishing procedures for an insurer to use in notifying the plan of the insurer's desire to provide coverage to applicants to the plan or existing insureds of the plan and in describing the types of risks in which the insurer is interested. The description of the desired risks must be on a form developed by the plan.

b.  Developing forms and procedures that provide an insurer with the information necessary to determine whether the insurer wants to write particular applicants to the plan or insureds of the plan.

c.  Developing procedures for notice to the plan and the applicant to the plan or insured of the plan that an insurer will insure the applicant or the insured of the plan, and notice of the cost of the coverage offered; and developing procedures for the selection of an insuring entity by the applicant or insured of the plan.

d.  Provide for a market-assistance plan to assist in the placement of employers. All applications for coverage in the plan received 45 days before the effective date for coverage shall be processed through the market-assistance plan. A market-assistance plan specifically designed to serve the needs of small, good policyholders as defined by the board must be finalized by January 1, 1994.

5.  Provide for policy and claims services to the insureds of the plan of the nature and quality provided for insureds in the voluntary market.

6.  Provide for the review of applications for coverage with the plan for reasonableness and accuracy, using any available historic information regarding the insured.

7.  Provide for procedures for auditing insureds of the plan which are based on reasonable business judgment and are designed to maximize the likelihood that the plan will collect the appropriate premiums.

8.  Authorize the plan to terminate the coverage of and refuse future coverage for any insured that submits a fraudulent application to the plan or provides fraudulent or grossly erroneous records to the plan or to any service provider of the plan in conjunction with the activities of the plan.

9.  Establish service standards for agents who submit business to the plan.

10.  Establish criteria and procedures to prohibit any agent who does not adhere to the established service standards from placing business with the plan or receiving, directly or indirectly, any commissions for business placed with the plan.

11.  Provide for the establishment of reasonable safety programs for all insureds in the plan. All insureds of the plan must participate in the safety program.

12.  Authorize the plan to terminate the coverage of and refuse future coverage to any insured who fails to pay premiums or surcharges when due; who, at the time of application, is delinquent in payments of workers' compensation or employer's liability insurance premiums or surcharges owed to an insurer, group self-insurers' fund, commercial self-insurance fund, or assessable mutual insurer licensed to write such coverage in this state; or who refuses to substantially comply with any safety programs recommended by the plan.

13.  Authorize the board of governors to provide the services required by the plan through staff employed by the plan, through reasonably compensated service providers who contract with the plan to provide services as specified by the board of governors, or through a combination of employees and service providers.

14.  Provide for service standards for service providers, methods of determining adherence to those service standards, incentives and disincentives for service, and procedures for terminating contracts for service providers that fail to adhere to service standards.

15.  Provide procedures for selecting service providers and standards for qualification as a service provider that reasonably assure that any service provider selected will continue to operate as an ongoing concern and is capable of providing the specified services in the manner required.

16.  Provide for reasonable accounting and data-reporting practices.

17.  Provide for annual review of costs associated with the administration and servicing of the policies issued by the plan to determine alternatives by which costs can be reduced.

18.  Authorize the acquisition of such excess insurance or reinsurance as is consistent with the purposes of the plan.

19.  Provide for an annual report to the office on a date specified by the office and containing such information as the office reasonably requires.

20.  Establish multiple rating plans for various classifications of risk which reflect risk of loss, hazard grade, actual losses, size of premium, and compliance with loss control. At least one of such plans must be a preferred-rating plan to accommodate small-premium policyholders with good experience as defined in sub-subparagraph 22.a.

21.  Establish agent commission schedules.

22.  For employers otherwise eligible for coverage under the plan, establish three tiers of employers meeting the criteria and subject to the rate limitations specified in this subparagraph.

a.  Tier One.--

(I)  Criteria; rated employers.--An employer that has an experience modification rating shall be included in Tier One if the employer meets all of the following:

(A)  The experience modification is below 1.00.

(B)  The employer had no lost-time claims subsequent to the applicable experience modification rating period.

(C)  The total of the employer's medical-only claims subsequent to the applicable experience modification rating period did not exceed 20 percent of premium.

(II)  Criteria; non-rated employers.--An employer that does not have an experience modification rating shall be included in Tier One if the employer meets all of the following:

(A)  The employer had no lost-time claims for the 3-year period immediately preceding the inception date or renewal date of the employer's coverage under the plan.

(B)  The total of the employer's medical-only claims for the 3-year period immediately preceding the inception date or renewal date of the employer's coverage under the plan did not exceed 20 percent of premium.

(C)  The employer has secured workers' compensation coverage for the entire 3-year period immediately preceding the inception date or renewal date of the employer's coverage under the plan.

(D)  The employer is able to provide the plan with a loss history generated by the employer's prior workers' compensation insurer, except if the employer is not able to produce a loss history due to the insolvency of an insurer, the receiver shall provide to the plan, upon the request of the employer or the employer's agent, a copy of the employer's loss history from the records of the insolvent insurer if the loss history is contained in records of the insurer which are in the possession of the receiver. If the receiver is unable to produce the loss history, the employer may, in lieu of the loss history, submit an affidavit from the employer and the employer's insurance agent setting forth the loss history.

(E)  The employer is not a new business.

(III)  Premiums.--The premiums for Tier One insureds shall be set at a premium level 25 percent above the comparable voluntary market premiums until the plan has sufficient experience as determined by the board to establish an actuarially sound rate for Tier One, at which point the board shall, subject to paragraph (e), adjust the rates, if necessary, to produce actuarially sound rates, provided such rate adjustment shall not take effect prior to January 1, 2007.

b.  Tier Two.--

(I)  Criteria; rated employers.--An employer that has an experience modification rating shall be included in Tier Two if the employer meets all of the following:

(A)  The experience modification is equal to or greater than 1.00 but not greater than 1.10.

(B)  The employer had no lost-time claims subsequent to the applicable experience modification rating period.

(C)  The total of the employer's medical-only claims subsequent to the applicable experience modification rating period did not exceed 20 percent of premium.

(II)  Criteria; non-rated employers.--An employer that does not have any experience modification rating shall be included in Tier Two if the employer is a new business. An employer shall be included in Tier Two if the employer has less than 3 years of loss experience in the 3-year period immediately preceding the inception date or renewal date of the employer's coverage under the plan and the employer meets all of the following:

(A)  The employer had no lost-time claims for the 3-year period immediately preceding the inception date or renewal date of the employer's coverage under the plan.

(B)  The total of the employer's medical-only claims for the 3-year period immediately preceding the inception date or renewal date of the employer's coverage under the plan did not exceed 20 percent of premium.

(C)  The employer is able to provide the plan with a loss history generated by the workers' compensation insurer that provided coverage for the portion or portions of such period during which the employer had secured workers' compensation coverage, except if the employer is not able to produce a loss history due to the insolvency of an insurer, the receiver shall provide to the plan, upon the request of the employer or the employer's agent, a copy of the employer's loss history from the records of the insolvent insurer if the loss history is contained in records of the insurer which are in the possession of the receiver. If the receiver is unable to produce the loss history, the employer may, in lieu of the loss history, submit an affidavit from the employer and the employer's insurance agent setting forth the loss history.

(III)  Premiums.--The premiums for Tier Two insureds shall be set at a rate level 50 percent above the comparable voluntary market premiums until the plan has sufficient experience as determined by the board to establish an actuarially sound rate for Tier Two, at which point the board shall, subject to paragraph (e), adjust the rates, if necessary, to produce actuarially sound rates, provided such rate adjustment shall not take effect prior to January 1, 2007.

c.  Tier Three.--

(I)  Eligibility.--An employer shall be included in Tier Three if the employer does not meet the criteria for Tier One or Tier Two.

(II)  Rates.--The board shall establish, subject to paragraph (e), and the plan shall charge, actuarially sound rates for Tier Three insureds.

23.  For Tier One or Tier Two employers which employ no nonexempt employees or which report payroll which is less than the minimum wage hourly rate for one full-time employee for 1 year at 40 hours per week, the plan shall establish actuarially sound premiums, provided, however, that the premiums may not exceed $2,500. These premiums shall be in addition to the fee specified in subparagraph 26. When the plan establishes actuarially sound rates for all employers in Tier One and Tier Two, the premiums for employers referred to in this paragraph are no longer subject to the $2,500 cap.

24.  Provide for a depopulation program to reduce the number of insureds in the plan. If an employer insured through the plan is offered coverage from a voluntary market carrier:

a.  During the first 30 days of coverage under the plan;

b.  Before a policy is issued under the plan;

c.  By issuance of a policy upon expiration or cancellation of the policy under the plan; or

d.  By assumption of the plan's obligation with respect to an in-force policy,

that employer is no longer eligible for coverage through the plan. The premium for risks assumed by the voluntary market carrier must be no greater than the premium the insured would have paid under the plan, and shall be adjusted upon renewal to reflect changes in the plan rates and the tier for which the insured would qualify as of the time of renewal. The insured may be charged such premiums only for the first 3 years of coverage in the voluntary market. A premium under this subparagraph is deemed approved and is not an excess premium for purposes of s. 627.171.

25.  Require that policies issued and applications must include a notice that the policy could be replaced by a policy issued from a voluntary market carrier and that, if an offer of coverage is obtained from a voluntary market carrier, the policyholder is no longer eligible for coverage through the plan. The notice must also specify that acceptance of coverage under the plan creates a conclusive presumption that the applicant or policyholder is aware of this potential.

26.  Require that each application for coverage and each renewal premium be accompanied by a nonrefundable fee of $475 to cover costs of administration and fraud prevention. The board may, with the approval of the office, increase the amount of the fee pursuant to a rate filing to reflect increased costs of administration and fraud prevention. The fee is not subject to commission and is fully earned upon commencement of coverage.

(d)1.  The funding of the plan shall include premiums as provided in subparagraph (c)22. and assessments as provided in this paragraph.

2.a.  If the board determines that a deficit exists in Tier One or Tier Two or that there is any deficit remaining attributable to any of the plan's former subplans and that the deficit cannot be funded without the use of deficit assessments, the board shall request the office to levy, by order, a deficit assessment against premiums charged to insureds for workers' compensation insurance by insurers as defined in s. 631.904(5). The office shall issue the order after verifying the amount of the deficit. The assessment shall be specified as a percentage of future premium collections, as recommended by the board and approved by the office. The same percentage shall apply to premiums on all workers' compensation policies issued or renewed during the 12-month period beginning on the effective date of the assessment, as specified in the order.

b.  With respect to each insurer collecting premiums that are subject to the assessment, the insurer shall collect the assessment at the same time as the insurer collects the premium payment for each policy and shall remit the assessments collected to the plan as provided in the order issued by the office. The office shall verify the accurate and timely collection and remittance of deficit assessments and shall report such information to the board. Each insurer collecting assessments shall provide such information with respect to premiums and collections as may be required by the office to enable the office to monitor and audit compliance with this paragraph.

c.  Deficit assessments are not considered part of an insurer's rate, are not premium, and are not subject to the premium tax, to the assessments under ss. 440.49 and 440.51, to the surplus lines tax, to any fees, or to any commissions. The deficit assessment imposed shall become plan funds at the moment of collection and shall not constitute income to the insurer for any purpose, including financial reporting on the insurer's income statement. An insurer is liable for all assessments that the insurer collects and must treat the failure of an insured to pay an assessment as a failure to pay premium. An insurer is not liable for uncollectible assessments.

d.  When an insurer is required to return unearned premium, the insurer shall also return any collected assessments attributable to the unearned premium.

e.  Deficit assessments as described in this subparagraph shall not be levied after July 1, 2007.

3.a.  All policies issued to Tier Three insureds shall be assessable. All Tier Three assessable policies must be clearly identified as assessable by containing, in contrasting color and in not less than 10-point type, the following statement:

"This is an assessable policy. If the plan is unable to pay its obligations, policyholders will be required to contribute on a pro rata earned premium basis the money necessary to meet any assessment levied."

b.  The board may from time to time assess Tier Three insureds to whom the plan has issued assessable policies for the purpose of funding plan deficits. Any such assessment shall be based upon a reasonable actuarial estimate of the amount of the deficit, taking into account the amount needed to fund medical and indemnity reserves and reserves for incurred but not reported claims, and allowing for general administrative expenses, the cost of levying and collecting the assessment, a reasonable allowance for estimated uncollectible assessments, and allocated and unallocated loss adjustment expenses.

c.  Each Tier Three insured's share of a deficit shall be computed by applying to the premium earned on the insured's policy or policies during the period to be covered by the assessment the ratio of the total deficit to the total premiums earned during such period upon all policies subject to the assessment. If one or more Tier Three insureds fail to pay an assessment, the other Tier Three insureds shall be liable on a proportionate basis for additional assessments to fund the deficit. The plan may compromise and settle individual assessment claims without affecting the validity of or amounts due on assessments levied against other insureds. The plan may offer and accept discounted payments for assessments which are promptly paid. The plan may offset the amount of any unpaid assessment against unearned premiums which may otherwise be due to an insured. The plan shall institute legal action when necessary and appropriate to collect the assessment from any insured who fails to pay an assessment when due.

d.  The venue of a proceeding to enforce or collect an assessment or to contest the validity or amount of an assessment shall be in the Circuit Court of Leon County.

e.  If the board finds that a deficit in Tier Three exists for any period and that an assessment is necessary, the board shall certify to the office the need for an assessment. No sooner than 30 days after the date of such certification, the board shall notify in writing each insured who is to be assessed that an assessment is being levied against the insured, and informing the insured of the amount of the assessment, the period for which the assessment is being levied, and the date by which payment of the assessment is due. The board shall establish a date by which payment of the assessment is due, which shall be no sooner than 30 days nor later than 120 days after the date on which notice of the assessment is mailed to the insured.

f.  Whenever the board makes a determination that the plan does not have a sufficient cash basis to meet 3 months of projected cash needs due to a deficit in Tier Three, the board may request the department to transfer funds from the Workers' Compensation Administration Trust Fund to the plan in an amount sufficient to fund the difference between the amount available and the amount needed to meet a 3-month projected cash need as determined by the board and verified by the office, subject to the approval of the Legislative Budget Commission. If the Legislative Budget Commission approves a transfer of funds under this sub-subparagraph, the plan shall report to the Legislature the transfer of funds and the Legislature shall review the plan during the next legislative session or the current legislative session, if the transfer occurs during a legislative session. This sub-subparagraph shall not apply until the plan determines and the office verifies that assessments collected by the plan pursuant to sub-subparagraph b. are insufficient to fund the deficit in Tier Three and to meet 3 months of projected cash needs.

4.  The plan may offer rating, dividend plans, and other plans to encourage loss prevention programs.

(e)  The plan shall establish and use its rates and rating plans, and the plan may establish and use changes in rating plans at any time, but no more frequently than two times per any rating class for any calendar year. By December 1, 1993, and December 1 of each year thereafter, except as provided in subparagraph (c)22., the board shall establish and use actuarially sound rates for use by the plan to assure that the plan is self-funding while those rates are in effect. Such rates and rating plans must be filed with the office within 30 calendar days after their effective dates, and shall be considered a "use and file" filing. Any disapproval by the office must have an effective date that is at least 60 days from the date of disapproval of the rates and rating plan and must have prospective effect only. The plan may not be subject to any order by the office to return to policyholders any portion of the rates disapproved by the office. The office may not disapprove any rates or rating plans unless it demonstrates that such rates and rating plans are excessive, inadequate, or unfairly discriminatory.

(f)  No later than June 1 of each year, the plan shall obtain an independent actuarial certification of the results of the operations of the plan for prior years, and shall furnish a copy of the certification to the office. If, after the effective date of the plan, the projected ultimate incurred losses and expenses and dividends for prior years exceed collected premiums, accrued net investment income, and prior assessments for prior years, the certification is subject to review and approval by the office before it becomes final.

(g)  Whenever a deficit exists, the plan shall, within 90 days, provide the office with a program to eliminate the deficit within a reasonable time. The deficit may be funded through increased premiums charged to insureds of the plan for subsequent years, through the use of policyholder surplus attributable to any year, through the use of assessments as provided in subparagraph (d)2., and through assessments on assessable policies as provided in subparagraph (d)3.

(h)  Any premium or assessments collected by the plan in excess of the amount necessary to fund projected ultimate incurred losses and expenses of the plan and not paid to insureds of the plan in conjunction with loss prevention or dividend programs shall be retained by the plan for future use.

(i)  The decisions of the board of governors do not constitute final agency action and are not subject to chapter 120.

(j)  Policies for insureds shall be issued by the plan.

(k)  The plan created under this subsection is liable only for payment for losses arising under policies issued by the plan with dates of accidents occurring on or after January 1, 1994.

(l)  Plan losses are the sole and exclusive responsibility of the plan, and payment for such losses must be funded in accordance with this subsection and must not come, directly or indirectly, from insurers or any guaranty association for such insurers.

(m)  Each joint underwriting plan or association created under this section is not a state agency, board, or commission. However, for the purposes of s. 199.183(1) only, the joint underwriting plan is a political subdivision of the state and is exempt from the corporate income tax.

(n)  Each joint underwriting plan or association may elect to pay premium taxes on the premiums received on its behalf or may elect to have the member insurers to whom the premiums are allocated pay the premium taxes if the member insurer had written the policy. The joint underwriting plan or association shall notify the member insurers and the Department of Revenue by January 15 of each year of its election for the same year. As used in this paragraph, the term "premiums received" means the consideration for insurance, by whatever name called, but does not include any policy assessment or surcharge received by the joint underwriting association as a result of apportioning losses or deficits of the association pursuant to this section.

(o)  Neither the plan nor any member of the board of governors is liable for monetary damages to any person for any statement, vote, decision, or failure to act, regarding the management or policies of the plan, unless:

1.  The member breached or failed to perform her or his duties as a member; and

2.  The member's breach of, or failure to perform, duties constitutes:

a.  A violation of the criminal law, unless the member had reasonable cause to believe her or his conduct was not unlawful. A judgment or other final adjudication against a member in any criminal proceeding for violation of the criminal law estops that member from contesting the fact that her or his breach, or failure to perform, constitutes a violation of the criminal law; but does not estop the member from establishing that she or he had reasonable cause to believe that her or his conduct was lawful or had no reasonable cause to believe that her or his conduct was unlawful;

b.  A transaction from which the member derived an improper personal benefit, either directly or indirectly; or

c.  Recklessness or any act or omission that was committed in bad faith or with malicious purpose or in a manner exhibiting wanton and willful disregard of human rights, safety, or property. For purposes of this sub-subparagraph, the term "recklessness" means the acting, or omission to act, in conscious disregard of a risk:

(I)  Known, or so obvious that it should have been known, to the member; and

(II)  Known to the member, or so obvious that it should have been known, to be so great as to make it highly probable that harm would follow from such act or omission.

(p)  No insurer shall provide workers' compensation and employer's liability insurance to any person who is delinquent in the payment of premiums, assessments, penalties, or surcharges owed to the plan or to any person who is an affiliated person of a person who is delinquent in the payment of premiums, assessments, penalties, or surcharges owed to the plan. For purposes of this paragraph, the term "affiliated person" of another person means:

1.  The spouse of such other natural person;

2.  Any person who directly or indirectly owns or controls, or holds with the power to vote, 5 percent or more of the outstanding voting securities of such other person;

3.  Any person who directly or indirectly owns 5 percent or more of the outstanding voting securities that are directly or indirectly owned or controlled, or held with the power to vote, by such other person;

4.  Any person or group of persons who directly or indirectly control, are controlled by, or are under common control with such other person;

5.  Any officer, director, trustee, partner, owner, manager, joint venturer, or employee, or other person performing duties similar to persons in those positions, of such other persons; or

6.  Any person who has an officer, director, trustee, partner, or joint venturer in common with such other person.

(q)  Effective July 1, 2004, the plan is exempt from the premium tax under s. 624.509 and any assessments under ss. 440.49 and 440.51.

(6)  As used in this section and ss. 215.555 and 627.351, the term "collateral protection insurance" means commercial property insurance of which a creditor is the primary beneficiary and policyholder and which protects or covers an interest of the creditor arising out of a credit transaction secured by real or personal property. Initiation of such coverage is triggered by the mortgagor's failure to maintain insurance coverage as required by the mortgage or other lending document. Collateral protection insurance is not residential coverage.

(7)(a)  The Florida Automobile Joint Underwriting Association created under this section shall be deemed to have appointed its general manager as its agent to receive service of all legal process issued against the association in any civil action or proceeding in this state. Process so served shall be valid and binding upon the insurer.

(b)  Service of process upon the association's general manager as the association's agent pursuant to such an appointment shall be the sole method of service of process upon the association.

History.--s. 441, ch. 59-205; ss. 13, 35, ch. 69-106; s. 1, ch. 74-51; s. 3, ch. 76-168; s. 16, ch. 77-290; s. 1, ch. 77-457; s. 21, ch. 78-95; s. 107, ch. 79-40; ss. 1, 2, 4, ch. 79-394; s. 238, ch. 79-400; ss. 1, 2, ch. 80-360; ss. 1, 2, ch. 80-362; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 34, ch. 89-289; s. 4, ch. 91-106; s. 64, ch. 91-108; ss. 25, 114, ch. 92-318; s. 98, ch. 93-415; s. 7, ch. 97-93; s. 321, ch. 97-102; s. 4, ch. 97-214; s. 3, ch. 98-173; s. 1, ch. 98-315; s. 66, ch. 99-5; s. 1, ch. 99-237; s. 13, ch. 99-240; s. 8, ch. 2000-150; s. 35, ch. 2001-91; s. 97, ch. 2002-1; s. 1, ch. 2003-108; s. 1, ch. 2003-169; s. 1096, ch. 2003-261; s. 35, ch. 2003-412; s. 1, ch. 2004-266; s. 46, ch. 2004-335; s. 11, ch. 2004-370; s. 156, ch. 2004-390.

¹Note.--Section 2, ch. 2004-266, provides that:

"Notwithstanding the provisions of ss. 440.50 and 440.51, Florida Statutes, subject to the following procedures and approval, the Department of Financial Services may request transfer funds from the Workers' Compensation Administration Trust Fund within the Department of Financial Services to the workers' compensation joint underwriting plan provided in s. 627.311(5), Florida Statutes.

"(1)  The department shall establish a contingency reserve within the Workers' Compensation Administration Trust Fund, from which the department is authorized to expend funds as provided in the subsection, in an amount not to exceed $15 million to be released only upon the approval of a budget amendment presented to the Legislative Budget Commission. For actuarial deficits projected for policyholders, based on actuarial best estimates, covered in subplan "D" prior to July 1, 2004, and upon verification by the Office of Insurance Regulation, the plan is authorized to request and the department is authorized to submit a budget amendment in an amount not to exceed $15 million for the purpose of funding deficits in subplan "D".

"(2)  After the contingency reserve is established, whenever the board determines subplan "D" does not have a sufficient cash basis to meet 3 months of projected cash needs due to any deficit in subplan "D," the board is authorized to request the department to transfer funds from the contingency reserve fund within the Workers' Compensation Administration Trust Fund to the plan in an amount sufficient to fund the difference between the amount available and the amount needed to meet subplan "D"'s projected cash need for the subsequent 3-month period. The board and the office must first certify to the Department of Financial Services that there is not sufficient cash within subplan "D" to meet the projected cash needs in subplan "D" within the subsequent 3 months. The amount requested for transfer to subplan "D" may not exceed the difference between the amount available within subplan "D" and the amount needed to meet subplan "D"'s projected cash need for the subsequent 3-month period, as jointly certified by the board and the Office of Insurance Regulation to the Department of Financial Services, attributable to the former subplan "D" policyholders. The Department of Financial Services may submit a budget amendment to request release of funds from the Workers' Compensation Administration Trust Fund, subject to the approval of the Legislative Budget Commission. The board will provide, for review of the Legislative Budget Commission, information on the reasonableness of the plan's administration, including, but not limited to, the plan of operations and costs, claims costs, claims administration costs, overhead costs, claims reserves, and the latest report submitted on administration cost reduction alternatives as required in s. 627.311(5)(c)17., Florida Statutes.

"(3)  This section expires July 1, 2007."

²Note.--Section 11, ch. 2004-370, and s. 156, ch. 2004-390, amended subsection (3) "[e]ffective July 1, 2004, and applicable to cancellation requests and notices received on or after that date."

³Note.--

A.  As amended by s. 35, ch. 2003-412, passed in 2003 Special Session A. Paragraph (4)(b), redesignated as paragraph (5)(b) by s. 1, ch. 2003-108, was also amended by s. 1096, ch. 2003-261, passed in the 2003 Regular Session, and that version reads:

(b)  The operation of the plan is subject to the supervision of a 13-member board of governors. The board of governors shall be comprised of:

1.  Five of the 20 domestic insurers, as defined in s. 624.06(1), having the largest voluntary direct premiums written in this state for workers' compensation and employer's liability insurance, which shall be elected by those 20 domestic insurers;

2.  Five of the 20 foreign insurers as defined in s. 624.06(2) having the largest voluntary direct premiums written in this state for workers' compensation and employer's liability insurance, which shall be elected by those 20 foreign insurers;

3.  One person, who shall serve as the chair, appointed by the Chief Financial Officer;

4.  One person appointed by the largest property and casualty insurance agents' association in this state; and

5.  The consumer advocate appointed under s. 627.0613 or the consumer advocate's designee.


Each board member shall serve a 4-year term and may serve consecutive terms. No board member shall be an insurer which provides service to the plan or which has an affiliate which provides services to the plan or which is serviced by a service company or third-party administrator which provides services to the plan or which has an affiliate which provides services to the plan. The minutes, audits, and procedures of the board of governors are subject to chapter 119.

B.  Section 49, ch. 2003-412, provides that "[i]f any law amended by this act was also amended by a law enacted at the 2003 Regular Session of the Legislature, such laws shall be construed as if they had been enacted at the same session of the Legislature, and full effect shall be given to each if possible."

627.312  Transitional provisions.--Effective upon this act becoming a law:

(1)  Notwithstanding s. 627.311(5), no policy in subplan "D" of the Florida Workers' Compensation Joint Underwriting Association is subject to an assessment for the purpose of funding a deficit.

(2)  Any policy issued by the Florida Workers' Compensation Joint Underwriting Association with an effective date between the date on which this act becomes a law and June 30, 2004, shall be rerated and placed in the appropriate tier provided in s. 627.311(5), as amended, effective July 1, 2004, and shall be subject to the premiums and charges provided for in that section as amended.

History.--s. 6, ch. 2004-266.

627.313  Workers' Compensation Joint Underwriting Plan; audit requirements.--The Workers' Compensation Joint Underwriting Association is subject to the Florida Single Audit Act, as provided in s. 215.97, if the association expends a total amount of state financial assistance equal to or in excess of $300,000 in any fiscal year. Such audit reports shall be submitted to the President of the Senate, the Speaker of the House of Representatives, and the Governor pursuant to s. 215.97.

History.--s. 4, ch. 2004-266.

627.314  Concerted action by two or more insurers.--

(1)  Subject to and in compliance with the provisions of this part authorizing insurers to be members or subscribers of rating or advisory organizations or to engage in joint underwriting or joint reinsurance, two or more insurers may act in concert with each other and with others with respect to any matters pertaining to:

(a)  The making of rates or rating systems except for private passenger automobile insurance rates;

(b)  The preparation or making of insurance policy or bond forms, underwriting rules, surveys, inspections, and investigations;

(c)  The furnishing of loss or expense statistics or other information and data; or

(d)  The carrying on of research.

(2)  With respect to any matters pertaining to the making of rates or rating systems; the preparation or making of insurance policy or bond forms, underwriting rules, surveys, inspections, and investigations; the furnishing of loss or expense statistics or other information and data; or the carrying on of research, two or more authorized insurers having a common ownership or operating in the state under common management or control are hereby authorized to act in concert between or among themselves the same as if they constituted a single insurer. To the extent that such matters relate to cosurety bonds, two or more authorized insurers executing such bonds are hereby authorized to act in concert between or among themselves the same as if they constituted a single insurer.

(3)(a)  Members and subscribers of rating or advisory organizations may use the rates, rating systems, underwriting rules, or policy or bond forms of such organizations, either consistently or intermittently; but, except as provided in subsection (2) and ss. 627.311 and 627.351, they shall not agree with each other or rating organizations or others to adhere thereto.

(b)  The fact that two or more authorized insurers, whether or not members or subscribers of a rating or advisory organization, use, either consistently or intermittently, the rates or rating systems made or adopted by a rating organization or the underwriting rules or policy or bond forms prepared by a rating or advisory organization shall not be sufficient in itself to support a finding that an agreement to so adhere exists, and may be used only for the purpose of supplementing or explaining direct evidence of the existence of any such agreement.

(c)  This subsection does not apply as to workers' compensation and employer's liability insurances.

(4)  Licensed rating organizations and authorized insurers are authorized to exchange information and experience data with rating organizations and insurers in this and other states and may consult with them with respect to ratemaking and the application of rating systems.

(5)  Upon compliance with the provisions of this part applicable thereto, any rating organization or advisory organization, and any group, association, or other organization of authorized insurers which engages in joint underwriting or joint reinsurance through such organization or by standing agreement among the members thereof, may conduct operations in this state. As respects insurance risks or operations in this state, no insurer shall be a member or subscriber of any such organization, group, or association that has not complied with the provisions of this part applicable to it.

(6)  Notwithstanding any other provisions of this part, insurers shall not participate directly or indirectly in the deliberations or decisions of rating organizations on private passenger automobile insurance. However, such rating organizations shall, upon request of individual insurers, be required to furnish at reasonable cost the rate indications resulting from the loss and expense statistics gathered by them. Individual insurers may modify the indications to reflect their individual experience in determining their own rates. Such rates shall be filed with the office for public inspection whenever requested and shall be available for public announcement only by the press, office, or insurer.

History.--s. 16, ch. 67-9; s. 1, ch. 70-320; s. 1, ch. 71-6(B); s. 3, ch. 76-168; s. 1, ch. 77-457; s. 108, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1098, ch. 2003-261.

627.318  Records.--Every insurer, rating organization, and advisory organization and every group, association, or other organization of insurers which engages in joint underwriting or joint reinsurance shall maintain reasonable records, of the type and kind reasonably adapted to its method of operation, of its experience or the experience of its members and of the data, statistics, or information collected or used by it in connection with the rates, rating plans, rating systems, underwriting rules, policy or bond forms, surveys, or inspections made or used by it, so that such records will be available at all reasonable times to enable the office to determine whether such organization, insurer, group, or association, and, in the case of an insurer or rating organization, every rate, rating plan, and rating system made or used by it, complies with the provisions of this part applicable to it. The maintenance of such records in the office of a licensed rating organization of which an insurer is a member or subscriber will be sufficient compliance with this section for any such insurer maintaining membership or subscribership in such organization, to the extent that the insurer uses the rates, rating plans, rating systems, or underwriting rules of such organization. Such records shall be maintained in an office within this state or shall be made available for examination or inspection within this state by the department at any time upon reasonable notice.

History.--s. 17, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 348, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1099, ch. 2003-261.

627.331  Recording and reporting of loss, expense, and claims experience; rating information.--

(1)  The commission may promulgate rules and statistical plans which shall thereafter be used by each insurer in the recording and reporting of its loss, expense, and claims experience, in order that the experience of all insurers may be made available at least annually in such form and detail as may be necessary to aid the office in determining whether the insurer's activities comply with the applicable standards of this code.

(2)  In promulgating such rules and plans, the commission shall give due consideration to the rating systems in use in this state and, in order that such rules and plans may be as uniform as is practicable among the several states, to the rules and to the form of the plans used for such rating systems in other states. No insurer shall be required to record or report its loss experience on a classification basis that is inconsistent with the rating system used by it, except for motor vehicle insurance as otherwise provided by law.

(3)  The office may designate one or more rating organizations or other agencies to assist it in gathering such experience and making compilations thereof; and such compilations shall be made available, subject to reasonable rules adopted by the commission, to insurers and rating organizations.

History.--s. 443, ch. 59-205; s. 19, ch. 67-9; ss. 13, 35, ch. 69-106; s. 1, ch. 70-75; s. 1, ch. 70-321; s. 1, ch. 70-439; s. 1, ch. 73-153; s. 1, ch. 74-320; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 27, ch. 77-468; ss. 2, 3, ch. 81-318; ss. 350, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 10, ch. 83-288; s. 1, ch. 84-352; s. 12, ch. 86-160; s. 22, ch. 89-360; s. 1, ch. 89-528; ss. 11, 35, ch. 90-119; s. 114, ch. 92-318; s. 1100, ch. 2003-261.

627.351  Insurance risk apportionment plans.--

(1)  MOTOR VEHICLE INSURANCE RISK APPORTIONMENT.--Agreements may be made among casualty and surety insurers with respect to the equitable apportionment among them of insurance which may be afforded applicants who are in good faith entitled to, but are unable to, procure such insurance through ordinary methods, and such insurers may agree among themselves on the use of reasonable rate modifications for such insurance. Such agreements and rate modifications shall be subject to the approval of the office. The office shall, after consultation with the insurers licensed to write automobile liability insurance in this state, adopt a reasonable plan or plans for the equitable apportionment among such insurers of applicants for such insurance who are in good faith entitled to, but are unable to, procure such insurance through ordinary methods, and, when such plan has been adopted, all such insurers shall subscribe thereto and shall participate therein. Such plan or plans shall include rules for classification of risks and rates therefor. The plan or plans shall make available noncancelable coverage as provided in s. 627.7275(2). Any insured placed with the plan shall be notified of the fact that insurance coverage is being afforded through the plan and not through the private market, and such notification shall be given in writing within 10 days of such placement. To assure that plan rates are made adequate to pay claims and expenses, insurers shall develop a means of obtaining loss and expense experience at least annually, and the plan shall file such experience, when available, with the office in sufficient detail to make a determination of rate adequacy. Prior to the filing of such experience with the office, the plan shall poll each member insurer as to the need for an actuary who is a member of the Casualty Actuarial Society and who is not affiliated with the plan's statistical agent to certify the plan's rate adequacy. If a majority of those insurers responding indicate a need for such certification, the plan shall include the certification as part of its experience filing. Such experience shall be filed with the office not more than 9 months following the end of the annual statistical period under review, together with a rate filing based on said experience. The office shall initiate proceedings to disapprove the rate and so notify the plan or shall finalize its review within 60 days of receipt of the filing. Notification to the plan by the office of its preliminary findings, which include a point of entry to the plan pursuant to chapter 120, shall toll the 60-day period during any such proceedings and subsequent judicial review. The rate shall be deemed approved if the office does not issue notice to the plan of its preliminary findings within 60 days of the filing. In addition to provisions for claims and expenses, the ratemaking formula shall include a factor for projected claims trending and 5 percent for contingencies. In no instance shall the formula include a renewal discount for plan insureds. However, the plan shall reunderwrite each insured on an annual basis, based upon all applicable rating factors approved by the office. Trend factors shall not be found to be inappropriate if not in excess of trend factors normally used in the development of residual market rates by the appropriate licensed rating organization. Each application for coverage in the plan shall include, in boldfaced 12-point type immediately preceding the applicant's signature, the following statement:

"THIS INSURANCE IS BEING AFFORDED THROUGH THE FLORIDA JOINT UNDERWRITING ASSOCIATION AND NOT THROUGH THE PRIVATE MARKET. PLEASE BE ADVISED THAT COVERAGE WITH A PRIVATE INSURER MAY BE AVAILABLE FROM ANOTHER AGENT AT A LOWER COST. AGENT AND COMPANY LISTINGS ARE AVAILABLE IN THE LOCAL YELLOW PAGES."

The plan shall annually report to the office the number and percentage of plan insureds who are not surcharged due to their driving record.

(2)  WINDSTORM INSURANCE RISK APPORTIONMENT.--

(a)  Agreements may be made among property insurers with respect to the equitable apportionment among them of insurance which may be afforded applicants who are in good faith entitled to, but are unable to procure, such insurance through ordinary methods; and such insurers may agree among themselves on the use of reasonable rate modifications for such insurance. Such agreements and rate modifications shall be subject to the applicable provisions of this chapter.

(b)  The department shall require all insurers holding a certificate of authority to transact property insurance on a direct basis in this state, other than joint underwriting associations and other entities formed pursuant to this section, to provide windstorm coverage to applicants from areas determined to be eligible pursuant to paragraph (c) who in good faith are entitled to, but are unable to procure, such coverage through ordinary means; or it shall adopt a reasonable plan or plans for the equitable apportionment or sharing among such insurers of windstorm coverage, which may include formation of an association for this purpose. As used in this subsection, the term "property insurance" means insurance on real or personal property, as defined in s. 624.604, including insurance for fire, industrial fire, allied lines, farmowners multiperil, homeowners' multiperil, commercial multiperil, and mobile homes, and including liability coverages on all such insurance, but excluding inland marine as defined in s. 624.607(3) and excluding vehicle insurance as defined in s. 624.605(1)(a) other than insurance on mobile homes used as permanent dwellings. The department shall adopt rules that provide a formula for the recovery and repayment of any deferred assessments.

1.  For the purpose of this section, properties eligible for such windstorm coverage are defined as dwellings, buildings, and other structures, including mobile homes which are used as dwellings and which are tied down in compliance with mobile home tie-down requirements prescribed by the Department of Highway Safety and Motor Vehicles pursuant to s. 320.8325, and the contents of all such properties. An applicant or policyholder is eligible for coverage only if an offer of coverage cannot be obtained by or for the applicant or policyholder from an admitted insurer at approved rates.

2.a.(I)  All insurers required to be members of such association shall participate in its writings, expenses, and losses. Surplus of the association shall be retained for the payment of claims and shall not be distributed to the member insurers. Such participation by member insurers shall be in the proportion that the net direct premiums of each member insurer written for property insurance in this state during the preceding calendar year bear to the aggregate net direct premiums for property insurance of all member insurers, as reduced by any credits for voluntary writings, in this state during the preceding calendar year. For the purposes of this subsection, the term "net direct premiums" means direct written premiums for property insurance, reduced by premium for liability coverage and for the following if included in allied lines: rain and hail on growing crops; livestock; association direct premiums booked; National Flood Insurance Program direct premiums; and similar deductions specifically authorized by the plan of operation and approved by the department. A member's participation shall begin on the first day of the calendar year following the year in which it is issued a certificate of authority to transact property insurance in the state and shall terminate 1 year after the end of the calendar year during which it no longer holds a certificate of authority to transact property insurance in the state. The commissioner, after review of annual statements, other reports, and any other statistics that the commissioner deems necessary, shall certify to the association the aggregate direct premiums written for property insurance in this state by all member insurers.

(II)  Effective July 1, 2002, the association shall operate subject to the supervision and approval of a board of governors who are the same individuals that have been appointed by the Treasurer to serve on the board of governors of the Citizens Property Insurance Corporation.

(III)  The plan of operation shall provide a formula whereby a company voluntarily providing windstorm coverage in affected areas will be relieved wholly or partially from apportionment of a regular assessment pursuant to sub-sub-subparagraph d.(I) or sub-sub-subparagraph d.(II).

(IV)  A company which is a member of a group of companies under common management may elect to have its credits applied on a group basis, and any company or group may elect to have its credits applied to any other company or group.

(V)  There shall be no credits or relief from apportionment to a company for emergency assessments collected from its policyholders under sub-sub-subparagraph d.(III).

(VI)  The plan of operation may also provide for the award of credits, for a period not to exceed 3 years, from a regular assessment pursuant to sub-sub-subparagraph d.(I) or sub-sub-subparagraph d.(II) as an incentive for taking policies out of the Residential Property and Casualty Joint Underwriting Association. In order to qualify for the exemption under this sub-sub-subparagraph, the take-out plan must provide that at least 40 percent of the policies removed from the Residential Property and Casualty Joint Underwriting Association cover risks located in Dade, Broward, and Palm Beach Counties or at least 30 percent of the policies so removed cover risks located in Dade, Broward, and Palm Beach Counties and an additional 50 percent of the policies so removed cover risks located in other coastal counties, and must also provide that no more than 15 percent of the policies so removed may exclude windstorm coverage. With the approval of the department, the association may waive these geographic criteria for a take-out plan that removes at least the lesser of 100,000 Residential Property and Casualty Joint Underwriting Association policies or 15 percent of the total number of Residential Property and Casualty Joint Underwriting Association policies, provided the governing board of the Residential Property and Casualty Joint Underwriting Association certifies that the take-out plan will materially reduce the Residential Property and Casualty Joint Underwriting Association's 100-year probable maximum loss from hurricanes. With the approval of the department, the board may extend such credits for an additional year if the insurer guarantees an additional year of renewability for all policies removed from the Residential Property and Casualty Joint Underwriting Association, or for 2 additional years if the insurer guarantees 2 additional years of renewability for all policies removed from the Residential Property and Casualty Joint Underwriting Association.

b.  Assessments to pay deficits in the association under this subparagraph shall be included as an appropriate factor in the making of rates as provided in s. 627.3512.

c.  The Legislature finds that the potential for unlimited deficit assessments under this subparagraph may induce insurers to attempt to reduce their writings in the voluntary market, and that such actions would worsen the availability problems that the association was created to remedy. It is the intent of the Legislature that insurers remain fully responsible for paying regular assessments and collecting emergency assessments for any deficits of the association; however, it is also the intent of the Legislature to provide a means by which assessment liabilities may be amortized over a period of years.

d.(I)  When the deficit incurred in a particular calendar year is 10 percent or less of the aggregate statewide direct written premium for property insurance for the prior calendar year for all member insurers, the association shall levy an assessment on member insurers in an amount equal to the deficit.

(II)  When the deficit incurred in a particular calendar year exceeds 10 percent of the aggregate statewide direct written premium for property insurance for the prior calendar year for all member insurers, the association shall levy an assessment on member insurers in an amount equal to the greater of 10 percent of the deficit or 10 percent of the aggregate statewide direct written premium for property insurance for the prior calendar year for member insurers. Any remaining deficit shall be recovered through emergency assessments under sub-sub-subparagraph (III).

(III)  Upon a determination by the board of directors that a deficit exceeds the amount that will be recovered through regular assessments on member insurers, pursuant to sub-sub-subparagraph (I) or sub-sub-subparagraph (II), the board shall levy, after verification by the department, emergency assessments to be collected by member insurers and by underwriting associations created pursuant to this section which write property insurance, upon issuance or renewal of property insurance policies other than National Flood Insurance policies in the year or years following levy of the regular assessments. The amount of the emergency assessment collected in a particular year shall be a uniform percentage of that year's direct written premium for property insurance for all member insurers and underwriting associations, excluding National Flood Insurance policy premiums, as annually determined by the board and verified by the department. The department shall verify the arithmetic calculations involved in the board's determination within 30 days after receipt of the information on which the determination was based. Notwithstanding any other provision of law, each member insurer and each underwriting association created pursuant to this section shall collect emergency assessments from its policyholders without such obligation being affected by any credit, limitation, exemption, or deferment. The emergency assessments so collected shall be transferred directly to the association on a periodic basis as determined by the association. The aggregate amount of emergency assessments levied under this sub-sub-subparagraph in any calendar year may not exceed the greater of 10 percent of the amount needed to cover the original deficit, plus interest, fees, commissions, required reserves, and other costs associated with financing of the original deficit, or 10 percent of the aggregate statewide direct written premium for property insurance written by member insurers and underwriting associations for the prior year, plus interest, fees, commissions, required reserves, and other costs associated with financing the original deficit. The board may pledge the proceeds of the emergency assessments under this sub-sub-subparagraph as the source of revenue for bonds, to retire any other debt incurred as a result of the deficit or events giving rise to the deficit, or in any other way that the board determines will efficiently recover the deficit. The emergency assessments under this sub-sub-subparagraph shall continue as long as any bonds issued or other indebtedness incurred with respect to a deficit for which the assessment was imposed remain outstanding, unless adequate provision has been made for the payment of such bonds or other indebtedness pursuant to the document governing such bonds or other indebtedness. Emergency assessments collected under this sub-sub-subparagraph are not part of an insurer's rates, are not premium, and are not subject to premium tax, fees, or commissions; however, failure to pay the emergency assessment shall be treated as failure to pay premium.

(IV)  Each member insurer's share of the total regular assessments under sub-sub-subparagraph (I) or sub-sub-subparagraph (II) shall be in the proportion that the insurer's net direct premium for property insurance in this state, for the year preceding the assessment bears to the aggregate statewide net direct premium for property insurance of all member insurers, as reduced by any credits for voluntary writings for that year.

(V)  If regular deficit assessments are made under sub-sub-subparagraph (I) or sub-sub-subparagraph (II), or by the Residential Property and Casualty Joint Underwriting Association under sub-subparagraph (6)(b)3.a. or sub-subparagraph (6)(b)3.b., the association shall levy upon the association's policyholders, as part of its next rate filing, or by a separate rate filing solely for this purpose, a market equalization surcharge in a percentage equal to the total amount of such regular assessments divided by the aggregate statewide direct written premium for property insurance for member insurers for the prior calendar year. Market equalization surcharges under this sub-sub-subparagraph are not considered premium and are not subject to commissions, fees, or premium taxes; however, failure to pay a market equalization surcharge shall be treated as failure to pay premium.

e.  The governing body of any unit of local government, any residents of which are insured under the plan, may issue bonds as defined in s. 125.013 or s. 166.101 to fund an assistance program, in conjunction with the association, for the purpose of defraying deficits of the association. In order to avoid needless and indiscriminate proliferation, duplication, and fragmentation of such assistance programs, any unit of local government, any residents of which are insured by the association, may provide for the payment of losses, regardless of whether or not the losses occurred within or outside of the territorial jurisdiction of the local government. Revenue bonds may not be issued until validated pursuant to chapter 75, unless a state of emergency is declared by executive order or proclamation of the Governor pursuant to s. 252.36 making such findings as are necessary to determine that it is in the best interests of, and necessary for, the protection of the public health, safety, and general welfare of residents of this state and the protection and preservation of the economic stability of insurers operating in this state, and declaring it an essential public purpose to permit certain municipalities or counties to issue bonds as will provide relief to claimants and policyholders of the association and insurers responsible for apportionment of plan losses. Any such unit of local government may enter into such contracts with the association and with any other entity created pursuant to this subsection as are necessary to carry out this paragraph. Any bonds issued under this sub-subparagraph shall be payable from and secured by moneys received by the association from assessments under this subparagraph, and assigned and pledged to or on behalf of the unit of local government for the benefit of the holders of such bonds. The funds, credit, property, and taxing power of the state or of the unit of local government shall not be pledged for the payment of such bonds. If any of the bonds remain unsold 60 days after issuance, the department shall require all insurers subject to assessment to purchase the bonds, which shall be treated as admitted assets; each insurer shall be required to purchase that percentage of the unsold portion of the bond issue that equals the insurer's relative share of assessment liability under this subsection. An insurer shall not be required to purchase the bonds to the extent that the department determines that the purchase would endanger or impair the solvency of the insurer. The authority granted by this sub-subparagraph is additional to any bonding authority granted by subparagraph 6.

3.  The plan shall also provide that any member with a surplus as to policyholders of $20 million or less writing 25 percent or more of its total countrywide property insurance premiums in this state may petition the department, within the first 90 days of each calendar year, to qualify as a limited apportionment company. The apportionment of such a member company in any calendar year for which it is qualified shall not exceed its gross participation, which shall not be affected by the formula for voluntary writings. In no event shall a limited apportionment company be required to participate in any apportionment of losses pursuant to sub-sub-subparagraph 2.d.(I) or sub-sub-subparagraph 2.d.(II) in the aggregate which exceeds $50 million after payment of available plan funds in any calendar year. However, a limited apportionment company shall collect from its policyholders any emergency assessment imposed under sub-sub-subparagraph 2.d.(III). The plan shall provide that, if the department determines that any regular assessment will result in an impairment of the surplus of a limited apportionment company, the department may direct that all or part of such assessment be deferred. However, there shall be no limitation or deferment of an emergency assessment to be collected from policyholders under sub-sub-subparagraph 2.d.(III).

4.  The plan shall provide for the deferment, in whole or in part, of a regular assessment of a member insurer under sub-sub-subparagraph 2.d.(I) or sub-sub-subparagraph 2.d.(II), but not for an emergency assessment collected from policyholders under sub-sub-subparagraph 2.d.(III), if, in the opinion of the commissioner, payment of such regular assessment would endanger or impair the solvency of the member insurer. In the event a regular assessment against a member insurer is deferred in whole or in part, the amount by which such assessment is deferred may be assessed against the other member insurers in a manner consistent with the basis for assessments set forth in sub-sub-subparagraph 2.d.(I) or sub-sub-subparagraph 2.d.(II).

5.a.  The plan of operation may include deductibles and rules for classification of risks and rate modifications consistent with the objective of providing and maintaining funds sufficient to pay catastrophe losses.

b.  The association may require arbitration of a rate filing under s. 627.062(6). It is the intent of the Legislature that the rates for coverage provided by the association be actuarially sound and not competitive with approved rates charged in the admitted voluntary market such that the association functions as a residual market mechanism to provide insurance only when the insurance cannot be procured in the voluntary market. The plan of operation shall provide a mechanism to assure that, beginning no later than January 1, 1999, the rates charged by the association for each line of business are reflective of approved rates in the voluntary market for hurricane coverage for each line of business in the various areas eligible for association coverage.

c.  The association shall provide for windstorm coverage on residential properties in limits up to $10 million for commercial lines residential risks and up to $1 million for personal lines residential risks. If coverage with the association is sought for a residential risk valued in excess of these limits, coverage shall be available to the risk up to the replacement cost or actual cash value of the property, at the option of the insured, if coverage for the risk cannot be located in the authorized market. The association must accept a commercial lines residential risk with limits above $10 million or a personal lines residential risk with limits above $1 million if coverage is not available in the authorized market. The association may write coverage above the limits specified in this subparagraph with or without facultative or other reinsurance coverage, as the association determines appropriate.

d.  The plan of operation must provide objective criteria and procedures, approved by the department, to be uniformly applied for all applicants in determining whether an individual risk is so hazardous as to be uninsurable. In making this determination and in establishing the criteria and procedures, the following shall be considered:

(I)  Whether the likelihood of a loss for the individual risk is substantially higher than for other risks of the same class; and

(II)  Whether the uncertainty associated with the individual risk is such that an appropriate premium cannot be determined.

The acceptance or rejection of a risk by the association pursuant to such criteria and procedures must be construed as the private placement of insurance, and the provisions of chapter 120 do not apply.

e.  If the risk accepts an offer of coverage through the market assistance program or through a mechanism established by the association, either before the policy is issued by the association or during the first 30 days of coverage by the association, and the producing agent who submitted the application to the association is not currently appointed by the insurer, the insurer shall:

(I)  Pay to the producing agent of record of the policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the association; or

(II)  Offer to allow the producing agent of record of the policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the association's usual and customary commission for the type of policy written.

If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with sub-sub-subparagraph (I). Subject to the provisions of s. 627.3517, the policies issued by the association must provide that if the association obtains an offer from an authorized insurer to cover the risk at its approved rates under either a standard policy including wind coverage or, if consistent with the insurer's underwriting rules as filed with the department, a basic policy including wind coverage, the risk is no longer eligible for coverage through the association. Upon termination of eligibility, the association shall provide written notice to the policyholder and agent of record stating that the association policy must be canceled as of 60 days after the date of the notice because of the offer of coverage from an authorized insurer. Other provisions of the insurance code relating to cancellation and notice of cancellation do not apply to actions under this sub-subparagraph.

f.  When the association enters into a contractual agreement for a take-out plan, the producing agent of record of the association policy is entitled to retain any unearned commission on the policy, and the insurer shall:

(I)  Pay to the producing agent of record of the association policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the association; or

(II)  Offer to allow the producing agent of record of the association policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the association's usual and customary commission for the type of policy written.

If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with sub-sub-subparagraph (I).

6.a.  The plan of operation may authorize the formation of a private nonprofit corporation, a private nonprofit unincorporated association, a partnership, a trust, a limited liability company, or a nonprofit mutual company which may be empowered, among other things, to borrow money by issuing bonds or by incurring other indebtedness and to accumulate reserves or funds to be used for the payment of insured catastrophe losses. The plan may authorize all actions necessary to facilitate the issuance of bonds, including the pledging of assessments or other revenues.

b.  Any entity created under this subsection, or any entity formed for the purposes of this subsection, may sue and be sued, may borrow money; issue bonds, notes, or debt instruments; pledge or sell assessments, market equalization surcharges and other surcharges, rights, premiums, contractual rights, projected recoveries from the Florida Hurricane Catastrophe Fund, other reinsurance recoverables, and other assets as security for such bonds, notes, or debt instruments; enter into any contracts or agreements necessary or proper to accomplish such borrowings; and take other actions necessary to carry out the purposes of this subsection. The association may issue bonds or incur other indebtedness, or have bonds issued on its behalf by a unit of local government pursuant to subparagraph (6)(g)2., in the absence of a hurricane or other weather-related event, upon a determination by the association subject to approval by the department that such action would enable it to efficiently meet the financial obligations of the association and that such financings are reasonably necessary to effectuate the requirements of this subsection. Any such entity may accumulate reserves and retain surpluses as of the end of any association year to provide for the payment of losses incurred by the association during that year or any future year. The association shall incorporate and continue the plan of operation and articles of agreement in effect on the effective date of chapter 76-96, Laws of Florida, to the extent that it is not inconsistent with chapter 76-96, and as subsequently modified consistent with chapter 76-96. The board of directors and officers currently serving shall continue to serve until their successors are duly qualified as provided under the plan. The assets and obligations of the plan in effect immediately prior to the effective date of chapter 76-96 shall be construed to be the assets and obligations of the successor plan created herein.

c.  In recognition of s. 10, Art. I of the State Constitution, prohibiting the impairment of obligations of contracts, it is the intent of the Legislature that no action be taken whose purpose is to impair any bond indenture or financing agreement or any revenue source committed by contract to such bond or other indebtedness issued or incurred by the association or any other entity created under this subsection.

7.  On such coverage, an agent's remuneration shall be that amount of money payable to the agent by the terms of his or her contract with the company with which the business is placed. However, no commission will be paid on that portion of the premium which is in excess of the standard premium of that company.

8.  Subject to approval by the department, the association may establish different eligibility requirements and operational procedures for any line or type of coverage for any specified eligible area or portion of an eligible area if the board determines that such changes to the eligibility requirements and operational procedures are justified due to the voluntary market being sufficiently stable and competitive in such area or for such line or type of coverage and that consumers who, in good faith, are unable to obtain insurance through the voluntary market through ordinary methods would continue to have access to coverage from the association. When coverage is sought in connection with a real property transfer, such requirements and procedures shall not provide for an effective date of coverage later than the date of the closing of the transfer as established by the transferor, the transferee, and, if applicable, the lender.

9.  Notwithstanding any other provision of law:

a.  The pledge or sale of, the lien upon, and the security interest in any rights, revenues, or other assets of the association created or purported to be created pursuant to any financing documents to secure any bonds or other indebtedness of the association shall be and remain valid and enforceable, notwithstanding the commencement of and during the continuation of, and after, any rehabilitation, insolvency, liquidation, bankruptcy, receivership, conservatorship, reorganization, or similar proceeding against the association under the laws of this state or any other applicable laws.

b.  No such proceeding shall relieve the association of its obligation, or otherwise affect its ability to perform its obligation, to continue to collect, or levy and collect, assessments, market equalization or other surcharges, projected recoveries from the Florida Hurricane Catastrophe Fund, reinsurance recoverables, or any other rights, revenues, or other assets of the association pledged.

c.  Each such pledge or sale of, lien upon, and security interest in, including the priority of such pledge, lien, or security interest, any such assessments, emergency assessments, market equalization or renewal surcharges, projected recoveries from the Florida Hurricane Catastrophe Fund, reinsurance recoverables, or other rights, revenues, or other assets which are collected, or levied and collected, after the commencement of and during the pendency of or after any such proceeding shall continue unaffected by such proceeding.

d.  As used in this subsection, the term "financing documents" means any agreement, instrument, or other document now existing or hereafter created evidencing any bonds or other indebtedness of the association or pursuant to which any such bonds or other indebtedness has been or may be issued and pursuant to which any rights, revenues, or other assets of the association are pledged or sold to secure the repayment of such bonds or indebtedness, together with the payment of interest on such bonds or such indebtedness, or the payment of any other obligation of the association related to such bonds or indebtedness.

e.  Any such pledge or sale of assessments, revenues, contract rights or other rights or assets of the association shall constitute a lien and security interest, or sale, as the case may be, that is immediately effective and attaches to such assessments, revenues, contract, or other rights or assets, whether or not imposed or collected at the time the pledge or sale is made. Any such pledge or sale is effective, valid, binding, and enforceable against the association or other entity making such pledge or sale, and valid and binding against and superior to any competing claims or obligations owed to any other person or entity, including policyholders in this state, asserting rights in any such assessments, revenues, contract, or other rights or assets to the extent set forth in and in accordance with the terms of the pledge or sale contained in the applicable financing documents, whether or not any such person or entity has notice of such pledge or sale and without the need for any physical delivery, recordation, filing, or other action.

f.  There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member insurer or its agents or employees, agents or employees of the association, members of the board of directors of the association, or the department or its representatives, for any action taken by them in the performance of their duties or responsibilities under this subsection. Such immunity does not apply to actions for breach of any contract or agreement pertaining to insurance, or any willful tort.

(c)  The provisions of paragraph (b) are applicable only with respect to:

1.  Those areas that were eligible for coverage under this subsection on April 9, 1993; or

2.  Any county or area as to which the department, after public hearing, finds that the following criteria exist:

a.  Due to the lack of windstorm insurance coverage in the county or area so affected, economic growth and development is being deterred or otherwise stifled in such county or area, mortgages are in default, and financial institutions are unable to make loans;

b.  The county or area so affected is enforcing the structural requirements of the Florida Building Code, as defined in s. 553.73, for new construction and has included adequate minimum floor elevation requirements for structures in areas subject to inundation; and

c.  Extending windstorm insurance coverage to such county or area is consistent with and will implement and further the policies and objectives set forth in applicable state laws, rules, and regulations governing coastal management, coastal construction, comprehensive planning, beach and shore preservation, barrier island preservation, coastal zone protection, and the Coastal Zone Protection Act of 1985.

The department shall consider reports of the Florida Building Commission when evaluating building code enforcement. Any time after the department has determined that the criteria referred to in this subparagraph do not exist with respect to any county or area of the state, it may, after a subsequent public hearing, declare that such county or area is no longer eligible for windstorm coverage through the plan.

(d)  For the purpose of evaluating whether the criteria of paragraph (c) are met, such criteria shall be applied as the situation would exist if policies had not been written by the Florida Residential Property and Casualty Joint Underwriting Association and property insurance for such policyholders was not available.

(e)1.  Notwithstanding the provisions of subparagraph (c)2. or paragraph (d), eligibility shall not be extended to any area that was not eligible on March 1, 1997, except that the department may act with respect to any petition on which a hearing was held prior to May 9, 1997.

2.  Notwithstanding the provisions of subparagraph 1., the following area is eligible for coverage under this subsection effective July 1, 2002: the area within Port Canaveral which is bordered on the south by the City of Cape Canaveral, bordered on the west by the Banana River, and bordered on the north by United States Government property.

(f)  As used in this subsection, the term "department" means the former Department of Insurance.

(3)  POLITICAL SUBDIVISION; CASUALTY INSURANCE RISK APPORTIONMENT.--

(a)  The office shall, after consultation with the casualty insurers licensed in this state, adopt a plan or plans for the equitable apportionment among them of casualty insurance coverage which may be afforded political subdivisions which are in good faith entitled to, but are unable to, procure such coverage through the voluntary market at standard rates or through a statutorily approved plan authorized by the office. The office may adopt a joint underwriting plan which shall provide for one or more designated insurers able and willing to provide policyholder and claims service, including the issuance of insurance policies, to act on behalf of all other insurers required to participate in the joint underwriting plan. Any joint underwriting plan adopted shall provide for the equitable apportionment of any profits realized, or of losses and expenses incurred, among participating insurers. The plan shall include, but shall not be limited to:

1.  Rules for the classification of risks and rates which reflect the past loss experience and prospective loss experience in different geographic areas.

2.  A rating plan which reasonably reflects the prior claims experience of the insureds.

3.  Excess coverage by insurers if the office, in its discretion, requires such coverage by insurers participating in the joint underwriting plan.

(b)  In the event an underwriting deficit exists at the end of any year the plan is in effect, each policyholder shall pay to the joint underwriting plan a premium contingency assessment not to exceed one-third of the premium payment paid by such policyholder for that year. The joint underwriting plan shall pay no further claims on any policy for which the policyholder fails to pay the premium contingency assessment.

(c)  Any deficit sustained under the plan shall first be recovered through a premium contingency assessment. Concurrently, the rates for insureds shall be adjusted for the next year so as to be actuarially sound in conformance with rules adopted by the commission.

(d)  If there is any remaining deficit under the plan after maximum collection of the premium contingency assessment, such deficit shall be recovered from the companies participating in the plan in the proportion that the net direct premiums of each such member written during the preceding calendar year bear to the aggregate net direct premiums written in this state by all members of the joint underwriting plan.

(e)  Upon adoption of a plan, all casualty insurers licensed in the state shall subscribe thereto and participate therein.

(4)  MEDICAL MALPRACTICE RISK APPORTIONMENT.--

(a)  The office shall, after consultation with insurers as set forth in paragraph (b), adopt a joint underwriting plan as set forth in paragraph (d).

(b)  Entities licensed to issue casualty insurance as defined in s. 624.605(1)(b), (k), and (q) and self-insurers authorized to issue medical malpractice insurance under s. 627.357 shall participate in the plan and shall be members of the Joint Underwriting Association.

(c)  The Joint Underwriting Association shall operate subject to the supervision and approval of a board of governors consisting of representatives of five of the insurers participating in the Joint Underwriting Association, an attorney to be named by The Florida Bar, a physician to be named by the Florida Medical Association, a dentist to be named by the Florida Dental Association, and a hospital representative to be named by the Florida Hospital Association. The Chief Financial Officer shall select the representatives of the five insurers. One insurer representative shall be selected from recommendations of the American Insurance Association. One insurer representative shall be selected from recommendations of the Alliance of American Insurers. One insurer representative shall be selected from recommendations of the National Association of Independent Insurers. Two insurer representatives shall be selected to represent insurers that are not affiliated with these associations. The board of governors shall choose, during the first meeting of the board after June 30 of each year, one of its members to serve as chair of the board and another member to serve as vice chair of the board. There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member insurer, self-insurer, or its agents or employees, the Joint Underwriting Association or its agents or employees, members of the board of governors, or the office or its representatives for any action taken by them in the performance of their powers and duties under this subsection.

(d)  The plan shall provide coverage for claims arising out of the rendering of, or failure to render, medical care or services and, in the case of health care facilities, coverage for bodily injury or property damage to the person or property of any patient arising out of the insured's activities, in appropriate policy forms for all health care providers as defined in paragraph (h). The plan shall include, but shall not be limited to:

1.  Classifications of risks and rates which reflect past and prospective loss and expense experience in different areas of practice and in different geographical areas. To assure that plan rates are adequate to pay claims and expenses, the Joint Underwriting Association shall develop a means of obtaining loss and expense experience; and the plan shall file such experience, when available, with the office in sufficient detail to make a determination of rate adequacy. Within 60 days after a rate filing, the office shall approve such rates or rate revisions as are fully supported by the filing. In addition to provisions for claims and expenses, the ratemaking formula may include a factor for projected claims trending and a margin for contingencies. The use of trend factors shall not be found to be inappropriate.

2.  A rating plan which reasonably recognizes the prior claims experience of insureds.

3.  Provisions as to rates for:

a.  Insureds who are retired or semiretired.

b.  The estates of deceased insureds.

c.  Part-time professionals.

4.  Protection in an amount not to exceed $250,000 per claim, $750,000 annual aggregate for health care providers other than hospitals and in an amount not to exceed $1.5 million per claim, $5 million annual aggregate for hospitals. Such coverage for health care providers other than hospitals shall be available as primary coverage and as excess coverage for the layer of coverage between the primary coverage and the total limits of $250,000 per claim, $750,000 annual aggregate. The plan shall also provide tail coverage in these amounts to insureds whose claims-made coverage with another insurer or trust has or will be terminated. Such tail coverage shall provide coverage for incidents that occurred during the claims-made policy period for which a claim is made after the policy period.

5.  A risk management program for insureds of the association. This program shall include, but not be limited to: investigation and analysis of frequency, severity, and causes of adverse or untoward medical injuries; development of measures to control these injuries; systematic reporting of medical incidents; investigation and analysis of patient complaints; and auditing of association members to assure implementation of this program. The plan may refuse to insure any insured who refuses or fails to comply with the risk management program implemented by the association. Prior to cancellation or refusal to renew an insured, the association shall provide the insured 60 days' notice of intent to cancel or nonrenew and shall further notify the insured of any action which must be taken to be in compliance with the risk management program.

(e)  In the event an underwriting deficit exists for any policy year the plan is in effect, any surplus which has accrued from previous years and is not projected within reasonable actuarial certainty to be needed for payment of claims in the year the surplus arose shall be used to offset the deficit to the extent available.

1.  As to remaining deficit, except those relating to deficit assessment coverage, each policyholder shall pay to the association a premium contingency assessment not to exceed one-third of the premium payment paid by such policyholder to the association for that policy year. The association shall pay no further claims on any policy for the policyholder who fails to pay the premium contingency assessment.

2.  If there is any remaining deficit under the plan after maximum collection of the premium contingency assessment, such deficit shall be recovered from the companies participating in the plan in the proportion that the net direct premiums of each such member written during the calendar year immediately preceding the end of the policy year for which there is a deficit assessment bear to the aggregate net direct premiums written in this state by all members of the association. The term "premiums" as used herein means premiums for the lines of insurance defined in s. 624.605(1)(b), (k), and (q), including premiums for such coverage issued under package policies.

(f)  The plan shall provide for one or more insurers able and willing to provide policy service through licensed resident agents and claims service on behalf of all other insurers participating in the plan. In the event no insurer is able and willing to provide such services, the Joint Underwriting Association is authorized to perform any and all such services.

(g)  All books, records, documents, or audits relating to the Joint Underwriting Association or its operation shall be open to public inspection, except that a claim file in the possession of the Joint Underwriting Association is confidential and exempt from the provisions of s. 119.07(1) during the processing of that claim. Any information contained in these files that identifies an injured person is confidential and exempt from the provisions of s. 119.07(1).

(h)  As used in this subsection:

1.  "Health care provider" means hospitals licensed under chapter 395; physicians licensed under chapter 458; osteopathic physicians licensed under chapter 459; podiatric physicians licensed under chapter 461; dentists licensed under chapter 466; chiropractic physicians licensed under chapter 460; naturopaths licensed under chapter 462; nurses licensed under part I of chapter 464; midwives licensed under chapter 467; clinical laboratories registered under chapter 483; physician assistants licensed under chapter 458 or chapter 459; physical therapists and physical therapist assistants licensed under chapter 486; health maintenance organizations certificated under part I of chapter 641; ambulatory surgical centers licensed under chapter 395; other medical facilities as defined in subparagraph 2.; blood banks, plasma centers, industrial clinics, and renal dialysis facilities; or professional associations, partnerships, corporations, joint ventures, or other associations for professional activity by health care providers.

2.  "Other medical facility" means a facility the primary purpose of which is to provide human medical diagnostic services or a facility providing nonsurgical human medical treatment, to which facility the patient is admitted and from which facility the patient is discharged within the same working day, and which facility is not part of a hospital. However, a facility existing for the primary purpose of performing terminations of pregnancy or an office maintained by a physician or dentist for the practice of medicine shall not be construed to be an "other medical facility."

3.  "Health care facility" means any hospital licensed under chapter 395, health maintenance organization certificated under part I of chapter 641, ambulatory surgical center licensed under chapter 395, or other medical facility as defined in subparagraph 2.

(i)  The manager of the plan or the manager's assistant is the agent for service of process for the plan.

(5)  PROPERTY AND CASUALTY INSURANCE RISK APPORTIONMENT.--The commission shall adopt by rule a joint underwriting plan to equitably apportion among insurers authorized in this state to write property insurance as defined in s. 624.604 or casualty insurance as defined in s. 624.605, the underwriting of one or more classes of property insurance or casualty insurance, except for the types of insurance that are included within property insurance or casualty insurance for which an equitable apportionment plan, assigned risk plan, or joint underwriting plan is authorized under s. 627.311 or subsection (1), subsection (2), subsection (3), subsection (4), or subsection (5) and except for risks eligible for flood insurance written through the federal flood insurance program to persons with risks eligible under subparagraph (a)1. and who are in good faith entitled to, but are unable to, obtain such property or casualty insurance coverage, including excess coverage, through the voluntary market. For purposes of this subsection, an adequate level of coverage means that coverage which is required by state law or by responsible or prudent business practices. The Joint Underwriting Association shall not be required to provide coverage for any type of risk for which there are no insurers providing similar coverage in this state. The office may designate one or more participating insurers who agree to provide policyholder and claims service, including the issuance of policies, on behalf of the participating insurers.

(a)  The plan shall provide:

1.  A means of establishing eligibility of a risk for obtaining insurance through the plan, which provides that:

a.  A risk shall be eligible for such property insurance or casualty insurance as is required by Florida law if the insurance is unavailable in the voluntary market, including the market assistance program and the surplus lines market.

b.  A commercial risk not eligible under sub-subparagraph a. shall be eligible for property or casualty insurance if:

(I)  The insurance is unavailable in the voluntary market, including the market assistance plan and the surplus lines market;

(II)  Failure to secure the insurance would substantially impair the ability of the entity to conduct its affairs; and

(III)  The risk is not determined by the Risk Underwriting Committee to be uninsurable.

c.  In the event the Federal Government terminates the Federal Crime Insurance Program established under 44 C.F.R. ss. 80-83, Florida commercial and residential risks previously insured under the federal program shall be eligible under the plan.

d.(I)  In the event a risk is eligible under this paragraph and in the event the market assistance plan receives a minimum of 100 applications for coverage within a 3-month period, or 200 applications for coverage within a 1-year period or less, for a given class of risk contained in the classification system defined in the plan of operation of the Joint Underwriting Association, and unless the market assistance plan provides a quotation for at least 80 percent of such applicants, such classification shall immediately be eligible for coverage in the Joint Underwriting Association.

(II)  Any market assistance plan application which is rejected because an individual risk is so hazardous as to be practically uninsurable, considering whether the likelihood of a loss for such a risk is substantially higher than for other risks of the same class due to individual risk characteristics, prior loss experience, unwillingness to cooperate with a prior insurer, physical characteristics and physical location shall not be included in the minimum percentage calculation provided above. In the event that there is any legal or administrative challenge to a determination by the office that the conditions of this subparagraph have been met for eligibility for coverage in the Joint Underwriting Association for a given classification, any eligible risk may obtain coverage during the pendency of any such challenge.

e.  In order to qualify as a quotation for the purpose of meeting the minimum percentage calculation in this subparagraph, the quoted premium must meet the following criteria:

(I)  In the case of an admitted carrier, the quoted premium must not exceed the premium available for a given classification currently in use by the Joint Underwriting Association or the premium developed by using the rates and rating plans on file with the office by the quoting insurer, whichever is greater.

(II)  In the case of an authorized surplus lines insurer, the quoted premium must not exceed the premium available for a given classification currently in use by the Joint Underwriting Association by more than 25 percent, after consideration of any individual risk surcharge or credit.

f.  Any agent who falsely certifies the unavailability of coverage as provided by sub-subparagraphs a. and b., is subject to the penalties provided in s. 626.611.

2.  A means for the equitable apportionment of profits or losses and expenses among participating insurers.

3.  Rules for the classification of risks and rates which reflect the past and prospective loss experience.

4.  A rating plan which reasonably reflects the prior claims experience of the insureds. Such rating plan shall include at least two levels of rates for risks that have favorable loss experience and risks that have unfavorable loss experience, as established by the plan.

5.  Reasonable limits to available amounts of insurance. Such limits may not be less than the amounts of insurance required of eligible risks by Florida law.

6.  Risk management requirements for insurance where such requirements are reasonable and are expected to reduce losses.

7.  Deductibles as may be necessary to meet the needs of insureds.

8.  Policy forms which are consistent with the forms in use by the majority of the insurers providing coverage in the voluntary market for the coverage requested by the applicant.

9.  A means to remove risks from the plan once such risks no longer meet the eligibility requirements of this paragraph. For this purpose, the plan shall include the following requirements: At each 6-month interval after the activation of any class of insureds, the board of governors or its designated committee shall review the number of applications to the market assistance plan for that class. If, based on these latest numbers, at least 90 percent of such applications have been provided a quotation, the Joint Underwriting Association shall cease underwriting new applications for such class within 30 days, and notification of this decision shall be sent to the office, the major agents' associations, and the board of directors of the market assistance plan. A quotation for the purpose of this subparagraph shall meet the same criteria for a quotation as provided in sub-subparagraph 1.e. All policies which were previously written for that class shall continue in force until their normal expiration date, at which time, subject to the required timely notification of nonrenewal by the Joint Underwriting Association, the insured may then elect to reapply to the Joint Underwriting Association according to the requirements of eligibility. If, upon reapplication, those previously insured Joint Underwriting Association risks meet the eligibility requirements, the Joint Underwriting Association shall provide the coverage requested.

10.  A means for providing credits to insurers against any deficit assessment levied pursuant to paragraph (c), for risks voluntarily written through the market assistance plan by such insurers.

11.  That the Joint Underwriting Association shall operate subject to the supervision and approval of a board of governors consisting of 13 individuals appointed by the Chief Financial Officer, and shall have an executive or underwriting committee. At least four of the members shall be representatives of insurance trade associations as follows: one member from the American Insurance Association, one member from the Alliance of American Insurers, one member from the National Association of Independent Insurers, and one member from an unaffiliated insurer writing coverage on a national basis. Two representatives shall be from two of the statewide agents' associations. Each board member shall be appointed to serve for 2-year terms beginning on a date designated by the plan and shall serve at the pleasure of the Chief Financial Officer. Members may be reappointed for subsequent terms.

(b)  Rates used by the Joint Underwriting Association shall be actuarially sound. To the extent applicable, the rate standards set forth in s. 627.062 shall be considered by the office in establishing rates to be used by the joint underwriting plan. The initial rate level shall be determined using the rates, rules, rating plans, and classifications contained in the most current Insurance Services Office (ISO) filing with the office or the filing of other licensed rating organizations with an additional increment of 25 percent of premium. For any type of coverage or classification which lends itself to manual rating for which the Insurance Services Office or another licensed rating organization does not file or publish a rate, the Joint Underwriting Association shall file and use an initial rate based on the average current market rate. The initial rate level for the rate plan shall also be subject to an experience and schedule rating plan which may produce a maximum of 25 percent debits or credits. For any risk which does not lend itself to manual rating and for which no rate has been promulgated under the rate plan, the board shall develop and file with the office, subject to its approval, appropriate criteria and factors for rating the individual risk. Such criteria and factors shall include, but not be limited to, loss rating plans, composite rating plans, and unique and unusual risk rating plans. The initial rates required under this paragraph shall be adjusted in conformity with future filings by the Insurance Services Office with the office and shall remain in effect until such time as the Joint Underwriting Association has sufficient data as to independently justify an actuarially sound change in such rates.

(c)1.  In the event an underwriting deficit exists for any policy year the plan is in effect, any surplus which has accrued from previous years and is not projected within reasonable actuarial certainty to be needed for payment for claims in the year the surplus arose shall be used to offset the deficit to the extent available.

2.  As to any remaining deficit, the board of governors of the Joint Underwriting Association shall levy and collect an assessment in an amount sufficient to offset such deficit. Such assessment shall be levied against the insurers participating in the plan during the year giving rise to the assessment. Any assessments against insurers for the lines of property and casualty insurance issued to commercial risks shall be recovered from the participating insurers in the proportion that the net direct premium of each insurer for commercial risks written during the preceding calendar year bears to the aggregate net direct premium written for commercial risks by all members of the plan for the lines of insurance included in the plan. Any assessments against insurers for the lines of property and casualty insurance issued to personal risks eligible under sub-subparagraph (a)1.a. or sub-subparagraph (a)1.c. shall be recovered from the participating insurers in the proportion that the net direct premium of each insurer for personal risks written during the preceding calendar year bears to the aggregate net direct premium written for personal risks by all members of the plan for the lines of insurance included in the plan.

3.  The board shall take all reasonable and prudent steps necessary to collect the amount of assessment due from each participating insurer and policyholder, including, if prudent, filing suit to collect such assessment. If the board is unable to collect an assessment from any insurer, the uncollected assessments shall be levied as an additional assessment against the participating insurers and any participating insurer required to pay an additional assessment as a result of such failure to pay shall have a cause of action against such nonpaying insurer.

4.  Any funds or entitlements that the state may be eligible to receive by virtue of the Federal Government's termination of the Federal Crime Insurance Program referenced in sub-subparagraph (a)1.c. may be used under the plan to offset any subsequent underwriting deficits that may occur from risks previously insured with the Federal Crime Insurance Program.

5.  Assessments shall be included as an appropriate factor in the making of rates as provided in s. 627.3512.

6.a.  The Legislature finds that the potential for unlimited assessments under this paragraph may induce insurers to attempt to reduce their writings in the voluntary market, and that such actions would worsen the availability problems that the association was created to remedy. It is the intent of the Legislature that insurers remain fully responsible for covering any deficits of the association; however, it is also the intent of the Legislature to provide a means by which assessment liabilities may be amortized over a period of years.

b.  The total amount of deficit assessments under this paragraph with respect to any year may not exceed 10 percent of the statewide total gross written premium for all insurers for the coverages referred to in the introductory language of this subsection for the prior year, except that if the deficit with respect to any plan year exceeds such amount and bonds are issued under sub-subparagraph c. to defray the deficit, the total amount of assessments with respect to such deficit may not in any year exceed 10 percent of the deficit, or such lesser percentage as is sufficient to retire the bonds as determined by the board, and shall continue annually until the bonds are retired.

c.  The governing body of any unit of local government, any residents or businesses of which are insured by the association, may issue bonds as defined in s. 125.013 or s. 166.101 from time to time to fund an assistance program, in conjunction with the association, for the purpose of defraying deficits of the association. Revenue bonds may not be issued until validated pursuant to chapter 75, unless a state of emergency is declared by executive order or proclamation of the Governor pursuant to s. 252.36 making such findings as are necessary to determine that it is in the best interests of, and necessary for, the protection of the public health, safety, and general welfare of residents of this state and the protection and preservation of the economic stability of insurers operating in this state, and declaring it an essential public purpose to permit certain municipalities or counties to issue such bonds as will provide relief to claimants and policyholders of the joint underwriting association and insurers responsible for apportionment of association losses. The unit of local government shall enter into such contracts with the association as are necessary to carry out this paragraph. Any bonds issued under this sub-subparagraph shall be payable from and secured by moneys received by the association from assessments under this paragraph, and assigned and pledged to or on behalf of the unit of local government for the benefit of the holders of such bonds. The funds, credit, property, and taxing power of the state or of the unit of local government shall not be pledged for the payment of such bonds. If any of the bonds remain unsold 60 days after issuance, the office shall require all insurers subject to assessment to purchase the bonds, which shall be treated as admitted assets; each insurer shall be required to purchase that percentage of the unsold portion of the bond issue that equals the insurer's relative share of assessment liability under this subsection. An insurer shall not be required to purchase the bonds to the extent that the office determines that the purchase would endanger or impair the solvency of the insurer.

7.  The plan shall provide for the deferment, in whole or in part, of the assessment of an insurer if the office finds that payment of the assessment would endanger or impair the solvency of the insurer. In the event an assessment against an insurer is deferred in whole or in part, the amount by which such assessment is deferred may be assessed against the other member insurers in a manner consistent with the basis for assessments set forth in subparagraph 2.

(d)  Upon adoption of the plan, all insurers authorized in this state to underwrite property or casualty insurance shall participate in the plan.

(e)  A Risk Underwriting Committee of the Joint Underwriting Association composed of three members experienced in evaluating insurance risks is created to review risks rejected by the voluntary market for which application is made for insurance through the joint underwriting plan. The committee shall consist of a representative of the market assistance plan created under s. 627.3515, a member selected by the insurers participating in the Joint Underwriting Association, and a member named by the Chief Financial Officer. The Risk Underwriting Committee shall appoint such advisory committees as are provided for in the plan and are necessary to conduct its functions. The salaries and expenses of the members of the Risk Underwriting Committee and its advisory committees shall be paid by the joint underwriting plan. The plan approved by the office shall establish criteria and procedures for use by the Risk Underwriting Committee for determining whether an individual risk is so hazardous as to be uninsurable. In making this determination and in establishing the criteria and procedures, the following shall be considered:

1.  Whether the likelihood of a loss for the individual risk is substantially higher than for other risks of the same class; and

2.  Whether the uncertainty associated with the individual risk is such that an appropriate premium cannot be determined.

The acceptance or rejection of a risk by the underwriting committee shall be construed as the private placement of insurance, and the provisions of chapter 120 shall not apply.

(f)  There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member insurer or its agents or employees, the Florida Property and Casualty Joint Underwriting Association or its agents or employees, members of the board of governors, the Chief Financial Officer, or the office or its representatives for any action taken by them in the performance of their duties under this subsection. Such immunity does not apply to actions for breach of any contract or agreement pertaining to insurance, or any other willful tort.

(6)  CITIZENS PROPERTY INSURANCE CORPORATION.--

(a)1.  The Legislature finds that actual and threatened catastrophic losses to property in this state from hurricanes have caused insurers to be unwilling or unable to provide property insurance coverage to the extent sought and needed. It is in the public interest and a public purpose to assist in assuring that property in the state is insured so as to facilitate the remediation, reconstruction, and replacement of damaged or destroyed property in order to reduce or avoid the negative effects otherwise resulting to the public health, safety, and welfare; to the economy of the state; and to the revenues of the state and local governments needed to provide for the public welfare. It is necessary, therefore, to provide property insurance to applicants who are in good faith entitled to procure insurance through the voluntary market but are unable to do so. The Legislature intends by this subsection that property insurance be provided and that it continues, as long as necessary, through an entity organized to achieve efficiencies and economies, all toward the achievement of the foregoing public purposes. Because it is essential for the corporation to have the maximum financial resources to pay claims following a catastrophic hurricane, it is the intent of the Legislature that the income of the corporation be exempt from federal income taxation and that interest on the debt obligations issued by the corporation be exempt from federal income taxation.

2.  The Residential Property and Casualty Joint Underwriting Association originally created by this statute shall be known, as of July 1, 2002, as the Citizens Property Insurance Corporation. The corporation shall provide insurance for residential and commercial property, for applicants who are in good faith entitled, but are unable, to procure insurance through the voluntary market. The corporation shall operate pursuant to a plan of operation approved by order of the office. The plan is subject to continuous review by the office. The office may, by order, withdraw approval of all or part of a plan if the office determines that conditions have changed since approval was granted and that the purposes of the plan require changes in the plan. For the purposes of this subsection, residential coverage includes both personal lines residential coverage, which consists of the type of coverage provided by homeowner's, mobile home owner's, dwelling, tenant's, condominium unit owner's, and similar policies, and commercial lines residential coverage, which consists of the type of coverage provided by condominium association, apartment building, and similar policies.

(b)1.  All insurers authorized to write one or more subject lines of business in this state are subject to assessment by the corporation and, for the purposes of this subsection, are referred to collectively as "assessable insurers." Insurers writing one or more subject lines of business in this state pursuant to part VIII of chapter 626 are not assessable insurers, but insureds who procure one or more subject lines of business in this state pursuant to part VIII of chapter 626 are subject to assessment by the corporation and are referred to collectively as "assessable insureds." An authorized insurer's assessment liability shall begin on the first day of the calendar year following the year in which the insurer was issued a certificate of authority to transact insurance for subject lines of business in this state and shall terminate 1 year after the end of the first calendar year during which the insurer no longer holds a certificate of authority to transact insurance for subject lines of business in this state.

2.a.  All revenues, assets, liabilities, losses, and expenses of the corporation shall be divided into three separate accounts as follows:

(I)  A personal lines account for personal residential policies issued by the corporation or issued by the Residential Property and Casualty Joint Underwriting Association and renewed by the corporation that provide comprehensive, multiperil coverage on risks that are not located in areas eligible for coverage in the Florida Windstorm Underwriting Association as those areas were defined on January 1, 2002, and for such policies that do not provide coverage for the peril of wind on risks that are located in such areas;

(II)  A commercial lines account for commercial residential policies issued by the corporation or issued by the Residential Property and Casualty Joint Underwriting Association and renewed by the corporation that provide coverage for basic property perils on risks that are not located in areas eligible for coverage in the Florida Windstorm Underwriting Association as those areas were defined on January 1, 2002, and for such policies that do not provide coverage for the peril of wind on risks that are located in such areas; and

(III)  A high-risk account for personal residential policies and commercial residential and commercial nonresidential property policies issued by the corporation or transferred to the corporation that provide coverage for the peril of wind on risks that are located in areas eligible for coverage in the Florida Windstorm Underwriting Association as those areas were defined on January 1, 2002. The high-risk account must also include quota share primary insurance under subparagraph (c)2. The area eligible for coverage under the high-risk account also includes the area within Port Canaveral, which is bordered on the south by the City of Cape Canaveral, bordered on the west by the Banana River, and bordered on the north by Federal Government property. The office may remove territory from the area eligible for wind-only and quota share coverage if, after a public hearing, the office finds that authorized insurers in the voluntary market are willing and able to write sufficient amounts of personal and commercial residential coverage for all perils in the territory, including coverage for the peril of wind, such that risks covered by wind-only policies in the removed territory could be issued a policy by the corporation in either the personal lines or commercial lines account without a significant increase in the corporation's probable maximum loss in such account. Removal of territory from the area eligible for wind-only or quota share coverage does not alter the assignment of wind coverage written in such areas to the high-risk account.

b.  The three separate accounts must be maintained as long as financing obligations entered into by the Florida Windstorm Underwriting Association or Residential Property and Casualty Joint Underwriting Association are outstanding, in accordance with the terms of the corresponding financing documents. When the financing obligations are no longer outstanding, in accordance with the terms of the corresponding financing documents, the corporation may use a single account for all revenues, assets, liabilities, losses, and expenses of the corporation.

c.  Creditors of the Residential Property and Casualty Joint Underwriting Association shall have a claim against, and recourse to, the accounts referred to in sub-sub-subparagraphs a.(I) and (II) and shall have no claim against, or recourse to, the account referred to in sub-sub-subparagraph a.(III). Creditors of the Florida Windstorm Underwriting Association shall have a claim against, and recourse to, the account referred to in sub-sub-subparagraph a.(III) and shall have no claim against, or recourse to, the accounts referred to in sub-sub-subparagraphs a.(I) and (II).

d.  Revenues, assets, liabilities, losses, and expenses not attributable to particular accounts shall be prorated among the accounts.

e.  The Legislature finds that the revenues of the corporation are revenues that are necessary to meet the requirements set forth in documents authorizing the issuance of bonds under this subsection.

f.  No part of the income of the corporation may inure to the benefit of any private person.

3.  With respect to a deficit in an account:

a.  When the deficit incurred in a particular calendar year is not greater than 10 percent of the aggregate statewide direct written premium for the subject lines of business for the prior calendar year, the entire deficit shall be recovered through regular assessments of assessable insurers under paragraph (g) and assessable insureds.

b.  When the deficit incurred in a particular calendar year exceeds 10 percent of the aggregate statewide direct written premium for the subject lines of business for the prior calendar year, the corporation shall levy regular assessments on assessable insurers under paragraph (g) and on assessable insureds in an amount equal to the greater of 10 percent of the deficit or 10 percent of the aggregate statewide direct written premium for the subject lines of business for the prior calendar year. Any remaining deficit shall be recovered through emergency assessments under sub-subparagraph d.

c.  Each assessable insurer's share of the amount being assessed under sub-subparagraph a. or sub-subparagraph b. shall be in the proportion that the assessable insurer's direct written premium for the subject lines of business for the year preceding the assessment bears to the aggregate statewide direct written premium for the subject lines of business for that year. The assessment percentage applicable to each assessable insured is the ratio of the amount being assessed under sub-subparagraph a. or sub-subparagraph b. to the aggregate statewide direct written premium for the subject lines of business for the prior year. Assessments levied by the corporation on assessable insurers under sub-subparagraphs a. and b. shall be paid as required by the corporation's plan of operation and paragraph (g). Assessments levied by the corporation on assessable insureds under sub-subparagraphs a. and b. shall be collected by the surplus lines agent at the time the surplus lines agent collects the surplus lines tax required by s. 626.932 and shall be paid to the Florida Surplus Lines Service Office at the time the surplus lines agent pays the surplus lines tax to the Florida Surplus Lines Service Office. Upon receipt of regular assessments from surplus lines agents, the Florida Surplus Lines Service Office shall transfer the assessments directly to the corporation as determined by the corporation.

d.  Upon a determination by the board of governors that a deficit in an account exceeds the amount that will be recovered through regular assessments under sub-subparagraph a. or sub-subparagraph b., the board shall levy, after verification by the office, emergency assessments, for as many years as necessary to cover the deficits, to be collected by assessable insurers and the corporation and collected from assessable insureds upon issuance or renewal of policies for subject lines of business, excluding National Flood Insurance policies. The amount of the emergency assessment collected in a particular year shall be a uniform percentage of that year's direct written premium for subject lines of business and all accounts of the corporation, excluding National Flood Insurance Program policy premiums, as annually determined by the board and verified by the office. The office shall verify the arithmetic calculations involved in the board's determination within 30 days after receipt of the information on which the determination was based. Notwithstanding any other provision of law, the corporation and each assessable insurer that writes subject lines of business shall collect emergency assessments from its policyholders without such obligation being affected by any credit, limitation, exemption, or deferment. Emergency assessments levied by the corporation on assessable insureds shall be collected by the surplus lines agent at the time the surplus lines agent collects the surplus lines tax required by s. 626.932 and shall be paid to the Florida Surplus Lines Service Office at the time the surplus lines agent pays the surplus lines tax to the Florida Surplus Lines Service Office. The emergency assessments so collected shall be transferred directly to the corporation on a periodic basis as determined by the corporation and shall be held by the corporation solely in the applicable account. The aggregate amount of emergency assessments levied for an account under this sub-subparagraph in any calendar year may not exceed the greater of 10 percent of the amount needed to cover the original deficit, plus interest, fees, commissions, required reserves, and other costs associated with financing of the original deficit, or 10 percent of the aggregate statewide direct written premium for subject lines of business and for all accounts of the corporation for the prior year, plus interest, fees, commissions, required reserves, and other costs associated with financing the original deficit.

e.  The corporation may pledge the proceeds of assessments, projected recoveries from the Florida Hurricane Catastrophe Fund, other insurance and reinsurance recoverables, market equalization surcharges and other surcharges, and other funds available to the corporation as the source of revenue for and to secure bonds issued under paragraph (g), bonds or other indebtedness issued under subparagraph (c)3., or lines of credit or other financing mechanisms issued or created under this subsection, or to retire any other debt incurred as a result of deficits or events giving rise to deficits, or in any other way that the board determines will efficiently recover such deficits. The purpose of the lines of credit or other financing mechanisms is to provide additional resources to assist the corporation in covering claims and expenses attributable to a catastrophe. As used in this subsection, the term "assessments" includes regular assessments under sub-subparagraph a., sub-subparagraph b., or subparagraph (g)1. and emergency assessments under sub-subparagraph d. Emergency assessments collected under sub-subparagraph d. are not part of an insurer's rates, are not premium, and are not subject to premium tax, fees, or commissions; however, failure to pay the emergency assessment shall be treated as failure to pay premium. The emergency assessments under sub-subparagraph d. shall continue as long as any bonds issued or other indebtedness incurred with respect to a deficit for which the assessment was imposed remain outstanding, unless adequate provision has been made for the payment of such bonds or other indebtedness pursuant to the documents governing such bonds or other indebtedness.

f.  As used in this subsection, the term "subject lines of business" means insurance written by assessable insurers or procured by assessable insureds on real or personal property, as defined in s. 624.604, including insurance for fire, industrial fire, allied lines, farmowners multiperil, homeowners multiperil, commercial multiperil, and mobile homes, and including liability coverage on all such insurance, but excluding inland marine as defined in s. 624.607(3) and excluding vehicle insurance as defined in s. 624.605(1) other than insurance on mobile homes used as permanent dwellings.

g.  The Florida Surplus Lines Service Office shall determine annually the aggregate statewide written premium in subject lines of business procured by assessable insureds and shall report that information to the corporation in a form and at a time the corporation specifies to ensure that the corporation can meet the requirements of this subsection and the corporation's financing obligations.

h.  The Florida Surplus Lines Service Office shall verify the proper application by surplus lines agents of assessment percentages for regular assessments and emergency assessments levied under this subparagraph on assessable insureds and shall assist the corporation in ensuring the accurate, timely collection and payment of assessments by surplus lines agents as required by the corporation.

(c)  The plan of operation of the corporation:

1.  Must provide for adoption of residential property and casualty insurance policy forms and commercial residential and nonresidential property insurance forms, which forms must be approved by the office prior to use. The corporation shall adopt the following policy forms:

a.  Standard personal lines policy forms that are comprehensive multiperil policies providing full coverage of a residential property equivalent to the coverage provided in the private insurance market under an HO-3, HO-4, or HO-6 policy.

b.  Basic personal lines policy forms that are policies similar to an HO-8 policy or a dwelling fire policy that provide coverage meeting the requirements of the secondary mortgage market, but which coverage is more limited than the coverage under a standard policy.

c.  Commercial lines residential policy forms that are generally similar to the basic perils of full coverage obtainable for commercial residential structures in the admitted voluntary market.

d.  Personal lines and commercial lines residential property insurance forms that cover the peril of wind only. The forms are applicable only to residential properties located in areas eligible for coverage under the high-risk account referred to in sub-subparagraph (b)2.a.

e.  Commercial lines nonresidential property insurance forms that cover the peril of wind only. The forms are applicable only to nonresidential properties located in areas eligible for coverage under the high-risk account referred to in sub-subparagraph (b)2.a.

2.a.  Must provide that the corporation adopt a program in which the corporation and authorized insurers enter into quota share primary insurance agreements for hurricane coverage, as defined in s. 627.4025(2)(a), for eligible risks, and adopt property insurance forms for eligible risks which cover the peril of wind only. As used in this subsection, the term:

(I)  "Quota share primary insurance" means an arrangement in which the primary hurricane coverage of an eligible risk is provided in specified percentages by the corporation and an authorized insurer. The corporation and authorized insurer are each solely responsible for a specified percentage of hurricane coverage of an eligible risk as set forth in a quota share primary insurance agreement between the corporation and an authorized insurer and the insurance contract. The responsibility of the corporation or authorized insurer to pay its specified percentage of hurricane losses of an eligible risk, as set forth in the quota share primary insurance agreement, may not be altered by the inability of the other party to the agreement to pay its specified percentage of hurricane losses. Eligible risks that are provided hurricane coverage through a quota share primary insurance arrangement must be provided policy forms that set forth the obligations of the corporation and authorized insurer under the arrangement, clearly specify the percentages of quota share primary insurance provided by the corporation and authorized insurer, and conspicuously and clearly state that neither the authorized insurer nor the corporation may be held responsible beyond its specified percentage of coverage of hurricane losses.

(II)  "Eligible risks" means personal lines residential and commercial lines residential risks that meet the underwriting criteria of the corporation and are located in areas that were eligible for coverage by the Florida Windstorm Underwriting Association on January 1, 2002.

b.  The corporation may enter into quota share primary insurance agreements with authorized insurers at corporation coverage levels of 90 percent and 50 percent.

c.  If the corporation determines that additional coverage levels are necessary to maximize participation in quota share primary insurance agreements by authorized insurers, the corporation may establish additional coverage levels. However, the corporation's quota share primary insurance coverage level may not exceed 90 percent.

d.  Any quota share primary insurance agreement entered into between an authorized insurer and the corporation must provide for a uniform specified percentage of coverage of hurricane losses, by county or territory as set forth by the corporation board, for all eligible risks of the authorized insurer covered under the quota share primary insurance agreement.

e.  Any quota share primary insurance agreement entered into between an authorized insurer and the corporation is subject to review and approval by the office. However, such agreement shall be authorized only as to insurance contracts entered into between an authorized insurer and an insured who is already insured by the corporation for wind coverage.

f.  For all eligible risks covered under quota share primary insurance agreements, the exposure and coverage levels for both the corporation and authorized insurers shall be reported by the corporation to the Florida Hurricane Catastrophe Fund. For all policies of eligible risks covered under quota share primary insurance agreements, the corporation and the authorized insurer shall maintain complete and accurate records for the purpose of exposure and loss reimbursement audits as required by Florida Hurricane Catastrophe Fund rules. The corporation and the authorized insurer shall each maintain duplicate copies of policy declaration pages and supporting claims documents.

g.  The corporation board shall establish in its plan of operation standards for quota share agreements which ensure that there is no discriminatory application among insurers as to the terms of quota share agreements, pricing of quota share agreements, incentive provisions if any, and consideration paid for servicing policies or adjusting claims.

h.  The quota share primary insurance agreement between the corporation and an authorized insurer must set forth the specific terms under which coverage is provided, including, but not limited to, the sale and servicing of policies issued under the agreement by the insurance agent of the authorized insurer producing the business, the reporting of information concerning eligible risks, the payment of premium to the corporation, and arrangements for the adjustment and payment of hurricane claims incurred on eligible risks by the claims adjuster and personnel of the authorized insurer. Entering into a quota sharing insurance agreement between the corporation and an authorized insurer shall be voluntary and at the discretion of the authorized insurer.

3.  May provide that the corporation may employ or otherwise contract with individuals or other entities to provide administrative or professional services that may be appropriate to effectuate the plan. The corporation shall have the power to borrow funds, by issuing bonds or by incurring other indebtedness, and shall have other powers reasonably necessary to effectuate the requirements of this subsection. The corporation may, but is not required to, seek judicial validation of its bonds or other indebtedness under chapter 75. The corporation may issue bonds or incur other indebtedness, or have bonds issued on its behalf by a unit of local government pursuant to subparagraph (g)2., in the absence of a hurricane or other weather-related event, upon a determination by the corporation, subject to approval by the office, that such action would enable it to efficiently meet the financial obligations of the corporation and that such financings are reasonably necessary to effectuate the requirements of this subsection. The corporation is authorized to take all actions needed to facilitate tax-free status for any such bonds or indebtedness, including formation of trusts or other affiliated entities. The corporation shall have the authority to pledge assessments, projected recoveries from the Florida Hurricane Catastrophe Fund, other reinsurance recoverables, market equalization and other surcharges, and other funds available to the corporation as security for bonds or other indebtedness. In recognition of s. 10, Art. I of the State Constitution, prohibiting the impairment of obligations of contracts, it is the intent of the Legislature that no action be taken whose purpose is to impair any bond indenture or financing agreement or any revenue source committed by contract to such bond or other indebtedness.

4.  Must require that the corporation operate subject to the supervision and approval of a board of governors consisting of 7 individuals who are residents of this state, from different geographical areas of this state, appointed by the Chief Financial Officer. The Chief Financial Officer shall designate one of the appointees as chair. All board members serve at the pleasure of the Chief Financial Officer. All board members, including the chair, must be appointed to serve for 3-year terms beginning annually on a date designated by the plan. Any board vacancy shall be filled for the unexpired term by the Chief Financial Officer. The Chief Financial Officer shall appoint a technical advisory group to provide information and advice to the board of governors in connection with the board's duties under this subsection. The executive director and senior managers of the corporation shall be engaged by the Chief Financial Officer and serve at the pleasure of the Chief Financial Officer. The executive director is responsible for employing other staff as the corporation may require, subject to review and concurrence by the office of the Chief Financial Officer.

5.  Must provide a procedure for determining the eligibility of a risk for coverage, as follows:

a.  Subject to the provisions of s. 627.3517, with respect to personal lines residential risks, if the risk is offered coverage from an authorized insurer at the insurer's approved rate under either a standard policy including wind coverage or, if consistent with the insurer's underwriting rules as filed with the office, a basic policy including wind coverage, the risk is not eligible for any policy issued by the corporation. If the risk is not able to obtain any such offer, the risk is eligible for either a standard policy including wind coverage or a basic policy including wind coverage issued by the corporation; however, if the risk could not be insured under a standard policy including wind coverage regardless of market conditions, the risk shall be eligible for a basic policy including wind coverage unless rejected under subparagraph 8. The corporation shall determine the type of policy to be provided on the basis of objective standards specified in the underwriting manual and based on generally accepted underwriting practices.

(I)  If the risk accepts an offer of coverage through the market assistance plan or an offer of coverage through a mechanism established by the corporation before a policy is issued to the risk by the corporation or during the first 30 days of coverage by the corporation, and the producing agent who submitted the application to the plan or to the corporation is not currently appointed by the insurer, the insurer shall:

(A)  Pay to the producing agent of record of the policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the corporation; or

(B)  Offer to allow the producing agent of record of the policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the corporation's usual and customary commission for the type of policy written.


If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with sub-sub-sub-subparagraph (A).

(II)  When the corporation enters into a contractual agreement for a take-out plan, the producing agent of record of the corporation policy is entitled to retain any unearned commission on the policy, and the insurer shall:

(A)  Pay to the producing agent of record of the corporation policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the corporation; or

(B)  Offer to allow the producing agent of record of the corporation policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the corporation's usual and customary commission for the type of policy written.


If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with sub-sub-sub-subparagraph (A).

b.  With respect to commercial lines residential risks, if the risk is offered coverage under a policy including wind coverage from an authorized insurer at its approved rate, the risk is not eligible for any policy issued by the corporation. If the risk is not able to obtain any such offer, the risk is eligible for a policy including wind coverage issued by the corporation.

(I)  If the risk accepts an offer of coverage through the market assistance plan or an offer of coverage through a mechanism established by the corporation before a policy is issued to the risk by the corporation or during the first 30 days of coverage by the corporation, and the producing agent who submitted the application to the plan or the corporation is not currently appointed by the insurer, the insurer shall:

(A)  Pay to the producing agent of record of the policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the corporation; or

(B)  Offer to allow the producing agent of record of the policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the corporation's usual and customary commission for the type of policy written.


If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with sub-sub-sub-subparagraph (A).

(II)  When the corporation enters into a contractual agreement for a take-out plan, the producing agent of record of the corporation policy is entitled to retain any unearned commission on the policy, and the insurer shall:

(A)  Pay to the producing agent of record of the corporation policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the corporation; or

(B)  Offer to allow the producing agent of record of the corporation policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the corporation's usual and customary commission for the type of policy written.


If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with sub-sub-sub-subparagraph (A).

6.  Must include rules for classifications of risks and rates therefor.

7.  Must provide that if premium and investment income for an account attributable to a particular calendar year are in excess of projected losses and expenses for the account attributable to that year, such excess shall be held in surplus in the account. Such surplus shall be available to defray deficits in that account as to future years and shall be used for that purpose prior to assessing assessable insurers and assessable insureds as to any calendar year.

8.  Must provide objective criteria and procedures to be uniformly applied for all applicants in determining whether an individual risk is so hazardous as to be uninsurable. In making this determination and in establishing the criteria and procedures, the following shall be considered:

a.  Whether the likelihood of a loss for the individual risk is substantially higher than for other risks of the same class; and

b.  Whether the uncertainty associated with the individual risk is such that an appropriate premium cannot be determined.

The acceptance or rejection of a risk by the corporation shall be construed as the private placement of insurance, and the provisions of chapter 120 shall not apply.

9.  Must provide that the corporation shall make its best efforts to procure catastrophe reinsurance at reasonable rates, as determined by the board of governors.

10.  Must provide that in the event of regular deficit assessments under sub-subparagraph (b)3.a. or sub-subparagraph (b)3.b., in the personal lines account, the commercial lines residential account, or the high-risk account, the corporation shall levy upon corporation policyholders in its next rate filing, or by a separate rate filing solely for this purpose, a market equalization surcharge arising from a regular assessment in such account in a percentage equal to the total amount of such regular assessments divided by the aggregate statewide direct written premium for subject lines of business for the prior calendar year. Market equalization surcharges under this subparagraph are not considered premium and are not subject to commissions, fees, or premium taxes; however, failure to pay a market equalization surcharge shall be treated as failure to pay premium.

11.  The policies issued by the corporation must provide that, if the corporation or the market assistance plan obtains an offer from an authorized insurer to cover the risk at its approved rates, the risk is no longer eligible for renewal through the corporation.

12.  Corporation policies and applications must include a notice that the corporation policy could, under this section, be replaced with a policy issued by an authorized insurer that does not provide coverage identical to the coverage provided by the corporation. The notice shall also specify that acceptance of corporation coverage creates a conclusive presumption that the applicant or policyholder is aware of this potential.

13.  May establish, subject to approval by the office, different eligibility requirements and operational procedures for any line or type of coverage for any specified county or area if the board determines that such changes to the eligibility requirements and operational procedures are justified due to the voluntary market being sufficiently stable and competitive in such area or for such line or type of coverage and that consumers who, in good faith, are unable to obtain insurance through the voluntary market through ordinary methods would continue to have access to coverage from the corporation. When coverage is sought in connection with a real property transfer, such requirements and procedures shall not provide for an effective date of coverage later than the date of the closing of the transfer as established by the transferor, the transferee, and, if applicable, the lender.

14.  Must provide that, with respect to the high-risk account, any assessable insurer with a surplus as to policyholders of $25 million or less writing 25 percent or more of its total countrywide property insurance premiums in this state may petition the office, within the first 90 days of each calendar year, to qualify as a limited apportionment company. In no event shall a limited apportionment company be required to participate in the portion of any assessment, within the high-risk account, pursuant to sub-subparagraph (b)3.a. or sub-subparagraph (b)3.b. in the aggregate which exceeds $50 million after payment of available high-risk account funds in any calendar year. However, a limited apportionment company shall collect from its policyholders any emergency assessment imposed under sub-subparagraph (b)3.d. The plan shall provide that, if the office determines that any regular assessment will result in an impairment of the surplus of a limited apportionment company, the office may direct that all or part of such assessment be deferred as provided in subparagraph (g)4. However, there shall be no limitation or deferment of an emergency assessment to be collected from policyholders under sub-subparagraph (b)3.d.

15.  Must provide that the corporation appoint as its licensed agents only those agents who also hold an appointment as defined in s. 626.015(3) with an insurer who at the time of the agent's initial appointment by the corporation is authorized to write and is actually writing personal lines residential property coverage, commercial residential property coverage, or commercial nonresidential property coverage within the state.

(d)1.  It is the intent of the Legislature that the rates for coverage provided by the corporation be actuarially sound and not competitive with approved rates charged in the admitted voluntary market, so that the corporation functions as a residual market mechanism to provide insurance only when the insurance cannot be procured in the voluntary market. Rates shall include an appropriate catastrophe loading factor that reflects the actual catastrophic exposure of the corporation.

2.  For each county, the average rates of the corporation for each line of business for personal lines residential policies excluding rates for wind-only policies shall be no lower than the average rates charged by the insurer that had the highest average rate in that county among the 20 insurers with the greatest total direct written premium in the state for that line of business in the preceding year, except that with respect to mobile home coverages, the average rates of the corporation shall be no lower than the average rates charged by the insurer that had the highest average rate in that county among the 5 insurers with the greatest total written premium for mobile home owner's policies in the state in the preceding year.

¹3.  Rates for personal lines residential wind-only policies must be actuarially sound and not competitive with approved rates charged by authorized insurers. However, for personal lines residential wind-only policies issued or renewed between July 1, 2002, and June 30, 2003, the maximum premium increase must be no greater than 10 percent of the Florida Windstorm Underwriting Association premium for that policy in effect on June 30, 2002, as adjusted for coverage changes and seasonal occupancy surcharges. For personal lines residential wind-only policies issued or renewed between July 1, 2003, and June 30, 2004, the corporation shall use its existing filed and approved wind-only rating and classification plans, provided, however, that the maximum premium increase must be no greater than 20 percent of the premium for that policy in effect on June 30, 2003, as adjusted for coverage changes and seasonal occupancy surcharges. Corporation rate manuals shall include a rate surcharge for seasonal occupancy. To ensure that personal lines residential wind-only rates effective on or after July 1, 2004, are not competitive with approved rates charged by authorized insurers, the corporation, in conjunction with the office, shall develop a wind-only ratemaking methodology, which methodology shall be contained in a rate filing made by the corporation with the office by January 1, 2004. If the office thereafter determines that the wind-only rates or rating factors filed by the corporation fail to comply with the wind-only ratemaking methodology provided for in this subsection, it shall so notify the corporation and require the corporation to amend its rates or rating factors to come into compliance within 90 days of notice from the office. The office shall report to the Speaker of the House of Representatives and the President of the Senate on the provisions of the wind-only ratemaking methodology by January 31, 2004.

4.  Rates for commercial lines coverage shall not be subject to the requirements of subparagraph 2., but shall be subject to all other requirements of this paragraph and s. 627.062.

5.  Nothing in this paragraph shall require or allow the corporation to adopt a rate that is inadequate under s. 627.062.

6.  The corporation shall certify to the office at least twice annually that its personal lines rates comply with the requirements of subparagraphs 1. and 2. If any adjustment in the rates or rating factors of the corporation is necessary to ensure such compliance, the corporation shall make and implement such adjustments and file its revised rates and rating factors with the office. If the office thereafter determines that the revised rates and rating factors fail to comply with the provisions of subparagraphs 1. and 2., it shall notify the corporation and require the corporation to amend its rates or rating factors in conjunction with its next rate filing. The office must notify the corporation by electronic means of any rate filing it approves for any insurer among the insurers referred to in subparagraph 2.

7.  In addition to the rates otherwise determined pursuant to this paragraph, the corporation shall impose and collect an amount equal to the premium tax provided for in s. 624.509 to augment the financial resources of the corporation.

8.a.  To assist the corporation in developing additional ratemaking methods to assure compliance with subparagraphs 1. and 4., the corporation shall appoint a rate methodology panel consisting of one person recommended by the Florida Association of Insurance Agents, one person recommended by the Professional Insurance Agents of Florida, one person recommended by the Florida Association of Insurance and Financial Advisors, one person recommended by the insurer with the highest voluntary market share of residential property insurance business in the state, one person recommended by the insurer with the second-highest voluntary market share of residential property insurance business in the state, one person recommended by an insurer writing commercial residential property insurance in this state, one person recommended by the Office of Insurance Regulation, and one board member designated by the board chairman, who shall serve as chairman of the panel.

b.  By January 1, 2004, the rate methodology panel shall provide a report to the corporation of its findings and recommendations for the use of additional ratemaking methods and procedures, including the use of a rate equalization surcharge in an amount sufficient to assure that the total cost of coverage for policyholders or applicants to the corporation is sufficient to comply with subparagraph 1.

c.  Within 30 days after such report, the corporation shall present to the President of the Senate, the Speaker of the House of Representatives, the minority party leaders of each house of the Legislature, and the chairs of the standing committees of each house of the Legislature having jurisdiction of insurance issues, a plan for implementing the additional ratemaking methods and an outline of any legislation needed to facilitate use of the new methods.

d.  The plan must include a provision that producer commissions paid by the corporation shall not be calculated in such a manner as to include any rate equalization surcharge. However, without regard to the plan to be developed or its implementation, producer commissions paid by the corporation for each account, other than the quota share primary program, shall remain fixed as to percentage, effective rate, calculation, and payment method until January 1, 2004.

9.  By January 1, 2004, the corporation shall develop a notice to policyholders or applicants that the rates of Citizens Property Insurance Corporation are intended to be higher than the rates of any admitted carrier and providing other information the corporation deems necessary to assist consumers in finding other voluntary admitted insurers willing to insure their property.

(e)  If coverage in an account is deactivated pursuant to paragraph (f), coverage through the corporation shall be reactivated by order of the office only under one of the following circumstances:

1.  If the market assistance plan receives a minimum of 100 applications for coverage within a 3-month period, or 200 applications for coverage within a 1-year period or less for residential coverage, unless the market assistance plan provides a quotation from admitted carriers at their filed rates for at least 90 percent of such applicants. Any market assistance plan application that is rejected because an individual risk is so hazardous as to be uninsurable using the criteria specified in subparagraph (c)8. shall not be included in the minimum percentage calculation provided herein. In the event that there is a legal or administrative challenge to a determination by the office that the conditions of this subparagraph have been met for eligibility for coverage in the corporation, any eligible risk may obtain coverage during the pendency of such challenge.

2.  In response to a state of emergency declared by the Governor under s. 252.36, the office may activate coverage by order for the period of the emergency upon a finding by the office that the emergency significantly affects the availability of residential property insurance.

(f)1.  The corporation shall file with the office quarterly statements of financial condition, an annual statement of financial condition, and audited financial statements in the manner prescribed by law. In addition, the corporation shall report to the office monthly on the types, premium, exposure, and distribution by county of its policies in force, and shall submit other reports as the office requires to carry out its oversight of the corporation.

2.  The activities of the corporation shall be reviewed at least annually by the office to determine whether coverage shall be deactivated in an account on the basis that the conditions giving rise to its activation no longer exist.

(g)1.  The corporation shall certify to the office its needs for annual assessments as to a particular calendar year, and for any interim assessments that it deems to be necessary to sustain operations as to a particular year pending the receipt of annual assessments. Upon verification, the office shall approve such certification, and the corporation shall levy such annual or interim assessments. Such assessments shall be prorated as provided in paragraph (b). The corporation shall take all reasonable and prudent steps necessary to collect the amount of assessment due from each assessable insurer, including, if prudent, filing suit to collect such assessment. If the corporation is unable to collect an assessment from any assessable insurer, the uncollected assessments shall be levied as an additional assessment against the assessable insurers and any assessable insurer required to pay an additional assessment as a result of such failure to pay shall have a cause of action against such nonpaying assessable insurer. Assessments shall be included as an appropriate factor in the making of rates. The failure of a surplus lines agent to collect and remit any regular or emergency assessment levied by the corporation is considered to be a violation of s. 626.936 and subjects the surplus lines agent to the penalties provided in that section.

2.  The governing body of any unit of local government, any residents of which are insured by the corporation, may issue bonds as defined in s. 125.013 or s. 166.101 from time to time to fund an assistance program, in conjunction with the corporation, for the purpose of defraying deficits of the corporation. In order to avoid needless and indiscriminate proliferation, duplication, and fragmentation of such assistance programs, any unit of local government, any residents of which are insured by the corporation, may provide for the payment of losses, regardless of whether or not the losses occurred within or outside of the territorial jurisdiction of the local government. Revenue bonds under this subparagraph may not be issued until validated pursuant to chapter 75, unless a state of emergency is declared by executive order or proclamation of the Governor pursuant to s. 252.36 making such findings as are necessary to determine that it is in the best interests of, and necessary for, the protection of the public health, safety, and general welfare of residents of this state and declaring it an essential public purpose to permit certain municipalities or counties to issue such bonds as will permit relief to claimants and policyholders of the corporation. Any such unit of local government may enter into such contracts with the corporation and with any other entity created pursuant to this subsection as are necessary to carry out this paragraph. Any bonds issued under this subparagraph shall be payable from and secured by moneys received by the corporation from emergency assessments under sub-subparagraph (b)3.d., and assigned and pledged to or on behalf of the unit of local government for the benefit of the holders of such bonds. The funds, credit, property, and taxing power of the state or of the unit of local government shall not be pledged for the payment of such bonds. If any of the bonds remain unsold 60 days after issuance, the office shall require all insurers subject to assessment to purchase the bonds, which shall be treated as admitted assets; each insurer shall be required to purchase that percentage of the unsold portion of the bond issue that equals the insurer's relative share of assessment liability under this subsection. An insurer shall not be required to purchase the bonds to the extent that the office determines that the purchase would endanger or impair the solvency of the insurer.

3.a.  The corporation shall adopt one or more programs subject to approval by the office for the reduction of both new and renewal writings in the corporation. The corporation may consider any prudent and not unfairly discriminatory approach to reducing corporation writings, and may adopt a credit against assessment liability or other liability that provides an incentive for insurers to take risks out of the corporation and to keep risks out of the corporation by maintaining or increasing voluntary writings in counties or areas in which corporation risks are highly concentrated and a program to provide a formula under which an insurer voluntarily taking risks out of the corporation by maintaining or increasing voluntary writings will be relieved wholly or partially from assessments under sub-subparagraphs (b)3.a. and b. When the corporation enters into a contractual agreement for a take-out plan, the producing agent of record of the corporation policy is entitled to retain any unearned commission on such policy, and the insurer shall either:

(I)  Pay to the producing agent of record of the policy, for the first year, an amount which is the greater of the insurer's usual and customary commission for the type of policy written or a policy fee equal to the usual and customary commission of the corporation; or

(II)  Offer to allow the producing agent of record of the policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the insurer's usual and customary commission for the type of policy written. If the producing agent is unwilling or unable to accept appointment by the new insurer, the new insurer shall pay the agent in accordance with sub-sub-subparagraph (I).

b.  Any credit or exemption from regular assessments adopted under this subparagraph shall last no longer than the 3 years following the cancellation or expiration of the policy by the corporation. With the approval of the office, the board may extend such credits for an additional year if the insurer guarantees an additional year of renewability for all policies removed from the corporation, or for 2 additional years if the insurer guarantees 2 additional years of renewability for all policies so removed.

c.  There shall be no credit, limitation, exemption, or deferment from emergency assessments to be collected from policyholders pursuant to sub-subparagraph (b)3.d.

4.  The plan shall provide for the deferment, in whole or in part, of the assessment of an assessable insurer, other than an emergency assessment collected from policyholders pursuant to sub-subparagraph (b)3.d., if the office finds that payment of the assessment would endanger or impair the solvency of the insurer. In the event an assessment against an assessable insurer is deferred in whole or in part, the amount by which such assessment is deferred may be assessed against the other assessable insurers in a manner consistent with the basis for assessments set forth in paragraph (b).

(h)  Nothing in this subsection shall be construed to preclude the issuance of residential property insurance coverage pursuant to part VIII of chapter 626.

(i)  There shall be no liability on the part of, and no cause of action of any nature shall arise against, any assessable insurer or its agents or employees, the corporation or its agents or employees, members of the board of governors or their respective designees at a board meeting, corporation committee members, or the office or its representatives, for any action taken by them in the performance of their duties or responsibilities under this subsection. Such immunity does not apply to:

1.  Any of the foregoing persons or entities for any willful tort;

2.  The corporation or its producing agents for breach of any contract or agreement pertaining to insurance coverage;

3.  The corporation with respect to issuance or payment of debt; or

4.  Any assessable insurer with respect to any action to enforce an assessable insurer's obligations to the corporation under this subsection.

(j)  For the purposes of s. 199.183(1), the corporation shall be considered a political subdivision of the state and shall be exempt from the corporate income tax. The premiums, assessments, investment income, and other revenue of the corporation are funds received for providing property insurance coverage as required by this subsection, paying claims for Florida citizens insured by the corporation, securing and repaying debt obligations issued by the corporation, and conducting all other activities of the corporation, and shall not be considered taxes, fees, licenses, or charges for services imposed by the Legislature on individuals, businesses, or agencies outside state government. Bonds and other debt obligations issued by or on behalf of the corporation are not to be considered "state bonds" within the meaning of s. 215.58(8). The corporation is not subject to the procurement provisions of chapter 287, and policies and decisions of the corporation relating to incurring debt, levying of assessments and the sale, issuance, continuation, terms and claims under corporation policies, and all services relating thereto, are not subject to the provisions of chapter 120. The corporation is not required to obtain or to hold a certificate of authority issued by the office, nor is it required to participate as a member insurer of the Florida Insurance Guaranty Association. However, the corporation is required to pay, in the same manner as an authorized insurer, assessments pledged by the Florida Insurance Guaranty Association to secure bonds issued or other indebtedness incurred to pay covered claims arising from insurer insolvencies caused by, or proximately related to, hurricane losses. It is the intent of the Legislature that the tax exemptions provided in this paragraph will augment the financial resources of the corporation to better enable the corporation to fulfill its public purposes. Any bonds issued by the corporation, their transfer, and the income therefrom, including any profit made on the sale thereof, shall at all times be free from taxation of every kind by the state and any political subdivision or local unit or other instrumentality thereof; however, this exemption does not apply to any tax imposed by chapter 220 on interest, income, or profits on debt obligations owned by corporations other than the corporation.

(k)  Upon a determination by the office that the conditions giving rise to the establishment and activation of the corporation no longer exist, the corporation is dissolved. Upon dissolution, the assets of the corporation shall be applied first to pay all debts, liabilities, and obligations of the corporation, including the establishment of reasonable reserves for any contingent liabilities or obligations, and all remaining assets of the corporation shall become property of the state and shall be deposited in the Florida Hurricane Catastrophe Fund. However, no dissolution shall take effect as long as the corporation has bonds or other financial obligations outstanding unless adequate provision has been made for the payment of the bonds or other financial obligations pursuant to the documents authorizing the issuance of the bonds or other financial obligations.

(l)1.  Effective July 1, 2002, policies of the Residential Property and Casualty Joint Underwriting Association shall become policies of the corporation. All obligations, rights, assets and liabilities of the Residential Property and Casualty Joint Underwriting Association, including bonds, note and debt obligations, and the financing documents pertaining to them become those of the corporation as of July 1, 2002. The corporation is not required to issue endorsements or certificates of assumption to insureds during the remaining term of in-force transferred policies.

2.  Effective July 1, 2002, policies of the Florida Windstorm Underwriting Association are transferred to the corporation and shall become policies of the corporation. All obligations, rights, assets, and liabilities of the Florida Windstorm Underwriting Association, including bonds, note and debt obligations, and the financing documents pertaining to them are transferred to and assumed by the corporation on July 1, 2002. The corporation is not required to issue endorsement or certificates of assumption to insureds during the remaining term of in-force transferred policies.

3.  The Florida Windstorm Underwriting Association and the Residential Property and Casualty Joint Underwriting Association shall take all actions as may be proper to further evidence the transfers and shall provide the documents and instruments of further assurance as may reasonably be requested by the corporation for that purpose. The corporation shall execute assumptions and instruments as the trustees or other parties to the financing documents of the Florida Windstorm Underwriting Association or the Residential Property and Casualty Joint Underwriting Association may reasonably request to further evidence the transfers and assumptions, which transfers and assumptions, however, are effective on the date provided under this paragraph whether or not, and regardless of the date on which, the assumptions or instruments are executed by the corporation. Subject to the relevant financing documents pertaining to their outstanding bonds, notes, indebtedness, or other financing obligations, the moneys, investments, receivables, choses in action, and other intangibles of the Florida Windstorm Underwriting Association shall be credited to the high-risk account of the corporation, and those of the personal lines residential coverage account and the commercial lines residential coverage account of the Residential Property and Casualty Joint Underwriting Association shall be credited to the personal lines account and the commercial lines account, respectively, of the corporation.

4.  Effective July 1, 2002, a new applicant for property insurance coverage who would otherwise have been eligible for coverage in the Florida Windstorm Underwriting Association is eligible for coverage from the corporation as provided in this subsection.

5.  The transfer of all policies, obligations, rights, assets, and liabilities from the Florida Windstorm Underwriting Association to the corporation and the renaming of the Residential Property and Casualty Joint Underwriting Association as the corporation shall in no way affect the coverage with respect to covered policies as defined in s. 215.555(2)(c) provided to these entities by the Florida Hurricane Catastrophe Fund. The coverage provided by the Florida Hurricane Catastrophe Fund to the Florida Windstorm Underwriting Association based on its exposures as of June 30, 2002, and each June 30 thereafter shall be redesignated as coverage for the high-risk account of the corporation. Notwithstanding any other provision of law, the coverage provided by the Florida Hurricane Catastrophe Fund to the Residential Property and Casualty Joint Underwriting Association based on its exposures as of June 30, 2002, and each June 30 thereafter shall be transferred to the personal lines account and the commercial lines account of the corporation. Notwithstanding any other provision of law, the high-risk account shall be treated, for all Florida Hurricane Catastrophe Fund purposes, as if it were a separate participating insurer with its own exposures, reimbursement premium, and loss reimbursement. Likewise, the personal lines and commercial lines accounts shall be viewed together, for all Florida Hurricane Catastrophe Fund purposes, as if the two accounts were one and represent a single, separate participating insurer with its own exposures, reimbursement premium, and loss reimbursement. The coverage provided by the Florida Hurricane Catastrophe Fund to the corporation shall constitute and operate as a full transfer of coverage from the Florida Windstorm Underwriting Association and Residential Property and Casualty Joint Underwriting to the corporation.

(m)  Notwithstanding any other provision of law:

1.  The pledge or sale of, the lien upon, and the security interest in any rights, revenues, or other assets of the corporation created or purported to be created pursuant to any financing documents to secure any bonds or other indebtedness of the corporation shall be and remain valid and enforceable, notwithstanding the commencement of and during the continuation of, and after, any rehabilitation, insolvency, liquidation, bankruptcy, receivership, conservatorship, reorganization, or similar proceeding against the corporation under the laws of this state.

2.  No such proceeding shall relieve the corporation of its obligation, or otherwise affect its ability to perform its obligation, to continue to collect, or levy and collect, assessments, market equalization or other surcharges under subparagraph (c)10., or any other rights, revenues, or other assets of the corporation pledged pursuant to any financing documents.

3.  Each such pledge or sale of, lien upon, and security interest in, including the priority of such pledge, lien, or security interest, any such assessments, market equalization or other surcharges, or other rights, revenues, or other assets which are collected, or levied and collected, after the commencement of and during the pendency of, or after, any such proceeding shall continue unaffected by such proceeding. As used in this subsection, the term "financing documents" means any agreement or agreements, instrument or instruments, or other document or documents now existing or hereafter created evidencing any bonds or other indebtedness of the corporation or pursuant to which any such bonds or other indebtedness has been or may be issued and pursuant to which any rights, revenues, or other assets of the corporation are pledged or sold to secure the repayment of such bonds or indebtedness, together with the payment of interest on such bonds or such indebtedness, or the payment of any other obligation or financial product, as defined in the plan of operation of the corporation related to such bonds or indebtedness.

4.  Any such pledge or sale of assessments, revenues, contract rights, or other rights or assets of the corporation shall constitute a lien and security interest, or sale, as the case may be, that is immediately effective and attaches to such assessments, revenues, or contract rights or other rights or assets, whether or not imposed or collected at the time the pledge or sale is made. Any such pledge or sale is effective, valid, binding, and enforceable against the corporation or other entity making such pledge or sale, and valid and binding against and superior to any competing claims or obligations owed to any other person or entity, including policyholders in this state, asserting rights in any such assessments, revenues, or contract rights or other rights or assets to the extent set forth in and in accordance with the terms of the pledge or sale contained in the applicable financing documents, whether or not any such person or entity has notice of such pledge or sale and without the need for any physical delivery, recordation, filing, or other action.

(n)1.  The following records of the corporation are confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution:

a.  Underwriting files, except that a policyholder or an applicant shall have access to his or her own underwriting files.

b.  Claims files, until termination of all litigation and settlement of all claims arising out of the same incident, although portions of the claims files may remain exempt, as otherwise provided by law. Confidential and exempt claims file records may be released to other governmental agencies upon written request and demonstration of need; such records held by the receiving agency remain confidential and exempt as provided for herein.

c.  Records obtained or generated by an internal auditor pursuant to a routine audit, until the audit is completed, or if the audit is conducted as part of an investigation, until the investigation is closed or ceases to be active. An investigation is considered "active" while the investigation is being conducted with a reasonable, good faith belief that it could lead to the filing of administrative, civil, or criminal proceedings.

d.  Matters reasonably encompassed in privileged attorney-client communications.

e.  Proprietary information licensed to the corporation under contract and the contract provides for the confidentiality of such proprietary information.

f.  All information relating to the medical condition or medical status of a corporation employee which is not relevant to the employee's capacity to perform his or her duties, except as otherwise provided in this paragraph. Information which is exempt shall include, but is not limited to, information relating to workers' compensation, insurance benefits, and retirement or disability benefits.

g.  Upon an employee's entrance into the employee assistance program, a program to assist any employee who has a behavioral or medical disorder, substance abuse problem, or emotional difficulty which affects the employee's job performance, all records relative to that participation shall be confidential and exempt from the provisions of s. 119.07(1) and s. 24(a), Art. I of the State Constitution, except as otherwise provided in s. 112.0455(11).

h.  Information relating to negotiations for financing, reinsurance, depopulation, or contractual services, until the conclusion of the negotiations.

i.  Minutes of closed meetings regarding underwriting files, and minutes of closed meetings regarding an open claims file until termination of all litigation and settlement of all claims with regard to that claim, except that information otherwise confidential or exempt by law will be redacted.

When an authorized insurer is considering underwriting a risk insured by the corporation, relevant underwriting files and confidential claims files may be released to the insurer provided the insurer agrees in writing, notarized and under oath, to maintain the confidentiality of such files. When a file is transferred to an insurer that file is no longer a public record because it is not held by an agency subject to the provisions of the public records law. Underwriting files and confidential claims files may also be released to staff of and the board of governors of the market assistance plan established pursuant to s. 627.3515, who must retain the confidentiality of such files, except such files may be released to authorized insurers that are considering assuming the risks to which the files apply, provided the insurer agrees in writing, notarized and under oath, to maintain the confidentiality of such files. Finally, the corporation or the board or staff of the market assistance plan may make the following information obtained from underwriting files and confidential claims files available to licensed general lines insurance agents: name, address, and telephone number of the residential property owner or insured; location of the risk; rating information; loss history; and policy type. The receiving licensed general lines insurance agent must retain the confidentiality of the information received.

2.  Portions of meetings of the corporation are exempt from the provisions of s. 286.011 and s. 24(b), Art. I of the State Constitution wherein confidential underwriting files or confidential open claims files are discussed. All portions of corporation meetings which are closed to the public shall be recorded by a court reporter. The court reporter shall record the times of commencement and termination of the meeting, all discussion and proceedings, the names of all persons present at any time, and the names of all persons speaking. No portion of any closed meeting shall be off the record. Subject to the provisions hereof and s. 119.07(1)(b)-(d), the court reporter's notes of any closed meeting shall be retained by the corporation for a minimum of 5 years. A copy of the transcript, less any exempt matters, of any closed meeting wherein claims are discussed shall become public as to individual claims after settlement of the claim.

(o)  It is the intent of the Legislature that the amendments to this subsection enacted in 2002 should, over time, reduce the probable maximum windstorm losses in the residual markets and should reduce the potential assessments to be levied on property insurers and policyholders statewide. In furtherance of this intent:

1.  The board shall, on or before February 1 of each year, provide a report to the President of the Senate and the Speaker of the House of Representatives showing the reduction or increase in the 100-year probable maximum loss attributable to wind-only coverages and the quota share program under this subsection combined, as compared to the benchmark 100-year probable maximum loss of the Florida Windstorm Underwriting Association. For purposes of this paragraph, the benchmark 100-year probable maximum loss of the Florida Windstorm Underwriting Association shall be the calculation dated February 2001 and based on November 30, 2000, exposures. In order to ensure comparability of data, the board shall use the same methods for calculating its probable maximum loss as were used to calculate the benchmark probable maximum loss.

2.  Beginning February 1, 2007, if the report under subparagraph 1. for any year indicates that the 100-year probable maximum loss attributable to wind-only coverages and the quota share program combined does not reflect a reduction of at least 25 percent from the benchmark, the board shall reduce the boundaries of the high-risk area eligible for wind-only coverages under this subsection in a manner calculated to reduce such probable maximum loss to an amount at least 25 percent below the benchmark.

3.  Beginning February 1, 2012, if the report under subparagraph 1. for any year indicates that the 100-year probable maximum loss attributable to wind-only coverages and the quota share program combined does not reflect a reduction of at least 50 percent from the benchmark, the boundaries of the high-risk area eligible for wind-only coverages under this subsection shall be reduced by the elimination of any area that is not seaward of a line 1,000 feet inland from the Intracoastal Waterway.

(p)  In enacting the provisions of this section, the Legislature recognizes that both the Florida Windstorm Underwriting Association and the Residential Property and Casualty Joint Underwriting Association have entered into financing arrangements that obligate each entity to service its debts and maintain the capacity to repay funds secured under these financing arrangements. It is the intent of the Legislature that nothing in this section be construed to compromise, diminish, or interfere with the rights of creditors under such financing arrangements. It is further the intent of the Legislature to preserve the obligations of the Florida Windstorm Underwriting Association and Residential Property and Casualty Joint Underwriting Association with regard to outstanding financing arrangements, with such obligations passing entirely and unchanged to the corporation and, specifically, to the applicable account of the corporation. So long as any bonds, notes, indebtedness, or other financing obligations of the Florida Windstorm Underwriting Association or the Residential Property and Casualty Joint Underwriting Association are outstanding, under the terms of the financing documents pertaining to them, the governing board of the corporation shall have and shall exercise the authority to levy, charge, collect, and receive all premiums, assessments, surcharges, charges, revenues, and receipts that the associations had authority to levy, charge, collect, or receive under the provisions of subsection (2) and this subsection, respectively, as they existed on January 1, 2002, to provide moneys, without exercise of the authority provided by this subsection, in at least the amounts, and by the times, as would be provided under those former provisions of subsection (2) or this subsection, respectively, so that the value, amount, and collectability of any assets, revenues, or revenue source pledged or committed to, or any lien thereon securing such outstanding bonds, notes, indebtedness, or other financing obligations will not be diminished, impaired, or adversely affected by the amendments made by this act and to permit compliance with all provisions of financing documents pertaining to such bonds, notes, indebtedness, or other financing obligations, or the security or credit enhancement for them, and any reference in this subsection to bonds, notes, indebtedness, financing obligations, or similar obligations, of the corporation shall include like instruments or contracts of the Florida Windstorm Underwriting Association and the Residential Property and Casualty Joint Underwriting Association to the extent not inconsistent with the provisions of the financing documents pertaining to them.

(q)  The corporation shall not require the securing of flood insurance as a condition of coverage if the insured or applicant executes a form approved by the office affirming that flood insurance is not provided by the corporation and that if flood insurance is not secured by the applicant or insured in addition to coverage by the corporation, the risk will not be covered for flood damage. A corporation policyholder electing not to secure flood insurance and executing a form as provided herein making a claim for water damage against the corporation shall have the burden of proving the damage was not caused by flooding. Notwithstanding other provisions of this subsection, the corporation may deny coverage to an applicant or insured who refuses to execute the form described herein.

(r)  A salaried employee of the corporation who performs policy administration services subsequent to the effectuation of a corporation policy is not required to be licensed as an agent under the provisions of s. 626.112.

²(7)  COLLATERAL PROTECTION INSURANCE.--As used in this section and ss. 215.555 and 627.311, the term "collateral protection insurance" means commercial property insurance of which a creditor is the primary beneficiary and policyholder and which protects or covers an interest of the creditor arising out of a credit transaction secured by real or personal property. Initiation of such coverage is triggered by the mortgagor's failure to maintain insurance coverage as required by the mortgage or other lending document. Collateral protection insurance is not residential coverage.

History.--s. 445, ch. 59-205; ss. 13, 35, ch. 69-106; s. 1, ch. 69-199; ss. 1, 2, ch. 70-234; s. 1, ch. 72-22; s. 1, ch. 73-259; s. 1, ch. 74-216; s. 14, ch. 75-9; s. 3, ch. 75-279; s. 1, ch. 76-96; s. 3, ch. 76-168; s. 5, ch. 76-260; s. 3, ch. 77-64; s. 1, ch. 77-93; s. 1, ch. 77-174; s. 1, ch. 77-380; s. 1, ch. 77-457; s. 28, ch. 77-468; s. 1, ch. 78-47; s. 164, ch. 79-164; ss. 1, 2, ch. 79-185; ss. 1, 2, ch. 80-94; ss. 1, 2, ch. 81-4; ss. 2, 3, ch. 81-318; ss. 351, 357, 809(2nd), 810, ch. 82-243; ss. 48, 49, 79, ch. 82-386; ss. 1, 5, ch. 82-391; s. 1, ch. 83-124; s. 1, ch. 83-206; s. 95, ch. 83-216; s. 15, ch. 85-62; s. 24, ch. 85-175; s. 1, ch. 85-274; ss. 13, 44, ch. 86-160; s. 35, ch. 86-191; s. 14, ch. 86-287; s. 1, ch. 88-368; s. 5, ch. 88-390; s. 1, ch. 89-236; s. 1, ch. 90-108; s. 6, ch. 91-106; s. 59, ch. 91-110; s. 18, ch. 92-179; s. 114, ch. 92-318; s. 3, ch. 92-345; s. 21, ch. 93-260; s. 4, ch. 93-289; s. 3, ch. 93-401; s. 14, ch. 93-410; s. 1, ch. 95-233; s. 9, ch. 95-276; s. 8, ch. 96-194; s. 2, ch. 96-377; s. 379, ch. 96-406; s. 5, ch. 97-55; s. 28, ch. 97-94; ss. 1731, 1732, ch. 97-102; s. 57, ch. 97-264; s. 8, ch. 98-49; ss. 221, 290, ch. 98-166; s. 8, ch. 98-173; s. 56, ch. 98-287; s. 1, ch. 99-237; s. 132, ch. 2000-141; s. 139, ch. 2000-318; s. 35, ch. 2001-186; s. 4, ch. 2001-372; s. 2, ch. 2002-221; s. 2, ch. 2002-240; s. 11, ch. 2002-282; s. 90, ch. 2003-1; s. 1101, ch. 2003-261; s. 73, ch. 2003-281; s. 122, ch. 2004-5; s. 47, ch. 2004-335; s. 24, ch. 2004-374.

¹Note.--

A.  As amended by s. 73, ch. 2003-281. This material was also amended by s. 1101, ch. 2003-261, and that version amended a sentence deleted by s. 73, ch. 2003-281, authorizing rulemaking authority. As amended by s. 1101, ch. 2003-261, the sentence reads: "The commission may adopt rules to establish reporting requirements to obtain the necessary wind-only rate information from insurers to implement this provision."

B.  Section 1979, ch. 2003-261, provides that "[i]n the event of a conflict between this act and any other legislation enacted during the 2003 Regular Session, the provisions of this act shall prevail." The amendments to subparagraph (6)(d)3. by s. 1101, ch. 2003-261, were to language deleted by s. 73, ch. 2003-281.

²Note.--Also published at s. 215.555(15).

627.3511  Depopulation of Citizens Property Insurance Corporation.--

(1)  LEGISLATIVE INTENT.--The Legislature finds that the public policy of this state requires the maintenance of a residual market for residential property insurance. It is the intent of the Legislature to provide a variety of financial incentives to encourage the replacement of the highest possible number of Citizens Property Insurance Corporation policies with policies written by admitted insurers at approved rates.

(2)  TAKE-OUT BONUS.--The Citizens Property Insurance Corporation shall pay the sum of up to $100 to an insurer for each risk that the insurer removes from the corporation, either by issuance of a policy upon expiration or cancellation of the corporation policy or by assumption of the corporation's obligations with respect to an in-force policy. Such payment is subject to approval of the corporation board. In order to qualify for the bonus under this subsection, the take-out plan must include a minimum of 25,000 policies. Within 30 days after approval by the board, the office may reject the insurer's take-out plan and disqualify the insurer from the bonus, based on the following criteria:

(a)  The capacity of the insurer to absorb the policies proposed to be taken out of the corporation and the concentration of risks of those policies.

(b)  Whether the geographic and risk characteristics of policies in the proposed take-out plan serve to reduce the exposure of the corporation sufficiently to justify the bonus.

(c)  Whether coverage for risks to be taken out otherwise exists in the admitted voluntary market.

(d)  The degree to which the take-out bonus is promoting new capital being allocated by the insurer to Florida residential property coverage.

(3)  EXEMPTION FROM DEFICIT ASSESSMENTS.--

(a)  The calculation of an insurer's assessment liability under s. 627.351(6)(b)3.a. or b. shall, for an insurer that in any calendar year removes 50,000 or more risks from the Citizens Property Insurance Corporation, either by issuance of a policy upon expiration or cancellation of the corporation policy or by assumption of the corporation's obligations with respect to in-force policies, exclude such removed policies for the succeeding 3 years, as follows:

1.  In the first year following removal of the risks, the risks are excluded from the calculation to the extent of 100 percent.

2.  In the second year following removal of the risks, the risks are excluded from the calculation to the extent of 75 percent.

3.  In the third year following removal of the risks, the risks are excluded from the calculation to the extent of 50 percent.

If the removal of risks is accomplished through assumption of obligations with respect to in-force policies, the corporation shall pay to the assuming insurer all unearned premium with respect to such policies less any policy acquisition costs agreed to by the corporation and assuming insurer. The term "policy acquisition costs" is defined as costs of issuance of the policy by the corporation which includes agent commissions, servicing company fees, and premium tax. This paragraph does not apply to an insurer that, at any time within 5 years before removing the risks, had a market share in excess of 0.1 percent of the statewide aggregate gross direct written premium for any line of property insurance, or to an affiliate of such an insurer. This paragraph does not apply unless either at least 40 percent of the risks removed from the corporation are located in Dade, Broward, and Palm Beach Counties, or at least 30 percent of the risks removed from the corporation are located in such counties and an additional 50 percent of the risks removed from the corporation are located in other coastal counties.

(b)  An insurer that first wrote personal lines residential property coverage in this state on or after July 1, 1994, is exempt from regular deficit assessments imposed pursuant to s. 627.351(6)(b)3.a. and b., but not emergency assessments collected from policyholders pursuant to s. 627.351(6)(b)3.d., of the Citizens Property Insurance Corporation until the earlier of the following:

1.  The end of the calendar year in which it first wrote 0.5 percent or more of the statewide aggregate direct written premium for any line of residential property coverage; or

2.  December 31, 1997, or December 31 of the third year in which it wrote such coverage in this state, whichever is later.

(c)  Other than an insurer that is exempt under paragraph (b), an insurer that in any calendar year increases its total structure exposure subject to wind coverage by 25 percent or more over its exposure for the preceding calendar year is, with respect to that year, exempt from deficit assessments imposed pursuant to s. 627.351(6)(b)3.a. and b., but not emergency assessments collected from policyholders pursuant to s. 627.351(6)(b)3.d., of the Citizens Property Insurance Corporation attributable to such increase in exposure.

(d)  Any exemption or credit from regular assessments authorized by this section shall last no longer than 3 years following the cancellation or expiration of the policy by the corporation. With the approval of the office, the board may extend such credits for an additional year if the insurer guarantees an additional year of renewability for all policies removed from the corporation, or for 2 additional years if the insurer guarantees 2 additional years of renewability for all policies so removed.

(4)  AGENT BONUS.--When the corporation enters into a contractual agreement for a take-out plan that provides a bonus to the insurer, the producing agent of record of the corporation policy is entitled to retain any unearned commission on such policy, and the insurer shall either:

(a)  Pay to the producing agent of record of the association policy, for the first year, an amount that is the greater of the insurer's usual and customary commission for the type of policy written or a fee equal to the usual and customary commission of the corporation; or

(b)  Offer to allow the producing agent of record of the corporation policy to continue servicing the policy for a period of not less than 1 year and offer to pay the agent the greater of the insurer's or the corporation's usual and customary commission for the type of policy written.

If the producing agent is unwilling or unable to accept appointment, the new insurer shall pay the agent in accordance with paragraph (a). The requirement of this subsection that the producing agent of record is entitled to retain the unearned commission on an association policy does not apply to a policy for which coverage has been provided in the association for 30 days or less or for which a cancellation notice has been issued pursuant to s. 627.351(6)(c)11. during the first 30 days of coverage.

(5)  APPLICABILITY.--

(a)  The take-out bonus provided by subsection (2) and the exemption from assessment provided by paragraph (3)(a) apply only if the corporation policy is replaced by either a standard policy including wind coverage or, if consistent with the insurer's underwriting rules as filed with the office, a basic policy including wind coverage; however, with respect to risks located in areas where coverage through the high-risk account of the corporation is available, the replacement policy need not provide wind coverage. The insurer must renew the replacement policy at approved rates on substantially similar terms for two additional 1-year terms, unless canceled by the insurer for a lawful reason other than reduction of hurricane exposure. If an insurer assumes the corporation's obligations for a policy, it must issue a replacement policy for a 1-year term upon expiration of the corporation policy and must renew the replacement policy at approved rates on substantially similar terms for two additional 1-year terms, unless canceled by the insurer for a lawful reason other than reduction of hurricane exposure. For each replacement policy canceled or nonrenewed by the insurer for any reason during the 3-year coverage period required by this paragraph, the insurer must remove from the corporation one additional policy covering a risk similar to the risk covered by the canceled or nonrenewed policy. In addition to these requirements, the corporation must place the bonus moneys in escrow for a period of 3 years; such moneys may be released from escrow only to pay claims. A take-out bonus provided by subsection (2) or subsection (6) shall not be considered premium income for purposes of taxes and assessments under the Florida Insurance Code and shall remain the property of the corporation, subject to the prior security interest of the insurer under the escrow agreement until it is released from escrow, and after it is released from escrow it shall be considered an asset of the insurer and credited to the insurer's capital and surplus.

(b)  It is the intent of the Legislature that an insurer eligible for the exemption under paragraph (3)(a) establish a preference in appointment of agents for those agents who lose a substantial amount of business as a result of risks being removed from the corporation.

(6)  COMMERCIAL RESIDENTIAL TAKE-OUT PLANS.--

(a)  The corporation shall pay a bonus to an insurer for each commercial residential policy that the insurer removes from the corporation pursuant to an approved take-out plan, either by issuance of a new policy upon expiration of the corporation policy or by assumption of the corporation's obligations with respect to an in-force policy. The corporation board shall determine the amount of the bonus based on such factors as the coverage provided, relative hurricane risk, the length of time that the property has been covered by the corporation, and the criteria specified in paragraphs (b) and (c). The amount of the bonus with respect to a particular policy may not exceed 25 percent of the corporation's 1-year premium for the policy. Such payment is subject to approval of the corporation board. In order to qualify for the bonus under this subsection, the take-out plan must include policies reflecting at least $100 million in structure exposure.

(b)  In order for a plan to qualify for approval:

1.  At least 40 percent of the policies removed from the corporation under the plan must be located in Dade, Broward, and Palm Beach Counties, or at least 30 percent of the policies removed from the corporation under the plan must be located in such counties and an additional 50 percent of the policies removed from the corporation must be located in other coastal counties.

2.  The insurer must renew the replacement policy at approved rates on substantially similar terms for two additional 1-year terms, unless canceled or nonrenewed by the insurer for a lawful reason other than reduction of hurricane exposure. If an insurer assumes the corporation's obligations for a policy, it must issue a replacement policy for a 1-year term upon expiration of the corporation policy and must renew the replacement policy at approved rates on substantially similar terms for two additional 1-year terms, unless canceled by the insurer for a lawful reason other than reduction of hurricane exposure. For each replacement policy canceled or nonrenewed by the insurer for any reason during the 3-year coverage period required by this subparagraph, the insurer must remove from the corporation one additional policy covering a risk similar to the risk covered by the canceled or nonrenewed policy.

(c)  A take-out plan is deemed approved unless the office, within 120 days after the board votes to recommend the plan, disapproves the plan based on:

1.  The capacity of the insurer to absorb the policies proposed to be taken out of the corporation and the concentration of risks of those policies.

2.  Whether the geographic and risk characteristics of policies in the proposed take-out plan serve to reduce the exposure of the corporation sufficiently to justify the bonus.

3.  Whether coverage for risks to be taken out otherwise exists in the admitted voluntary market.

4.  The degree to which the take-out bonus is promoting new capital being allocated by the insurer to residential property coverage in this state.

(d)  The calculation of an insurer's regular assessment liability under s. 627.351(b)3.a. and b., but not emergency assessments collected from policyholders pursuant to s. 627.351(6)(b)3.d., shall, with respect to commercial residential policies removed from the corporation under an approved take-out plan, exclude such removed policies for the succeeding 3 years, as follows:

1.  In the first year following removal of the policies, the policies are excluded from the calculation to the extent of 100 percent.

2.  In the second year following removal of the policies, the policies are excluded from the calculation to the extent of 75 percent.

3.  In the third year following removal of the policies, the policies are excluded from the calculation to the extent of 50 percent.

(e)  An insurer that first wrote commercial residential property coverage in this state on or after June 1, 1996, is exempt from regular assessments under s. 627.351(6)(b)3.a. and b., but not emergency assessments collected from policyholders pursuant to s. 627.351(6)(b)3.d., with respect to commercial residential policies until the earlier of:

1.  The end of the calendar year in which such insurer first wrote 0.5 percent or more of the statewide aggregate direct written premium for commercial residential property coverage; or

2.  December 31 of the third year in which such insurer wrote commercial residential property coverage in this state.

(f)  An insurer that is not otherwise exempt from regular assessments under s. 627.351(6)(b)3.a. and b. with respect to commercial residential policies is, for any calendar year in which such insurer increased its total commercial residential hurricane exposure by 25 percent or more over its exposure for the preceding calendar year, exempt from regular assessments under s. 627.351(6)(b)3.a. and b., but not emergency assessments collected from policyholders pursuant to s. 627.351(6)(b)3.d., attributable to such increased exposure.

(7)  A minority business, which is at least 51 percent owned by minority persons as described in s. 288.703(3), desiring to operate or become licensed as a property and casualty insurer may exempt up to $50 of the escrow requirements of the take-out bonus, as described in this section. Such minority business, which has applied for a certificate of authority to engage in business as a property and casualty insurer, may simultaneously file the business' proposed take-out plan, as described in this section, with the corporation.

History.--s. 10, ch. 95-276; s. 10, ch. 96-194; s. 6, ch. 97-55; s. 24, ch. 97-93; s. 1, ch. 99-142; s. 7, ch. 2000-333; s. 3, ch. 2002-221; s. 3, ch. 2002-240; s. 1102, ch. 2003-261.

627.3512  Recoupment of residual market deficit assessments.--

(1)  An insurer or insurer group may recoup any assessments that have been paid during or after 1995 by the insurer or insurer group to defray deficits of an insurance risk apportionment plan or assigned risk plan under ss. 627.311 and 627.351, net of any earnings returned to the insurer or insurer group by the association or plan for any year after 1993. The recoupment shall be made by applying a separate assessment factor on policies of the same line or type as were considered by the residual markets in determining the assessment liability of the insurer or insurer group. An insurer or insurer group shall calculate a separate assessment factor for personal lines and commercial lines. The separate assessment factor shall provide for full recoupment of the assessments over a period of 1 year, unless the insurer or insurer group, at its option, elects to recoup the assessments over a longer period. The assessment factor expires upon collection of the full amount allowed to be recouped. Amounts recouped under this section are not subject to premium taxes, fees, or commissions.

(2)  The assessment factor must not be more than 3 percentage points above the ratio of the deficit assessment to the Florida direct written premium for policies for the lines or types of business as to which the assessment was calculated, as written in the year the deficit assessment was paid. If an insurer or insurer group fails to collect the full amount of the deficit assessment, the insurer or insurer group must carry forward the amount of the deficit and adjust the deficit assessment to be recouped in a subsequent year by that amount.

(3)  The insurer or insurer group shall file with the office a statement setting forth the amount of the assessment factor and an explanation of how the factor will be applied, at least 15 days prior to the factor being applied to any policies. The statement shall include documentation of the assessment paid by the insurer or insurer group and the arithmetic calculations supporting the assessment factor. The office shall complete its review within 15 days after receipt of the filing and shall limit its review to verification of the arithmetic calculations. The insurer or insurer group may use the assessment factor at any time after the expiration of the 15-day period unless the office has notified the insurer or insurer group in writing that the arithmetic calculations are incorrect.

(4)  The commission may adopt rules to implement this section.

History.--s. 11, ch. 95-276; s. 7, ch. 97-55; s. 1103, ch. 2003-261.

627.3513  Standards for sale of bonds by Citizens Property Insurance Corporation.--

(1)(a)  The purpose of this section is to provide standards for the sale of bonds pursuant to s. 627.351(2) and (6).

(b)  The term "corporation," as used in this section, means the Citizens Property Insurance Corporation.

(2)  The plan of operation of the corporation shall provide for the selection of financial services providers and underwriters. Such provisions shall include the method for publicizing or otherwise providing reasonable notice to potential financial services providers, underwriters, and other interested parties, which may include expedited procedures and methods for emergency situations. The corporation shall not engage the services of any person or firm as a securities broker or bond underwriter that is not eligible to be engaged by the state under the provisions of s. 215.684. The corporation shall make all selections of financial service providers and managing underwriters at a noticed public meeting.

(3)  The plan of operation of the corporation shall provide for any managing underwriter or financial adviser to provide to the corporation a disclosure statement containing at least the following information:

(a)  An itemized list setting forth the nature and estimated amounts of expenses to be incurred by the managing underwriter in connection with the issuance of such bonds. Notwithstanding the foregoing, any such list may include an item for miscellaneous expenses, provided such item includes only minor items of expense which cannot be easily categorized elsewhere in the statement.

(b)  The names, addresses, and estimated amounts of compensation of any finders connected with the issuance of the bonds.

(c)  The amount of underwriting spread expected to be realized and the amount of fees and expenses expected to be paid to the financial adviser.

(d)  Any management fee charged by the managing underwriter.

(e)  Any other fee, bonus, or compensation estimated to be paid by the managing underwriter in connection with the bond issue to any person not regularly employed or retained by it.

(f)  The name and address of each financial adviser or managing underwriter, if any, connected with the bond issue.

(g)  Any other disclosure which the corporation may require.

(4)(a)  No underwriter, commercial bank, investment banker, or financial consultant or adviser shall pay any finder any bonus, fee, or gratuity in connection with the sale of bonds issued by the corporation unless full disclosure is made in writing to the corporation prior to or concurrently with the submission of a purchase proposal for bonds by the underwriter, commercial bank, investment banker, or financial consultant or adviser, providing the name and address of any finder and the amount of bonus, fee, or gratuity paid to such finder. A violation of this subsection shall not affect the validity of the bond issue.

(b)  As used in this subsection, the term "finder" means a person who is neither regularly employed by, nor a partner or officer of, an underwriter, bank, banker, or financial consultant or adviser and who enters into an understanding with either the issuer or the managing underwriter, or both, for any paid or promised compensation or valuable consideration, directly or indirectly, expressed or implied, to act solely as an intermediary between such issuer and managing underwriter for the purpose of influencing any transaction in the purpose of such bonds.

(5)  This section is not intended to restrict or prohibit the employment of professional services relating to bonds issued under s. 627.351(6) or the issuance of bonds by the corporation.

(6)  The failure of the corporation to comply with one or more provisions of this section shall not affect the validity of the bond issue; however, the failure of the corporation to comply in good faith both with this section and with the plan as amended shall be a violation of its plan of operation and a violation of the insurance code.

History.--s. 8, ch. 97-55; s. 1104, ch. 2003-261.

627.3515  Market assistance plan; property and casualty risks.--

(1)  The office shall adopt a market assistance plan to assist in the placement of risks of applicants who are unable to procure property insurance as defined in s. 624.604 or casualty insurance as defined in s. 624.605(1)(b), (e), (f), (g), or (h) from authorized insurers when such insurance is otherwise generally available from insurers authorized to transact and actually writing that kind and class of insurance in this state. Through such measures as are found appropriate by the board of governors, the market assistance plan shall take affirmative steps to assist in the removal from the Citizens Property Insurance Corporation any risk that can be placed in the voluntary market. All property and casualty insurers licensed in this state shall participate in the plan.

(2)(a)  Each person serving as a member of the board of governors of the Citizens Property Insurance Corporation shall also serve as a member of the board of governors of the market assistance plan.

(b)  The plan shall be funded through payments from the Citizens Property Insurance Corporation and annual assessments of residential property insurers in the amount of $450.

(c)  The plan is not required to assist in the placement of any workers' compensation, employer's liability, malpractice, or motor vehicle insurance coverage.

History.--s. 1, ch. 85-92; s. 43, ch. 86-160; s. 1, ch. 86-286; s. 6, ch. 88-390; ss. 26, 114, ch. 92-318; s. 12, ch. 95-276; s. 3, ch. 96-377; s. 1105, ch. 2003-261.

627.3517  Consumer choice.--No provision of s. 627.351, s. 627.3511, or s. 627.3515 shall be construed to impair the right of any insurance risk apportionment plan policyholder, upon receipt of any keepout or take-out offer, to retain his or her current agent, so long as that agent is duly licensed and appointed by the insurance risk apportionment plan or otherwise authorized to place business with the insurance risk apportionment plan. This right shall not be canceled, suspended, impeded, abridged, or otherwise compromised by any rule, plan of operation, or depopulation plan, whether through keepout, take-out, midterm assumption, or any other means, of any insurance risk apportionment plan or depopulation plan, including, but not limited to, those described in s. 627.351, s. 627.3511, or s. 627.3515. The commission shall adopt any rules necessary to cause any insurance risk apportionment plan or market assistance plan under such sections to demonstrate that the operations of the plan do not interfere with, promote, or allow interference with the rights created under this section. If the policyholder's current agent is unable or unwilling to be appointed with the insurer making the take-out or keepout offer, the policyholder shall not be disqualified from participation in the appropriate insurance risk apportionment plan because of an offer of coverage in the voluntary market. An offer of full property insurance coverage by the insurer currently insuring either the ex-wind or wind-only coverage on the policy to which the offer applies shall not be considered a take-out or keepout offer. Any rule, plan of operation, or plan of depopulation, through keepout, take-out, midterm assumption, or any other means, of any property insurance risk apportionment plan under s. 627.351(2) or (6) is subject to ss. 627.351(2)(b) and (6)(c) and 627.3511(4).

History.--s. 4, ch. 2002-221; s. 4, ch. 2002-240; s. 1106, ch. 2003-261.

627.357  Medical malpractice self-insurance.--

(1)  DEFINITIONS.--As used in this section, the term:

(a)  "Fund" means a group or association of health care providers authorized to self-insure.

(b)  "Health care provider" means any:

1.  Hospital licensed under chapter 395.

2.  Physician licensed, or physician assistant licensed, under chapter 458.

3.  Osteopathic physician or physician assistant licensed under chapter 459.

4.  Podiatric physician licensed under chapter 461.

5.  Health maintenance organization certificated under part I of chapter 641.

6.  Ambulatory surgical center licensed under chapter 395.

7.  Chiropractic physician licensed under chapter 460.

8.  Psychologist licensed under chapter 490.

9.  Optometrist licensed under chapter 463.

10.  Dentist licensed under chapter 466.

11.  Pharmacist licensed under chapter 465.

12.  Registered nurse, licensed practical nurse, or advanced registered nurse practitioner licensed or registered under part I of chapter 464.

13.  Other medical facility.

14.  Professional association, partnership, corporation, joint venture, or other association established by the individuals set forth in subparagraphs 2., 3., 4., 7., 8., 9., 10., 11., and 12. for professional activity.

(c)  "Other medical facility" means a facility the primary purpose of which is to provide human medical diagnostic services or a facility providing nonsurgical human medical treatment and in which the patient is admitted to and discharged from such facility within the same working day, and which is not part of a hospital. The term does not include a facility existing for the primary purpose of performing terminations of pregnancies or an office maintained by a physician or dentist for the practice of medicine.

(d)  "Hospital subsidiary corporation" means any corporation over which a hospital or the hospital's parent corporation exercises financial or operational control and which provides health care services to the hospital or the hospital parent corporation or another hospital subsidiary corporation.

(e)  "Hospital parent corporation" means any corporation which has financial or operational control over a hospital and which provides health care services to the hospital or another hospital subsidiary corporation.

(f)  "Committee" means a committee or board of trustees of a health care provider or group of health care providers established to make recommendations, policies, or decisions regarding patient institutional utilization, patient treatment, or institutional staff privileges or to perform other administrative or professional purposes or functions.

(2)  A group or association of health care providers composed of any number of members, is authorized to self-insure against claims arising out of the rendering of, or failure to render, medical care or services, or against claims for injury or death to the insured's patients arising out of the insured's activities, upon obtaining approval from the office and upon complying with the following conditions:

(a)  Establishment of a Medical Malpractice Risk Management Trust Fund to provide coverage against professional medical malpractice liability.

(b)  Employment of professional consultants for loss prevention and claims management coordination under a risk management program.

(3)  The fund may insure hospital parent corporations, hospital subsidiary corporations, and committees against claims arising out of the rendering of, or failure to render, medical care or services.

(4)  The fund is subject to regulation and investigation by the office. The fund is subject to rules of the commission and to part IX of chapter 626, relating to trade practices and frauds.

(5)  The trust fund may purchase medical malpractice insurance, specific excess insurance, and aggregate excess insurance, up to determined limits, as necessary to provide the insurance coverages authorized by this section, consistent with market availability. The trust fund may purchase such risk management services as may be required, pay claims as may arise under any deductible provisions, and engage in prudent investment of trust funds and other activities reasonably relating to the payment of claims and to providing medical malpractice self-insurance, to the extent otherwise consistent with this section and law generally applicable to medical malpractice insurers.

(6)  The commission shall adopt rules to implement this section, including rules that ensure that a trust fund remains solvent and maintains a sufficient reserve to cover contingent liabilities under subsection (7) in the event of its dissolution.

(7)(a)  The liability of each member for the obligations of the trust fund is individual, several, and proportionate, but not joint, except as provided in this subsection.

(b)  Each member has a contingent assessment liability for payment of actual losses and expenses incurred while the member's policy was in force.

(c)  The trust fund may from time to time assess members of the fund liable therefor under the terms of their policies and pursuant to this section. The office may assess the members in the event of liquidation of the fund.

(d)  A member's share of a deficiency for which an assessment is made is computed by applying to the premium earned on the member's policy or policies during the period to be covered by the assessment the ratio of the total deficiency to the total premiums earned during such period upon all policies subject to the assessment. If one or more members fail to pay an assessment, the other members are liable on a proportionate basis for an additional assessment. The fund, acting on behalf of all members who paid the additional assessment, shall institute legal action, when necessary and appropriate, to recover the assessment from members who failed to pay it.

(e)  In computing the earned premiums for the purposes of this section, the gross premium received by the fund for the policy shall be used as a base, deducting therefrom solely charges not recurring upon the renewal or extension of the policy.

(f)  No member has an offset against any assessment for which the member is liable, on account of any claim for unearned premium of losses payable.

(g)  If the assets of a trust fund are at any time insufficient to comply with the requirements of law, discharge the fund's liabilities, or meet the required conditions of financial soundness, or if a judgment against the fund has remained unsatisfied for 30 days, the trust fund must immediately make up the deficiency or levy an assessment upon the members for the amount needed to make up the deficiency, subject to the limitations set forth in this subsection.

(h)  If the trust fund fails to make an assessment as required by paragraph (g), the office shall order the fund to do so. If the deficiency is not sufficiently made up within 60 days after the date of the order, the fund is deemed insolvent and grounds exist to proceed against the fund as provided for in part I of chapter 631.

(i)  Subject to this section, any rehabilitation, liquidation, conservation, or dissolution of a trust fund shall be conducted under the supervision of the department, which has all power with respect thereto granted to it under part I of chapter 631 governing the rehabilitation, liquidation, conservation, or dissolution of insurers.

(8)  The expense factors associated with rates used by a fund shall be filed with the office at least 30 days prior to use and may not be used until approved by the office. The office shall disapprove the rates unless the filed expense factors associated therewith are justified and reasonable for the benefits and services provided.

(9)  Premiums, contributions, and assessments received by a fund are subject to ss. 624.509(1) and (2) and 624.5092, except that the tax rate is 1.6 percent of the gross amount of such premiums, contributions, or assessments.

History.--ss. 1, 2, 3, ch. 72-265; s. 162, ch. 73-333; s. 4, ch. 75-9; s. 3, ch. 76-168; s. 8, ch. 76-260; s. 5, ch. 77-64; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 353, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 15, ch. 86-160; s. 30, ch. 87-226; s. 6, ch. 88-206; s. 17, ch. 89-167; s. 13, ch. 90-249; s. 60, ch. 91-110; ss. 27, 114, ch. 92-318; s. 58, ch. 97-264; s. 9, ch. 98-49; ss. 222, 291, ch. 98-166; s. 140, ch. 2000-318; s. 57, ch. 2001-63; s. 1107, ch. 2003-261; s. 42, ch. 2003-416.

Note.--Former s. 627.355; s. 768.52, 1976 Supplement.

627.361  False or misleading information.--No person shall willfully withhold information from or knowingly give false or misleading information to the office, any statistical agency designated by the office, any rating organization, or any insurer, which will affect the rates or premiums chargeable under this part.

History.--s. 446, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 354, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1108, ch. 2003-261.

627.371  Hearings.--

(1)  Any person aggrieved by any rate charged, rating plan, rating system, or underwriting rule followed or adopted by an insurer, and any person aggrieved by any rating plan, rating system, or underwriting rule followed or adopted by a rating organization, may herself or himself or by her or his authorized representative make written request of the insurer or rating organization to review the manner in which the rate, plan, system, or rule has been applied with respect to insurance afforded her or him. If the request is not granted within 30 days after it is made, the requester may treat it as rejected. Any person aggrieved by the refusal of an insurer or rating organization to grant the review requested, or by the failure or refusal to grant all or part of the relief requested, may file a written complaint with the office, specifying the grounds relied upon. If the office has already disposed of the issue as raised by a similar complaint or believes that probable cause for the complaint does not exist or that the complaint is not made in good faith, it shall so notify the complainant. Otherwise, and if it also finds that the complaint charges a violation of this chapter and that the complainant would be aggrieved if the violation is proven, it shall proceed as provided in subsection (2).

(2)  If after examination of an insurer, rating organization, advisory organization, or group, association, or other organization of insurers which engages in joint underwriting or joint reinsurance, upon the basis of other information, or upon sufficient complaint as provided in subsection (1), the office has good cause to believe that such insurer, organization, group, or association, or any rate, rating plan, or rating system made or used by any such insurer or rating organization, does not comply with the requirements and standards of this part applicable to it, it shall, unless it has good cause to believe such noncompliance is willful, give notice in writing to such insurer, organization, group, or association stating therein in what manner and to what extent noncompliance is alleged to exist and specifying therein a reasonable time, not less than 10 days thereafter, in which the noncompliance may be corrected, including any premium adjustment.

(3)  If the office has good cause to believe that such noncompliance is willful or if, within the period prescribed by the office in the notice required by subsection (2), the insurer, organization, group, or association does not make such changes as may be necessary to correct the noncompliance specified by the office or establish to the satisfaction of the office that such specified noncompliance does not exist, then the office is required to proceed to further determine the matter. If no notice has been given as provided in subsection (2), the notice shall state in what manner and to what extent noncompliance is alleged to exist. The proceedings shall not consider any subject not specified in the notice required by subsections (2) and (3).

History.--s. 447, ch. 59-205; s. 20, ch. 67-9; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 355, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 5, ch. 93-289; s. 322, ch. 97-102; s. 1109, ch. 2003-261.

627.381  Penalty for violation.--

(1)  The office may, if it finds that any person or organization has violated any provision of this part, impose an administrative fine pursuant to s. 624.4211.

(2)  The office may suspend the license or authority of any rating organization or insurer which fails to comply with an order of the office within the time limited by such order, or any extension thereof which the office may grant. The office shall not suspend the license or authority of any rating organization or insurer for failure to comply with an order until the time prescribed for an appeal therefrom has expired or, if an appeal has been taken, until such order has been affirmed. The office may determine when a suspension of license or authority shall become effective and it shall remain in effect for the period fixed by it, unless it modifies or rescinds such suspension, or until the order upon which such suspension is based is modified, rescinded, or reversed.

History.--s. 448, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 356, 357, 809(2nd), ch. 82-243; ss. 49, 79, ch. 82-386; s. 114, ch. 92-318; s. 1110, ch. 2003-261.

PART II

THE INSURANCE CONTRACT

627.401  Scope of this part.

627.402  Definitions; specified certificates not included.

627.4025  Residential coverage and hurricane coverage defined.

627.403  "Premium" defined.

627.4035  Cash payment of premiums; claims.

627.404  Insurable interest; personal insurance.

627.405  Insurable interest; property.

627.406  Power to contract; purchase of insurance by or for minor.

627.407  Alteration of application.

627.408  Application as evidence.

627.4085  Insurer name, agent name, and license identification number required on application.

627.409  Representations in applications; warranties.

627.4091  Specific reasons for denial, cancellation, or nonrenewal.

627.410  Filing, approval of forms.

627.4101  Credit insurance enrollment forms.

627.4105  Life and health insurance; reduced premiums upon rigorous physical examination.

627.411  Grounds for disapproval.

627.412  Standard provisions, in general.

627.413  Contents of policies, in general; identification.

627.4131  Telephone number required.

627.4132  Stacking of coverages prohibited.

627.4133  Notice of cancellation, nonrenewal, or renewal premium.

627.4135  Casualty insurance contracts subject to general provisions for insurance contracts.

627.4136  Nonjoinder of insurers.

627.4137  Disclosure of certain information required.

627.414  Additional policy contents.

627.4143  Outline of coverage.

627.4145  Readable language in insurance policies.

627.4147  Medical malpractice insurance contracts.

627.4148  Medical malpractice insurers; required offer of coverage limits.

627.41495  Public notice of medical malpractice rate filings.

627.415  Charter, bylaw provisions.

627.416  Execution of policies.

627.417  Underwriters' and combination policies.

627.418  Validity of noncomplying contracts.

627.419  Construction of policies.

627.4195  Health insurance; claims for payment of psychotherapeutic services; confidentiality.

627.420  Binders.

627.4205  Coverage identification number required.

627.421  Delivery of policy.

627.422  Assignment of policies.

627.423  Payment discharges insurer.

627.4232  Health insurance out-of-hospital benefits.

627.4233  Total disability defined.

627.4234  Health insurance cost containment provisions required.

627.4235  Coordination of benefits.

627.4236  Coverage for bone marrow transplant procedures.

627.4237  Sickness disability or disability due to sickness.

627.4238  Health insurer examinations.

627.4239  Coverage for use of drugs in treatment of cancer.

627.42395  Coverage for certain prescription and nonprescription enteral formulas.

627.424  Minor may give acquittance.

627.425  Forms for proof of loss to be furnished.

627.426  Claims administration.

627.4265  Payment of settlement.

627.427  Payment of judgment by insurer; penalty for failure.

627.428  Attorney's fee.

627.429  Medical tests for HIV infection and AIDS for insurance purposes.

627.4295  Dental procedures; anesthesia and hospitalization coverage.

627.4301  Genetic information for insurance purposes.

627.4302  Identification cards for processing prescription drug claims.

627.441  Commercial general liability policies; coverage to contractors for completed operations.

627.401  Scope of this part.--No provision of this part of this chapter applies to:

(1)  Reinsurance.

(2)  Policies or contracts not issued for delivery in this state nor delivered in this state, except as otherwise provided in this code.

(3)  Wet marine and transportation insurance, except ss. 627.409, 627.420, and 627.428.

(4)  Title insurance, except ss. 627.406, 627.415, 627.416, 627.419, 627.427, and 627.428.

(5)  Credit life or credit disability insurance, except ss. 627.419(5) and 627.428.

History.--s. 450, ch. 59-205; s. 1, ch. 70-322; s. 1, ch. 70-371; s. 1, ch. 71-45; s. 163, ch. 73-333; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 358, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.402  Definitions; specified certificates not included.--As used in this part, the term:

(1)  "Policy" means a written contract of insurance or written agreement for or effecting insurance, or the certificate thereof, by whatever name called, and includes all clauses, riders, endorsements, and papers which are a part thereof.

(2)  The word "certificate" as used in this section does not include certificates as to group life or health insurance or as to group annuities issued to individual insureds.

History.--s. 451, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 359, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 28, 114, ch. 92-318.

627.4025  Residential coverage and hurricane coverage defined.--

(1)  Residential coverage includes both personal lines residential coverage, which consists of the type of coverage provided by homeowner's, mobile home owner's, dwelling, tenant's, condominium unit owner's, cooperative unit owner's, and similar policies, and commercial lines residential coverage, which consists of the type of coverage provided by condominium association, cooperative association, apartment building, and similar policies, including policies covering the common elements of a homeowners' association. Residential coverage for personal lines and commercial lines as set forth in this section includes policies that provide coverage for particular perils such as windstorm and hurricane or coverage for insurer insolvency or deductibles.

(2)  As used in policies providing residential coverage:

(a)  "Hurricane coverage" is coverage for loss or damage caused by the peril of windstorm during a hurricane. The term includes ensuing damage to the interior of a building, or to property inside a building, caused by rain, snow, sleet, hail, sand, or dust if the direct force of the windstorm first damages the building, causing an opening through which rain, snow, sleet, hail, sand, or dust enters and causes damage.

(b)  "Windstorm" for purposes of paragraph (a) means wind, wind gusts, hail, rain, tornadoes, or cyclones caused by or resulting from a hurricane which results in direct physical loss or damage to property.

(c)  "Hurricane" for purposes of paragraphs (a) and (b) means a storm system that has been declared to be a hurricane by the National Hurricane Center of the National Weather Service. The duration of the hurricane includes the time period, in Florida:

1.  Beginning at the time a hurricane watch or hurricane warning is issued for any part of Florida by the National Hurricane Center of the National Weather Service;

2.  Continuing for the time period during which the hurricane conditions exist anywhere in Florida; and

3.  Ending 72 hours following the termination of the last hurricane watch or hurricane warning issued for any part of Florida by the National Hurricane Center of the National Weather Service.

History.--s. 8, ch. 95-276; s. 11, ch. 96-194; s. 10, ch. 97-55.

627.403  "Premium" defined.--"Premium" is the consideration for insurance, by whatever name called. Any "assessment," or any "membership," "policy," "survey," "inspection," "service" or similar fee or charge in consideration for an insurance contract is deemed part of the premium.

History.--s. 452, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.4035  Cash payment of premiums; claims.--

(1)  The premiums for insurance contracts issued in this state or covering risk located in this state shall be paid in cash consisting of coins, currency, checks, or money orders or by using a debit card, credit card, automatic electronic funds transfer, or payroll deduction plan.

(2)  Subsection (1) is not applicable to:

(a)  Reinsurance agreements;

(b)  Pension plans;

(c)  Premium loans, whether or not subject to an automatic provision;

(d)  Dividends, whether to purchase additional paid-up insurance or to shorten the dividend payment period;

(e)  Salary deduction plans;

(f)  Preauthorized check plans;

(g)  Waivers of premiums on disability;

(h)  Nonforfeiture provisions affording benefits under supplementary contracts; or

(i)  Such other methods of paying for life insurance as may be permitted by the commission pursuant to rule or regulation.

(3)  All payments of claims made in this state under any contract of insurance shall be paid:

(a)  In cash consisting of coins, currency, checks, drafts, or money orders and, if by check or draft, shall be in such form as will comply with the standards for cash items adopted by the Federal Reserve System to facilitate the sorting, routing, and mechanized processing of such items; or

(b)  If authorized in writing by the recipient or the recipient's representative, by debit card or any other form of electronic transfer. Any fees or costs to be charged against the recipient must be disclosed in writing to the recipient or the recipient's representative at the time of written authorization.

History.--s. 1, ch. 70-69; s. 1, ch. 70-439; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 11, ch. 83-288; s. 114, ch. 92-318; s. 1, ch. 2000-113; s. 1111, ch. 2003-261; s. 1, ch. 2003-267; s. 1, ch. 2003-281.

627.404  Insurable interest; personal insurance.--

(1)  An insurer shall be entitled to rely upon all statements, declarations, and representations made by an applicant for insurance relative to the insurable interest which such applicant has in the insured; and no insurer shall incur any legal liability except as set forth in the policy, by virtue of any untrue statements, declarations, or representations so relied upon in good faith by the insurer.

(2)  A charitable organization that meets the requirements of s. 501(c)(3) of the Internal Revenue Code of 1986, as amended, may own or purchase life insurance on an insured who consents to the ownership or purchase of that insurance.

History.--s. 453, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 13, ch. 91-296; s. 114, ch. 92-318.

627.405  Insurable interest; property.--

(1)  No contract of insurance of property or of any interest in property or arising from property shall be enforceable as to the insurance except for the benefit of persons having an insurable interest in the things insured as at the time of the loss.

(2)  "Insurable interest" as used in this section means any actual, lawful, and substantial economic interest in the safety or preservation of the subject of the insurance free from loss, destruction, or pecuniary damage or impairment.

(3)  The measure of an insurable interest in property is the extent to which the insured might be damnified by loss, injury, or impairment thereof.

History.--s. 454, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.406  Power to contract; purchase of insurance by or for minor.--

(1)  Any person of competent legal capacity may contract for insurance.

(2)  Any minor of the age of 15 years or more, as determined by the nearest birthday, may, notwithstanding his or her minority, contract for annuities or for insurance on his or her own life, body, health, property, liabilities, or other interests or on the person of another in whom the minor has an insurable interest. Such a minor shall, notwithstanding such minority, be deemed competent to exercise all rights and powers with respect to or under any contract for annuity or for insurance upon his or her own life, body, or health or any contract such minor effected on his or her own property, liabilities, or other interests or on the person of another, as might be exercised by a person of full legal age. Such minor may at any time surrender his or her interest in any such contracts and give a valid discharge for any benefits accruing or money payable thereunder. Such a minor shall not, by reason of his or her minority, be entitled to rescind, avoid, or repudiate the contract, nor to rescind, avoid, or repudiate any exercise of a right or privilege thereunder, except that such a minor, not otherwise emancipated, shall not be bound by any unperformed agreement to pay, by promissory note or otherwise, any premium on any such annuity or insurance contract.

(3)  If any minor mentioned in subsection (2) is possessed of an estate that is being administered by a guardian or curator, no such contract shall be binding upon such estate as to payment of premiums, except as and when consented to by the guardian or curator and approved by the probate court of the county in which the administration of the estate is pending; and such consent and approval shall be required as to each premium payment.

(4)  Any annuity contract or policy of life or health insurance procured by or for a minor under subsection (2) shall be made payable either to the minor or his or her estate or to a person having an insurable interest in the life of such minor.

History.--s. 455, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 360, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 323, ch. 97-102.

627.407  Alteration of application.--No alteration of any written application for any life or health insurance policy shall be made by any person other than the applicant without his or her written consent, except that insertions may be made by the insurer, for administrative purposes only, in such manner as to indicate clearly that such insertions are not to be ascribed to the applicant.

History.--s. 456, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 361, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 324, ch. 97-102.

627.408  Application as evidence.--

(1)  An application for the issuance of any life or health insurance policy or annuity contract is not admissible in evidence in an action relative to the policy or contract unless a true copy of the application was attached to or otherwise made a part of the policy or contract when issued.

(2)  After reinstatement or renewal of a policy of insurance delivered or issued for delivery in this state, the insured may, in writing, request from the insurer a copy of the original application, or the application for renewal or reinstatement, if any. The insured or the beneficiary or assignee of a life or health insurance policy may request the application. Within 30 days after receiving the request, the insurer must deliver or mail a legible copy of the application to the person requesting it. If the request is made by a beneficiary, the 30-day period does not begin to run until after receipt of evidence satisfactory to the insurer of the beneficiary's vested interest in the policy or contract.

History.--s. 457, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 362, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 29, 114, ch. 92-318.

627.4085  Insurer name, agent name, and license identification number required on application.--

(1)  All applications for an insurance policy or annuity contract shall prominently display the name of the insuring entity on the first page of the application form at the time the coverage is bound or premium is quoted. Such applications shall also disclose the name and license identification number of the agent as shown on the agent's license issued by the department, which information may be typed, printed, stamped, or handwritten if legible.

(2)  This section does not apply to surplus lines business under the provisions of ss. 626.913-626.937.

History.--ss. 34, 65, ch. 88-166; s. 39, ch. 92-146; s. 114, ch. 92-318.

627.409  Representations in applications; warranties.--

(1)  Any statement or description made by or on behalf of an insured or annuitant in an application for an insurance policy or annuity contract, or in negotiations for a policy or contract, is a representation and is not a warranty. A misrepresentation, omission, concealment of fact, or incorrect statement may prevent recovery under the contract or policy only if any of the following apply:

(a)  The misrepresentation, omission, concealment, or statement is fraudulent or is material either to the acceptance of the risk or to the hazard assumed by the insurer.

(b)  If the true facts had been known to the insurer pursuant to a policy requirement or other requirement, the insurer in good faith would not have issued the policy or contract, would not have issued it at the same premium rate, would not have issued a policy or contract in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss.

(2)  A breach or violation by the insured of any warranty, condition, or provision of any wet marine or transportation insurance policy, contract of insurance, endorsement, or application therefor does not void the policy or contract, or constitute a defense to a loss thereon, unless such breach or violation increased the hazard by any means within the control of the insured.

History.--s. 458, ch. 59-205; s. 2, ch. 71-45; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 363, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 30, 114, ch. 92-318.

627.4091  Specific reasons for denial, cancellation, or nonrenewal.--

(1)  The denial of an application for an insurance policy must be accompanied by the specific reasons for denial, including the specific underwriting reasons, if applicable.

(2)  Each notice of nonrenewal or cancellation must be accompanied by the specific reasons for nonrenewal or cancellation, including the specific underwriting reasons, if applicable.

(3)  No cause of action in the nature of defamation, invasion of privacy, or negligence shall arise against any person for disclosing personal or privileged information in accordance with this section, nor shall such a cause of action arise against any person for furnishing personal or privileged information to an insurance institution, agent, or insurance-support organization; however, this section shall provide no immunity for disclosing or furnishing false information through gross negligence or with malice or willful intent to injure any person.

(4)  The provisions of any other statute respecting disclosure of personal information control to the extent of any conflict with this section.

(5)  When an insurer refuses to provide private passenger automobile insurance or personal lines residential property insurance, including, but not limited to, homeowner's, mobile home owner's, condominium unit owner's, or other insurance covering a personal residential structure, to an applicant due to adverse underwriting information, the insurer shall:

(a)  Provide to the applicant specific information regarding the reasons for the refusal to insure.

(b)  If the reason for the refusal to insure is based on a loss underwriting history or report from a consumer reporting agency, to the extent applicable identify the loss underwriting history and notify the applicant of his or her right under the federal Fair and Accurate Credit Transactions Act to obtain a copy of the report from the consumer reporting agency.

History.--s. 31, ch. 92-318; s. 12, ch. 2004-370; s. 157, ch. 2004-390.

627.410  Filing, approval of forms.--

(1)  No basic insurance policy or annuity contract form, or application form where written application is required and is to be made a part of the policy or contract, or group certificates issued under a master contract delivered in this state, or printed rider or endorsement form or form of renewal certificate, shall be delivered or issued for delivery in this state, unless the form has been filed with the office by or in behalf of the insurer which proposes to use such form and has been approved by the office. This provision does not apply to surety bonds or to policies, riders, endorsements, or forms of unique character which are designed for and used with relation to insurance upon a particular subject (other than as to health insurance), or which relate to the manner of distribution of benefits or to the reservation of rights and benefits under life or health insurance policies and are used at the request of the individual policyholder, contract holder, or certificateholder. As to group insurance policies effectuated and delivered outside this state but covering persons resident in this state, the group certificates to be delivered or issued for delivery in this state shall be filed with the office for information purposes only.

(2)  Every such filing must be made not less than 30 days in advance of any such use or delivery. At the expiration of such 30 days, the form so filed will be deemed approved unless prior thereto it has been affirmatively approved or disapproved by order of the office. The approval of any such form by the office constitutes a waiver of any unexpired portion of such waiting period. The office may extend by not more than an additional 15 days the period within which it may so affirmatively approve or disapprove any such form, by giving notice of such extension before expiration of the initial 30-day period. At the expiration of any such period as so extended, and in the absence of such prior affirmative approval or disapproval, any such form shall be deemed approved.

(3)  The office may, for cause, withdraw a previous approval. No insurer shall issue or use any form disapproved by the office, or as to which the office has withdrawn approval, after the effective date of the order of the office.

(4)  The office may, by order, exempt from the requirements of this section for so long as it deems proper any insurance document or form or type thereof as specified in such order, to which, in its opinion, this section may not practicably be applied, or the filing and approval of which are, in its opinion, not desirable or necessary for the protection of the public.

(5)  This section also applies to any such form used by domestic insurers for delivery in a jurisdiction outside this state if the insurance supervisory official of such jurisdiction informs the office that such form is not subject to approval or disapproval by such official, and upon the order of the office requiring the form to be submitted to it for the purpose. The applicable same standards apply to such forms as apply to forms for domestic use.

(6)(a)  An insurer shall not deliver or issue for delivery or renew in this state any health insurance policy form until it has filed with the office a copy of every applicable rating manual, rating schedule, change in rating manual, and change in rating schedule; if rating manuals and rating schedules are not applicable, the insurer must file with the office applicable premium rates and any change in applicable premium rates. This paragraph does not apply to group health insurance policies, effectuated and delivered in this state, insuring groups of 51 or more persons, except for Medicare supplement insurance, long-term care insurance, and any coverage under which the increase in claim costs over the lifetime of the contract due to advancing age or duration is prefunded in the premium.

(b)  The commission may establish by rule, for each type of health insurance form, procedures to be used in ascertaining the reasonableness of benefits in relation to premium rates and may, by rule, exempt from any requirement of paragraph (a) any health insurance policy form or type thereof (as specified in such rule) to which form or type such requirements may not be practically applied or to which form or type the application of such requirements is not desirable or necessary for the protection of the public. With respect to any health insurance policy form or type thereof which is exempted by rule from any requirement of paragraph (a), premium rates filed pursuant to ss. 627.640 and 627.662 shall be for informational purposes.

(c)  Every filing made pursuant to this subsection shall be made within the same time period provided in, and shall be deemed to be approved under the same conditions as those provided in, subsection (2).

(d)  Every filing made pursuant to this subsection, except disability income policies and accidental death policies, shall be prohibited from applying the following rating practices:

1.  Select and ultimate premium schedules.

2.  Premium class definitions which classify insured based on year of issue or duration since issue.

3.  Attained age premium structures on policy forms under which more than 50 percent of the policies are issued to persons age 65 or over.

(e)  Except as provided in subparagraph 1., an insurer shall continue to make available for purchase any individual policy form issued on or after October 1, 1993. A policy form shall not be considered to be available for purchase unless the insurer has actively offered it for sale in the previous 12 months.

1.  An insurer may discontinue the availability of a policy form if the insurer provides to the office in writing its decision at least 30 days prior to discontinuing the availability of the form of the policy or certificate. After receipt of the notice by the office, the insurer shall no longer offer for sale the policy form or certificate form in this state.

2.  An insurer that discontinues the availability of a policy form pursuant to subparagraph 1. shall not file for approval a new policy form providing similar benefits as the discontinued form for a period of 5 years after the insurer provides notice to the office of the discontinuance. The period of discontinuance may be reduced if the office determines that a shorter period is appropriate.

3.  The experience of all policy forms providing similar benefits shall be combined for all rating purposes.

(7)(a)  Each insurer subject to the requirements of subsection (6) shall make an annual filing with the office no later than 12 months after its previous filing, demonstrating the reasonableness of benefits in relation to premium rates. The office, after receiving a request to be exempted from the provisions of this section, may, for good cause due to insignificant numbers of policies in force or insignificant premium volume, exempt a company, by line of coverage, from filing rates or rate certification as required by this section.

(b)  The filing required by this subsection shall be satisfied by one of the following methods:

1.  A rate filing prepared by an actuary which contains documentation demonstrating the reasonableness of benefits in relation to premiums charged in accordance with the applicable rating laws and rules promulgated by the commission.

2.  If no rate change is proposed, a filing which consists of a certification by an actuary that benefits are reasonable in relation to premiums currently charged in accordance with applicable laws and rules promulgated by the commission.

(c)  As used in this section, "actuary" means an individual who is a member of the Society of Actuaries or the American Academy of Actuaries. If an insurer does not employ or otherwise retain the services of an actuary, the insurer's certification shall be prepared by insurer personnel or consultants with a minimum of 5 years' experience in insurance ratemaking. The chief executive officer of the insurer shall review and sign the certification indicating his or her agreement with its conclusions.

(d)  If at the time a filing is required under this section an insurer is in the process of completing a rate review, the insurer may apply to the office for an extension of up to an additional 30 days in which to make the filing. The request for extension must be received by the office no later than the date the filing is due.

(e)  If an insurer fails to meet the filing requirements of this subsection and does not submit the filing within 60 days following the date the filing is due, the office may, in addition to any other penalty authorized by law, order the insurer to discontinue the issuance of policies for which the required filing was not made, until such time as the office determines that the required filing is properly submitted.

(8)(a)  For the purposes of subsections (6) and (7), benefits of an individual accident and health insurance policy form, including Medicare supplement policies as defined in s. 627.672, when authorized by rules adopted by the commission, and excluding long-term care insurance policies as defined in s. 627.9404, and other policy forms under which more than 50 percent of the policies are issued to individuals age 65 and over, are deemed to be reasonable in relation to premium rates if the rates are filed pursuant to a loss ratio guarantee and both the initial rates and the durational and lifetime loss ratios have been approved by the office, and such benefits shall continue to be deemed reasonable for renewal rates while the insurer complies with such guarantee, provided the currently expected lifetime loss ratio is not more than 5 percent less than the filed lifetime loss ratio as certified to by an actuary. The office shall have the right to bring an administrative action should it deem that the lifetime loss ratio will not be met. For Medicare supplement filings, the office may withdraw a previously approved filing which was made pursuant to a loss ratio guarantee if it determines that the filing is not in compliance with ss. 627.671-627.675 or the currently expected lifetime loss ratio is less than the filed lifetime loss ratio as certified by an actuary in the initial guaranteed loss ratio filing. If this section conflicts with ss. 627.671-627.675, ss. 627.671-627.675 shall control.

(b)  The renewal premium rates shall be deemed to be approved upon filing with the office if the filing is accompanied by the most current approved loss ratio guarantee. The loss ratio guarantee shall be in writing, shall be signed by an officer of the insurer, and shall contain at least:

1.  A recitation of the anticipated lifetime and durational target loss ratios contained in the actuarial memorandum filed with the policy form when it was originally approved. The durational target loss ratios shall be calculated for 1-year experience periods. If statutory changes have rendered any portion of such actuarial memorandum obsolete, the loss ratio guarantee shall also include an amendment to the actuarial memorandum reflecting current law and containing new lifetime and durational loss ratio targets.

2.  A guarantee that the applicable loss ratios for the experience period in which the new rates will take effect, and for each experience period thereafter until new rates are filed, will meet the loss ratios referred to in subparagraph 1.

3.  A guarantee that the applicable loss ratio results for the experience period will be independently audited at the insurer's expense. The audit shall be performed in the second calendar quarter of the year following the end of the experience period, and the audited results shall be reported to the office no later than the end of such quarter. The commission shall establish by rule the minimum information reasonably necessary to be included in the report. The audit shall be done in accordance with accepted accounting and actuarial principles.

4.  A guarantee that affected policyholders in this state shall be issued a proportional refund, based on the premium earned, of the amount necessary to bring the applicable experience period loss ratio up to the durational target loss ratio referred to in subparagraph 1. The refund shall be made to all policyholders in this state who are insured under the applicable policy form as of the last day of the experience period, except that no refund need be made to a policyholder in an amount less than $10. Refunds less than $10 shall be aggregated and paid pro rata to the policyholders receiving refunds. The refund shall include interest at the then-current variable loan interest rate for life insurance policies established by the National Association of Insurance Commissioners, from the end of the experience period until the date of payment. Payments shall be made during the third calendar quarter of the year following the experience period for which a refund is determined to be due. However, no refunds shall be made until 60 days after the filing of the audit report in order that the office has adequate time to review the report.

5.  A guarantee that if the applicable loss ratio exceeds the durational target loss ratio for that experience period by more than 20 percent, provided there are at least 2,000 policyholders on the form nationwide or, if not, then accumulated each calendar year until 2,000 policyholder years is reached, the insurer, if directed by the office, shall withdraw the policy form for the purposes of issuing new policies.

(c)  As used in this subsection:

1.  "Loss ratio" means the ratio of incurred claims to earned premium.

2.  "Applicable loss ratio" means the loss ratio attributable solely to this state if there are 2,000 or more policyholders in the state. If there are 500 or more policyholders in this state but less than 2,000, it is the linear interpolation of the nationwide loss ratio and the loss ratio for this state. If there are less than 500 policyholders in this state, it is the nationwide loss ratio.

3.  "Experience period" means the period, ordinarily a calendar year, for which a loss ratio guarantee is calculated.

History.--s. 459, ch. 59-205; ss. 13, 35, ch. 69-106; s. 1, ch. 71-17; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 364, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 2, ch. 84-235; s. 3, ch. 89-360; s. 20, ch. 90-249; s. 12, ch. 90-366; s. 1, ch. 91-73; ss. 32, 114, ch. 92-318; s. 62, ch. 93-129; s. 22, ch. 93-260; s. 325, ch. 97-102; s. 3, ch. 98-159; s. 4, ch. 98-173; s. 5, ch. 2002-282; s. 1112, ch. 2003-261; s. 20, ch. 2004-297.

627.4101  Credit insurance enrollment forms.--All credit insurance enrollment forms must be approved by the office pursuant to the provisions of s. 627.410 or s. 627.682.

History.--s. 11, ch. 2002-57; s. 1113, ch. 2003-261.

627.4105  Life and health insurance; reduced premiums upon rigorous physical examination.--Upon request, the office may approve special life and health insurance policy forms providing for reduced premiums for each applicant passing a rigorous physical examination.

History.--s. 1, ch. 78-248; s. 2, ch. 81-318; ss. 365, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1114, ch. 2003-261.

627.411  Grounds for disapproval.--

(1)  The office shall disapprove any form filed under s. 627.410, or withdraw any previous approval thereof, only if the form:

(a)  Is in any respect in violation of, or does not comply with, this code.

(b)  Contains or incorporates by reference, where such incorporation is otherwise permissible, any inconsistent, ambiguous, or misleading clauses, or exceptions and conditions which deceptively affect the risk purported to be assumed in the general coverage of the contract.

(c)  Has any title, heading, or other indication of its provisions which is misleading.

(d)  Is printed or otherwise reproduced in such manner as to render any material provision of the form substantially illegible.

(e)  Is for health insurance, and:

1.  Provides benefits that are unreasonable in relation to the premium charged;

2.  Contains provisions that are unfair or inequitable or contrary to the public policy of this state or that encourage misrepresentation;

3.  Contains provisions that apply rating practices that result in unfair discrimination pursuant to s. 626.9541(1)(g)2.

(f)  Excludes coverage for human immunodeficiency virus infection or acquired immune deficiency syndrome or contains limitations in the benefits payable, or in the terms or conditions of such contract, for human immunodeficiency virus infection or acquired immune deficiency syndrome which are different than those which apply to any other sickness or medical condition.

(2)  In determining whether the benefits are reasonable in relation to the premium charged, the office, in accordance with reasonable actuarial techniques, shall consider:

(a)  Past loss experience and prospective loss experience within and without this state.

(b)  Allocation of expenses.

(c)  Risk and contingency margins, along with justification of such margins.

(d)  Acquisition costs.

(3)(a)  For health insurance coverage as described in s. 627.6561(5)(a)2., the minimum loss ratio standard of incurred claims to earned premium for the form shall be 65 percent.

(b)  Incurred claims are claims occurring within a fixed period, whether or not paid during the same period, under the terms of the policy period.

1.  Claims include scheduled benefit payments or services provided by a provider or through a provider network for dental, vision, disability, and similar health benefits.

2.  Claims do not include state assessments, taxes, company expenses, or any expense incurred by the company for the cost of adjusting and settling a claim, including the review, qualification, oversight, management, or monitoring of a claim or incentives or compensation to providers for other than the provisions of health care services.

3.  A company may at its discretion include costs that are demonstrated to reduce claims, such as fraud intervention programs or case management costs, which are identified in each filing, are demonstrated to reduce claims costs, and do not result in increasing the experience period loss ratio by more than 5 percent.

4.  For scheduled claim payments, such as disability income or long-term care, the incurred claims shall be the present value of the benefit payments discounted for continuance and interest.

History.--s. 460, ch. 59-205; ss. 13, 35, 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 366, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 48, ch. 88-380; s. 114, ch. 92-318; s. 63, ch. 93-129; s. 1, ch. 2003-139; s. 1115, ch. 2003-261.

627.412  Standard provisions, in general.--

(1)  Insurance contracts shall contain such standard or uniform provisions as are required by the applicable provisions of this code pertaining to contracts of particular kinds of insurance. The office may waive the required use of a particular provision in a particular insurance policy form if:

(a)  It finds such provision unnecessary for the protection of the insured and inconsistent with the purposes of the policy; and

(b)  The policy is otherwise approved by it.

(2)  No policy shall contain any provision inconsistent with or contradictory to any standard or uniform provision used or required to be used, but the office may approve any substitute provision which is, in its opinion, not less favorable in any particular to the insured or beneficiary than the provisions otherwise required.

(3)  In lieu of the provisions required by this code for contracts for particular kinds of insurance, substantially similar provisions required by the law of the domicile of a foreign or alien insurer may be used when approved by the office.

History.--s. 461, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1116, ch. 2003-261.

627.413  Contents of policies, in general; identification.--

(1)  Every policy shall specify:

(a)  The names of the parties to the contract.

(b)  The subject of the insurance.

(c)  The risks insured against.

(d)  The time when the insurance thereunder takes effect and the period during which the insurance is to continue.

(e)  The premium.

(f)  The conditions pertaining to the insurance.

(g)  The form numbers and edition dates or numeric code indicating edition dates, when such code has been supplied to the office, of all endorsements attached to a policy. This requirement applies to life insurance policies and health insurance policies only at the time of original issue.

(2)  If under the policy the exact amount of premium is determinable only at stated intervals or termination of the contract, a statement of the basis and rates upon which the premium is to be determined and paid shall be included.

(3)  Subsections (1) and (2) do not apply to surety contracts or to group insurance policies.

(4)  All policies and annuity contracts issued by insurers, and the forms thereof filed with the office, shall have printed thereon an appropriate designating letter or figure, or combination of letters or figures or terms identifying the respective forms of policies or contracts. Whenever any change is made in any such form, the designating letters, figures, or terms thereon shall be correspondingly changed.

(5)  Any policy that is a minimum premium policy issued by an insurer pursuant to the minimum premium provisions of rules adopted by rating organizations licensed by the office, shall have typed, printed, stamped, or legibly handwritten on the certificate the words "minimum premium policy" or equivalent language. The office may impose an administrative fine pursuant to s. 624.4211 if the office finds any violation of this subsection.

History.--s. 462, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 367, 377, 809(2nd), ch. 82-243; ss. 50, 79, ch. 82-386; s. 114, ch. 92-318; s. 16, ch. 98-174; s. 1117, ch. 2003-261.

627.4131  Telephone number required.--Each insurer issuing a policy subject to this part, or issuing a policy of title insurance, credit life insurance, or credit disability insurance in this state, must make a telephone number available for policyholders and certificateholders to present inquiries or obtain information about coverage and to provide assistance in resolving complaints. The policy or certificate must provide notice of the telephone number and its purposes.

History.--s. 34, ch. 92-318.

627.4132  Stacking of coverages prohibited.--If an insured or named insured is protected by any type of motor vehicle insurance policy for liability, personal injury protection, or other coverage, the policy shall provide that the insured or named insured is protected only to the extent of the coverage she or he has on the vehicle involved in the accident. However, if none of the insured's or named insured's vehicles is involved in the accident, coverage is available only to the extent of coverage on any one of the vehicles with applicable coverage. Coverage on any other vehicles shall not be added to or stacked upon that coverage. This section does not apply:

(1)  To uninsured motorist coverage which is separately governed by s. 627.727.

(2)  To reduce the coverage available by reason of insurance policies insuring different named insureds.

History.--s. 10, ch. 76-266; s. 1, ch. 80-364; s. 2, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 14, ch. 88-370; s. 114, ch. 92-318; s. 326, ch. 97-102.

627.4133  Notice of cancellation, nonrenewal, or renewal premium.--

(1)  Except as provided in subsection (2):

(a)  An insurer issuing a policy providing coverage for workers' compensation and employer's liability insurance, property, casualty, except mortgage guaranty, surety, or marine insurance, other than motor vehicle insurance subject to s. 627.728, shall give the named insured at least 45 days' advance written notice of nonrenewal or of the renewal premium. If the policy is not to be renewed, the written notice shall state the reason or reasons as to why the policy is not to be renewed. This requirement applies only if the insured has furnished all of the necessary information so as to enable the insurer to develop the renewal premium prior to the expiration date of the policy to be renewed.

(b)  An insurer issuing a policy providing coverage for property, casualty, except mortgage guaranty, surety, or marine insurance, other than motor vehicle insurance subject to s. 627.728 or s. 627.7281, shall give the named insured written notice of cancellation or termination other than nonrenewal at least 45 days prior to the effective date of the cancellation or termination, including in the written notice the reason or reasons for the cancellation or termination, except that:

1.  When cancellation is for nonpayment of premium, at least 10 days' written notice of cancellation accompanied by the reason therefor shall be given; and

2.  When such cancellation or termination occurs during the first 90 days during which the insurance is in force and the insurance is canceled or terminated for reasons other than nonpayment of premium, at least 20 days' written notice of cancellation or termination accompanied by the reason therefor shall be given except where there has been a material misstatement or misrepresentation or failure to comply with the underwriting requirements established by the insurer.

After the policy has been in effect for 90 days, no such policy shall be canceled by the insurer except when there has been a material misstatement, a nonpayment of premium, a failure to comply with underwriting requirements established by the insurer within 90 days of the date of effectuation of coverage, or a substantial change in the risk covered by the policy or when the cancellation is for all insureds under such policies for a given class of insureds. The provisions of this subsection shall not apply to individually rated risks having a policy term of less than 90 days.

(c)  If an insurer fails to provide the 45-day or 20-day written notice required under this section, the coverage provided to the named insured shall remain in effect until 45 days after the notice is given or until the effective date of replacement coverage obtained by the named insured, whichever occurs first. The premium for the coverage shall remain the same during any such extension period except that, in the event of failure to provide notice of nonrenewal, if the rate filing then in effect would have resulted in a premium reduction, the premium during such extension of coverage shall be calculated based upon the later rate filing.

(2)  With respect to any personal lines or commercial residential property insurance policy, including, but not limited to, any homeowner's, mobile home owner's, farmowner's, condominium association, condominium unit owner's, apartment building, or other policy covering a residential structure or its contents:

(a)  The insurer shall give the named insured at least 45 days' advance written notice of the renewal premium.

(b)  The insurer shall give the named insured written notice of nonrenewal, cancellation, or termination at least 90 days prior to the effective date of the nonrenewal, cancellation, or termination. The notice must include the reason or reasons for the nonrenewal, cancellation, or termination, except that:

1.  When cancellation is for nonpayment of premium, at least 10 days' written notice of cancellation accompanied by the reason therefor shall be given.

2.  When such cancellation or termination occurs during the first 90 days during which the insurance is in force and the insurance is canceled or terminated for reasons other than nonpayment of premium, at least 20 days' written notice of cancellation or termination accompanied by the reason therefor shall be given except where there has been a material misstatement or misrepresentation or failure to comply with the underwriting requirements established by the insurer.

After the policy has been in effect for 90 days, the policy shall not be canceled by the insurer except when there has been a material misstatement, a nonpayment of premium, a failure to comply with underwriting requirements established by the insurer within 90 days of the date of effectuation of coverage, or a substantial change in the risk covered by the policy or when the cancellation is for all insureds under such policies for a given class of insureds. This paragraph does not apply to individually rated risks having a policy term of less than 90 days.

(c)  If the insurer fails to provide the notice required by this subsection, other than the 10-day notice, the coverage provided to the named insured shall remain in effect until the effective date of replacement coverage or until the expiration of a period of days after the notice is given equal to the required notice period, whichever occurs first. The premium for the coverage shall remain the same during any such extension period except that, in the event of failure to provide notice of nonrenewal, if the rate filing then in effect would have resulted in a premium reduction, the premium during such extension shall be calculated based on the later rate filing.

(3)  Claims on property insurance policies that are the result of an act of God may not be used as a cause for cancellation or nonrenewal, unless the insurer can demonstrate, by claims frequency or otherwise, that the insured has failed to take action reasonably necessary as requested by the insurer to prevent recurrence of damage to the insured property.

(4)  Notwithstanding the provisions of s. 440.42(3), if cancellation of a policy providing coverage for workers' compensation and employer's liability insurance is requested by the insured, such cancellation shall be effective on the date the carrier sends the notice of cancellation to the insured.

(5)  An insurer that cancels a property insurance policy on property secured by a mortgage due to the failure of the lender to timely pay the premium when due shall reinstate the policy as required by s. 501.137.

(6)  A single claim on a property insurance policy which is the result of water damage may not be used as the sole cause for cancellation or nonrenewal unless the insurer can demonstrate that the insured has failed to take action reasonably requested by the insurer to prevent a future similar occurrence of damage to the insured property.

History.--s. 16, ch. 86-160; s. 2, ch. 87-50; s. 8, ch. 87-124; s. 12, ch. 90-119; ss. 35, 114, ch. 92-318; s. 15, ch. 93-410; s. 99, ch. 93-415; s. 13, ch. 2004-370; s. 43, ch. 2004-374; ss. 109, 158, ch. 2004-390.

627.4135  Casualty insurance contracts subject to general provisions for insurance contracts.--All contracts of casualty insurance covering subjects resident, located, or to be performed in this state shall be subject to the applicable provisions of this part and to the other applicable provisions of this code.

History.--s. 610, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 563, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 36, 114, ch. 92-318.

Note.--Former s. 627.726.

627.4136  Nonjoinder of insurers.--

(1)  It shall be a condition precedent to the accrual or maintenance of a cause of action against a liability insurer by a person not an insured under the terms of the liability insurance contract that such person shall first obtain a settlement or verdict against a person who is an insured under the terms of such policy for a cause of action which is covered by such policy.

(2)  Notwithstanding subsection (1), any insurer who pays any taxable costs or attorney's fees which would be recoverable by the insured but for the fact that such costs or fees were paid by the insurer shall be considered a party for the purpose of recovering such fees or costs. No person who is not an insured under the terms of a liability insurance policy shall have any interest in such policy, either as a third-party beneficiary or otherwise, prior to first obtaining a settlement or verdict against a person who is an insured under the terms of such policy for a cause of action which is covered by such policy.

(3)  Insurers are affirmatively granted the substantive right to insert in liability insurance policies contractual provisions that preclude persons who are not designated as insureds in such policies from joining a liability insurer as a party defendant with its insured prior to the rendition of a verdict. The contractual provisions authorized in this subsection shall be fully enforceable.

(4)  At the time a judgment is entered or a settlement is reached during the pendency of litigation, a liability insurer may be joined as a party defendant for the purposes of entering final judgment or enforcing the settlement by the motion of any party, unless the insurer denied coverage under the provisions of s. 627.426(2) or defended under a reservation of rights pursuant to s. 627.426(2). A copy of the motion to join the insurer shall be served on the insurer by certified mail. If a judgment is reversed or remanded on appeal, the insurer's presence shall not be disclosed to the jury in a subsequent trial.

History.--s. 12, ch. 76-266; s. 2, ch. 81-318; ss. 542, 563, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 38, ch. 90-119; ss. 37, 114, ch. 92-318.

Note.--Former s. 627.7262.

627.4137  Disclosure of certain information required.--

(1)  Each insurer which does or may provide liability insurance coverage to pay all or a portion of any claim which might be made shall provide, within 30 days of the written request of the claimant, a statement, under oath, of a corporate officer or the insurer's claims manager or superintendent setting forth the following information with regard to each known policy of insurance, including excess or umbrella insurance:

(a)  The name of the insurer.

(b)  The name of each insured.

(c)  The limits of the liability coverage.

(d)  A statement of any policy or coverage defense which such insurer reasonably believes is available to such insurer at the time of filing such statement.

(e)  A copy of the policy.

In addition, the insured, or her or his insurance agent, upon written request of the claimant or the claimant's attorney, shall disclose the name and coverage of each known insurer to the claimant and shall forward such request for information as required by this subsection to all affected insurers. The insurer shall then supply the information required in this subsection to the claimant within 30 days of receipt of such request.

(2)  The statement required by subsection (1) shall be amended immediately upon discovery of facts calling for an amendment to such statement.

History.--ss. 543, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 22, ch. 83-288; ss. 38, 114, ch. 92-318; s. 327, ch. 97-102.

Note.--Former s. 627.7264.

627.414  Additional policy contents.--A policy may contain additional provisions not inconsistent with this code and which are:

(1)  Required to be inserted by the laws of the insurer's domicile;

(2)  Necessary, on account of the manner in which the insurer is constituted or operated, in order to state the rights and obligations of the parties to the contract; or

(3)  Desired by the insurer and neither prohibited by law nor in conflict with any provisions required to be included therein.

History.--s. 463, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.4143  Outline of coverage.--

(1)  No private passenger automobile or basic homeowner's policy shall be delivered or issued for delivery in this state unless an appropriate outline of coverage has been delivered prior to issuance of the policy or accompanies the policy when issued.

(2)  The outline of coverage shall contain all of the following:

(a)  A brief description of the principal benefits and coverage provided in the policy, broken down by each class or type of coverage provided under the policy for which a premium is charged, and itemization of the applicable premium.

(b)  A summary statement of the principal exclusions and limitations or reductions contained in the policy by class or type, including, but not limited to, deductibles, coinsurance, and any other limitations or reductions.

(c)  A summary statement of any renewal or cancellation provisions.

(d)  A description of the credit or surcharge plan that is being applied. The description may display numerical or alphabetical codes on the declarations page or premium notice to enable the insured to determine the reason or reasons why her or his policy is being surcharged or is receiving a credit.

(e)  A list of any additional coverage provided through any rider or endorsement which accompanies the policy. The list shall contain a descriptive reference to each additional coverage, rather than solely a reference to a form or code number.

(f)  For a private passenger motor vehicle insurance policy, the extent of coverage provided to the insured in the event of collision damage to a rental vehicle rented by the insured. The proof-of-insurance card required by s. 316.646 must also specify whether rental car coverage is provided, and may refer to the outline of coverage as to the details or extent of coverage.

(3)  The outline of coverage is required only on the initial policy issued by an insurer.

(4)  An insurer must insert the following language on the outline of coverage:

"The following outline of coverage is for informational purposes only. Florida law prohibits this outline from changing any of the provisions of the insurance contract which is the subject of this outline. Any endorsement regarding changes in types of coverage, exclusions, limitations, reductions, deductibles, coinsurance, renewal provisions, cancellation provisions, surcharges, or credits will be sent separately."

(5)  Neither this section nor the outline of coverage mandated by this section alters or modifies the terms of the insurance contract, creates a cause of action, or is admissible in any civil action.

History.--s. 23, ch. 89-360; s. 1, ch. 90-192; ss. 39, 114, ch. 92-318; s. 328, ch. 97-102.

627.4145  Readable language in insurance policies.--

(1)  Every policy shall be readable as required by this section. For the purposes of this section, the term "policy" means a policy form or endorsement. A policy is deemed readable if:

(a)  The text achieves a minimum score of 45 on the Flesch reading ease test as computed in subsection (5) or an equivalent score on any other test comparable in result and approved by the office;

(b)  It uses layout and spacing which separate the paragraphs from each other and from the border of the paper;

(c)  It has section titles that are captioned in boldfaced type or that otherwise stand out significantly from the text;

(d)  It avoids the use of unnecessarily long, complicated, or obscure words, sentences, paragraphs, or constructions;

(e)  The style, arrangement, and overall appearance of the policy give no undue prominence to any portion of the text of the policy or to any endorsements or riders; and

(f)  It contains a table of contents or an index of the principal sections of the policy, if the policy has more than 3,000 words or more than three pages.

(2)  The office may authorize a lower score than the Flesch reading ease test score required in subsection (1) whenever it finds that a lower score will provide a more accurate reflection of the readability of a policy form, is warranted by the nature of a particular policy form or type or class of policy forms, or is the result of language which is used to conform to the requirements of any law.

(3)  A filing subject to this section shall be accompanied by a certification signed by an officer of the insurer stating that the policy meets the requirements of subsection (1). Such certification shall state that the policy meets the minimum reading ease test score on the test used or that the score is lower than the minimum required but should be approved in accordance with subsection (2). The office may require the submission of further information to verify any certification.

(4)  Any non-English language policy shall be deemed to be in compliance with this section if the insurer certifies that such policy is translated from an English language policy which complies with this section.

(5)  A Flesch reading ease test score shall be measured by the following method:

(a)  For policy forms containing 10,000 words or fewer of text, the entire form shall be analyzed. For policy forms containing more than 10,000 words, the readability of two 200-word samples per page may be analyzed instead of the entire form. The samples shall be separated by at least 20 printed lines.

(b)  The total number of words in the text shall be counted and divided by the total number of sentences, and the figure obtained shall be multiplied by a factor of 1.015.

(c)  The total number of syllables shall be counted and divided by the total number of words, and the figure obtained shall be multiplied by a factor of 84.6.

(d)  The sum of the figures computed under paragraphs (b) and (c) subtracted from 206.835 equals the Flesch reading ease test score for the policy form.

(e)  For purposes of this subsection:

1.  A contraction, hyphenated word, or numerals and letters, when separated by spaces, shall be counted as one word; and

2.  A unit of words ending with a period, semicolon, or colon, excluding headings and captions, shall be counted as one sentence.

(f)  The term "text" as used in this subsection includes all printed matter except:

1.  The name and address of the insurer; the name, number, or title of the policy; the table of contents or index; captions and subcaptions; specification pages; schedules; or tables;

2.  Policy language required by any collectively bargained agreement;

3.  Any medical terminology;

4.  Words which are defined in the policy; and

5.  Any policy language required by law, if the insurer identifies the language or terminology excepted by this paragraph and certifies to the office, in writing, that the language or terminology is entitled to be excepted under this paragraph.

(g)  At the option of the insurer, riders, endorsements, applications, and other forms made a part of the policy may be scored as separate forms or as part of the policy with which they are to be used.

(6)  This section does not apply to:

(a)  Any policy which is a security subject to federal jurisdiction;

(b)  Any group policy covering a group of 1,000 or more lives at date of issue, other than a group credit life insurance policy or a group credit health insurance policy; however, this paragraph does not exempt any certificate issued pursuant to a group policy delivered or issued for delivery in this state;

(c)  Any group annuity contract which serves as a funding vehicle for pension, profit-sharing, or deferred compensation plans;

(d)  Any form used in connection with, as a conversion from, as an addition to, or in exchange pursuant to a contractual provision for a policy delivered or issued for delivery on a form approved or permitted to be issued prior to the dates such forms must be approved under this section;

(e)  Any policy or form, or partial revision thereof, or renewal thereof, which policy or form is filed prior to October 1, 1983; or

(f)  Endorsements filed on or after October 1, 1983, which modify policy forms prior to October 1, 1983.

(g)  Mortgage guaranty insurance policies, as defined in s. 635.011.

(7)  This section applies to forms filed on or after October 1, 1983.

History.--ss. 368, 809(2nd), ch. 82-243; ss. 51, 79, ch. 82-386; s. 96, ch. 83-216; s. 13, ch. 83-288; s. 2, ch. 84-352; s. 114, ch. 92-318; s. 1118, ch. 2003-261.

627.4147  Medical malpractice insurance contracts.--

(1)  In addition to any other requirements imposed by law, each self-insurance policy as authorized under s. 627.357 or s. 624.462 or insurance policy providing coverage for claims arising out of the rendering of, or the failure to render, medical care or services, including those of the Florida Medical Malpractice Joint Underwriting Association, shall include:

(a)  A clause requiring the insured to cooperate fully in the review process prescribed under s. 766.106 if a notice of intent to file a claim for medical malpractice is made against the insured.

(b)1.  Except as provided in subparagraph 2., a clause authorizing the insurer or self-insurer to determine, to make, and to conclude, without the permission of the insured, any offer of admission of liability and for arbitration pursuant to s. 766.106, settlement offer, or offer of judgment, if the offer is within the policy limits. It is against public policy for any insurance or self-insurance policy to contain a clause giving the insured the exclusive right to veto any offer for admission of liability and for arbitration made pursuant to s. 766.106, settlement offer, or offer of judgment, when such offer is within the policy limits. However, any offer of admission of liability, settlement offer, or offer of judgment made by an insurer or self-insurer shall be made in good faith and in the best interests of the insured.

2.a.  With respect to dentists licensed under chapter 466, a clause clearly stating whether or not the insured has the exclusive right to veto any offer of admission of liability and for arbitration pursuant to s. 766.106, settlement offer, or offer of judgment if the offer is within policy limits. An insurer or self-insurer shall not make or conclude, without the permission of the insured, any offer of admission of liability and for arbitration pursuant to s. 766.106, settlement offer, or offer of judgment, if such offer is outside the policy limits. However, any offer for admission of liability and for arbitration made under s. 766.106, settlement offer, or offer of judgment made by an insurer or self-insurer shall be made in good faith and in the best interest of the insured.

b.  If the policy contains a clause stating the insured does not have the exclusive right to veto any offer or admission of liability and for arbitration made pursuant to s. 766.106, settlement offer or offer of judgment, the insurer or self-insurer shall provide to the insured or the insured's legal representative by certified mail, return receipt requested, a copy of the final offer of admission of liability and for arbitration made pursuant to s. 766.106, settlement offer or offer of judgment and at the same time such offer is provided to the claimant. A copy of any final agreement reached between the insurer and claimant shall also be provided to the insurer or his or her legal representative by certified mail, return receipt requested not more than 10 days after affecting such agreement.

(c)  A clause requiring the insurer or self-insurer to notify the insured no less than 90 days prior to the effective date of cancellation of the policy or contract and, in the event of a determination by the insurer or self-insurer not to renew the policy or contract, to notify the insured no less than 90 days prior to the end of the policy or contract period. If cancellation or nonrenewal is due to nonpayment or loss of license, 10 days' notice is required.

(d)  A clause requiring the insurer or self-insurer to notify the insured no less than 60 days prior to the effective date of a rate increase. The provisions of s. 627.4133 shall apply to such notice and to the failure of the insurer to provide such notice to the extent not in conflict with this section.

(2)  Each insurer covered by this section may require the insured to be a member in good standing, i.e., not subject to expulsion or suspension, of a duly recognized state or local professional society of health care providers which maintains a medical review committee. No professional society shall expel or suspend a member solely because he or she participates in a health maintenance organization licensed under part I of chapter 641.

(3)  This section shall apply to all policies issued or renewed after October 1, 2003.

History.--ss. 6, 44, ch. 85-175; s. 5, ch. 86-287; s. 114, ch. 92-318; s. 23, ch. 95-211; s. 1, ch. 96-361; s. 1733, ch. 97-102; s. 29, ch. 99-3; s. 43, ch. 2003-416.

627.4148  Medical malpractice insurers; required offer of coverage limits.--An insurer issuing policies of professional liability coverage for claims arising out of the rendering of, or the failure to render, medical care or services shall make available to physicians licensed under chapter 458 and to osteopathic physicians licensed under chapter 459 coverage with the following limits, subject to usual underwriting standards:

(1)  One hundred thousand dollars per claim, $300,000 annual aggregate; and

(2)  Two hundred fifty thousand dollars per claim, $750,000 annual aggregate.

History.--s. 46, ch. 86-160; s. 2, ch. 87-50; s. 1, ch. 90-249; s. 114, ch. 92-318.

Note.--Former s. 627.6057.

627.41495  Public notice of medical malpractice rate filings.--

(1)  Upon the filing of a proposed rate change by a medical malpractice insurer or self-insurance fund, which filing would result in an average statewide increase of 25 percent or more, pursuant to standards determined by the office, the insurer or self-insurance fund shall mail notice of such filing to each of its policyholders or members.

(2)  The rate filing shall be available for public inspection.

History.--s. 44, ch. 2003-416.

627.415  Charter, bylaw provisions.--No policy shall contain any provision purporting to make any portion of the charter, bylaws, or other constituent document of the insurer (other than the subscribers' agreement or power of attorney of a reciprocal insurer) a part of the contract unless such portion is set forth in full in the policy. Any policy provision in violation of this section is invalid.

History.--s. 464, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.416  Execution of policies.--

(1)  Every insurance policy shall be executed in the name of and on behalf of the insurer by its officer, attorney in fact, employee, or representative duly authorized by the insurer.

(2)  A facsimile signature of any such executing individual may be used in lieu of an original signature.

(3)  No insurance contract which is otherwise valid shall be rendered invalid by reason of the apparent execution thereof on behalf of the insurer by the imprinted facsimile signature of an individual not authorized so to execute as of the date of the policy.

History.--s. 465, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 369, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.417  Underwriters' and combination policies.--

(1)  Two or more authorized insurers may jointly issue, and shall be jointly and severally liable on, an underwriters' policy bearing their names. Any one insurer may issue a policy in the name of an underwriter's department, and such policy shall plainly show the true name of the insurer.

(2)  Two or more authorized insurers may, with the approval of the office, issue a combination policy which shall contain provisions substantially as follows:

(a)  That the insurers executing the policy shall be severally liable for the full amount of any loss or damage, according to the terms of the policy, or for specified percentages or amounts thereof, aggregating the full amount of insurance under the policy; and

(b)  That service of process, or of any notice or proof of loss required by such policy, upon any of the insurers executing the policy, shall constitute service upon all such insurers.

(3)  This section does not apply to cosurety obligations.

History.--s. 466, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1119, ch. 2003-261.

627.418  Validity of noncomplying contracts.--

(1)  Any insurance policy, rider, or endorsement otherwise valid which contains any condition or provision not in compliance with the requirements of this code shall not be thereby rendered invalid, except as provided in s. 627.415, but shall be construed and applied in accordance with such conditions and provisions as would have applied had such policy, rider, or endorsement been in full compliance with this code. In the event an insurer issues or delivers any policy for an amount which exceeds any limitations otherwise provided in this code, such insurer shall be liable to the insured or his or her beneficiary for the full amount stated in the policy in addition to any other penalties that may be imposed under this code.

(2)  Any insurance contract delivered or issued for delivery in this state covering a subject or subjects of insurance resident, located, or to be performed in this state, which subjects, pursuant to the provisions of this code, the insurer may not lawfully insure under such a contract, shall be cancelable at any time by the insurer, any provision of the contract to the contrary notwithstanding; and the insurer shall promptly cancel the contract in accordance with the request of the office therefor. No such illegality or cancellation shall be deemed to relieve the insurer of any liability incurred by it under the contract while in force, or to prohibit the insurer from retaining the pro rata earned premium thereon. This provision does not relieve the insurer from any penalty otherwise incurred by the insurer under this code on account of any such violation.

History.--s. 467, ch. 59-205; ss. 13, 35, ch. 69-106; s. 1, ch. 72-23; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 370, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 329, ch. 97-102; s. 1120, ch. 2003-261.

Note.--Former s. 627.0117.

627.419  Construction of policies.--

(1)  Every insurance contract shall be construed according to the entirety of its terms and conditions as set forth in the policy and as amplified, extended, or modified by any application therefor or any rider or endorsement thereto.

(2)  The word "physician" or "medical doctor," when used in any health insurance policy, health care services plan, or other contract providing for the payment of surgical procedures which are specified in the policy or contract or are performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist's professional license, shall be construed to include a dentist who performs such specified procedures.

(3)  Notwithstanding any other provision of law, when any health insurance policy, health care services plan, or other contract provides for the payment for procedures specified in the policy or contract which are within the scope of an optometrist's or podiatric physician's professional license, such policy shall be construed to include payment to an optometrist or podiatric physician who performs such procedures. In the case of podiatric services, such payments shall be made in accordance with the coverage now provided for medical and surgical benefits.

(4)  Notwithstanding any other provision of law, when any health insurance policy, health care services plan, or other contract provides for the payment for medical expense benefits or procedures, such policy, plan, or contract shall be construed to include payment to a chiropractic physician who provides the medical service benefits or procedures which are within the scope of a chiropractic physician's license. Any limitation or condition placed upon payment to, or upon services, diagnosis, or treatment by, any licensed physician shall apply equally to all licensed physicians without unfair discrimination to the usual and customary treatment procedures of any class of physicians.

(5)  For purposes of coverage under a policy of disability income or credit disability insurance, no determination of disability shall be rejected solely on the basis of the chapter under which the physician is licensed; however, such determination may be rejected on the basis that the determination is outside the scope of the physician's authorized practice. However, the insurance carrier shall have the option after 30 days of disability to seek a second physician's opinion prior to paying additional benefits.

(6)  Notwithstanding any other provision of law, when any health insurance policy, health care services plan, or other contract provides for payment for surgical first assisting benefits or services, the policy, plan, or contract is to be construed as providing for payment to a registered nurse first assistant or employers of a physician assistant or nurse first assistant who performs such services that are within the scope of a physician assistant's or a registered nurse first assistant's professional license. The provisions of this subsection apply only if reimbursement for an assisting physician, licensed under chapter 458 or chapter 459, would be covered and a physician assistant or a registered nurse first assistant who performs such services is used as a substitute.

(7)  No health insurance policy, health care services plan, or other contract which provides coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton shall discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. This subsection shall not be construed to affect any other coverage under this part or to restrict the scope of coverage under any policy, plan, or contract. Nothing in this subsection shall be construed to discourage appropriate nonsurgical procedures or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the jaw and facial region. Furthermore, nothing in this subsection requires coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes. This section does not apply to accident only, disability income, specified disease, hospital indemnity, credit, Medicare supplement, or long-term care insurance policies.

(8)  If an insurer or licensee advertises an insurance policy in a language other than English, the advertisements shall not be construed to modify or change the insurance policy written in English. The advertisement must disclose that the policy written in English controls in the event of a dispute and that statements contained in the advertisement do not necessarily, as a result of possible linguistic differences, reflect the contents of the policy written in English. Nothing in this subsection shall affect the provisions of s. 626.9541 relating to misrepresentations and false advertising of insurance policies.

(9)  With respect to any group or individual insurer covering dental services, each claimant, or dentist acting for a claimant, who has had a claim denied as not medically or dentally necessary or who has had a claim payment based on an alternate dental service in accordance with accepted dental standards for adequate and appropriate care must be provided an opportunity for an appeal to the insurer's licensed dentist who is responsible for the medical necessity reviews under the plan or is a member of the plan's peer review group. The appeal may be by telephone, and the insurer's dentist must respond within a reasonable time, not to exceed 15 business days.

History.--s. 468, ch. 59-205; s. 1, ch. 69-245; ss. 1, 2, ch. 72-11; s. 163A, ch. 73-333; s. 1, ch. 74-34; s. 1, ch. 74-87; s. 1, ch. 76-167; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 371, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 86-40; s. 3, ch. 90-255; s. 114, ch. 92-318; s. 5, ch. 94-96; s. 2, ch. 96-361; s. 1, ch. 97-5; s. 3, ch. 97-178; s. 223, ch. 98-166; s. 3, ch. 2001-176; s. 107, ch. 2001-277.

Note.--Former s. 627.0118.

627.4195  Health insurance; claims for payment of psychotherapeutic services; confidentiality.--An insurer must maintain strict confidentiality against unauthorized or inadvertent disclosure of confidential information to persons inside or outside the insurer's organization regarding claims for payment of psychotherapeutic services provided by psychotherapists licensed under chapter 490 or chapter 491 and psychotherapeutic records and reports related to the claims. A report, in lieu of records, may be submitted by a psychotherapist in support of a claim. Such report must include clear statements summarizing the insured's presenting symptoms, what transpired in any provided therapy, what progress, if any, was made by the insured and results obtained. However, the insurer may require the records upon which the report is based, if the report does not contain sufficient information for properly processing the claim. A psychotherapist submitting records in support of a claim may obscure portions to conceal the names, identities, or identifying information of people other than the insured if this information is unnecessary to utilization review, quality management, discharge planning, case management, or claims processing conducted by the insurer. An insurer may provide aggregate data which does not disclose subscriber identities or identities of other persons to entities such as payors, sponsors, researchers and accreditation bodies. As used in this section, "insurer" means an individual health insurance policy subject to this chapter, an insurer issuing a group health insurance policy or certificate pursuant to s. 627.651, a plan of self-insurance providing the health coverage benefits to residents of this state pursuant to s. 627.651, an insurer delivering a group health policy issued or delivered outside this state under which a resident of this state is provided coverage pursuant to s. 627.6515, a preferred provider organization as defined in s. 627.6471, an exclusive provider organization as defined in s. 627.6472, and prepaid health service organizations providing mental health services pursuant to chapter 636.

History.--s. 2, ch. 96-180.

Note.--Former s. 627.66995.

627.420  Binders.--Binders or other contracts for temporary property, marine, casualty, or surety insurance may be made orally or in writing, and shall be deemed to include all the usual terms of the policy as to which the binder was given together with such applicable endorsements as are designated in the binder, except as superseded by the clear and express terms of the binder. No notice of cancellation or notice of nonrenewal otherwise required by this chapter shall be required unless the duration of the binder exceeds 60 days. However, for purposes of ss. 627.728 and 627.7281, an insurer shall give 5 days' prior notice of cancellation of a binder, unless the binder is replaced by a policy or another binder in the same or another company.

History.--s. 469, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 85-51; s. 114, ch. 92-318.

627.4205  Coverage identification number required.--An insurer shall provide to the named insured a coverage identification number no later than the time insurance coverage under a policy, binder, or other contract providing any insurance or surety coverage becomes effective. The coverage identification number shall be construed for regulatory purposes under this code as a policy number.

History.--s. 17, ch. 86-160; s. 2, ch. 87-50; s. 114, ch. 92-318.

627.421  Delivery of policy.--

(1)  Subject to the insurer's requirement as to payment of premium, every policy shall be mailed or delivered to the insured or to the person entitled thereto not later than 60 days after the effectuation of coverage.

(2)  In the event the original policy is delivered or is so required to be delivered to or for deposit with any vendor, mortgagee, or pledgee of any motor vehicle, and in which policy any interest of the vendee, mortgagor, or pledgor in or with reference to such vehicle is insured, a duplicate of such policy setting forth the name and address of the insurer, insurance classification of vehicle, type of coverage, limits of liability, premiums for the respective coverages, and duration of the policy, or memorandum thereof containing the same such information, shall be delivered by the vendor, mortgagee, or pledgee to each such vendee, mortgagor, or pledgor named in the policy or coming within the group of persons designated in the policy to be so included. If the policy does not provide coverage of legal liability for injury to persons or damage to the property of third parties, a statement of such fact shall be printed, written, or stamped conspicuously on the face of such duplicate policy or memorandum. This subsection does not apply to inland marine floater policies.

(3)  Any automobile liability or physical damage policy shall contain on the front page a summary of major coverages, conditions, exclusions, and limitations contained in that policy. Any such summary shall state that the issued policy should be referred to for the actual contractual governing provisions. The company may, in lieu of the summary, provide a readable policy.

History.--s. 470, ch. 59-205; s. 1, ch. 75-218; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 18, ch. 86-160; s. 114, ch. 92-318.

627.422  Assignment of policies.--A policy may be assignable, or not assignable, as provided by its terms. Subject to its terms relating to assignability, any life or health insurance policy under the terms of which the beneficiary may be changed upon the sole request of the policyowner may be assigned either by pledge or transfer of title, by an assignment executed by the policyowner alone and delivered to the insurer, whether or not the pledgee or assignee is the insurer. Any such assignment shall entitle the insurer to deal with the assignee as the owner or pledgee of the policy in accordance with the terms of the assignment, until the insurer has received at its home office written notice of termination of the assignment or pledge or written notice by or on behalf of some other person claiming some interest in the policy in conflict with the assignment.

History.--s. 471, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 372, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.423  Payment discharges insurer.--Whenever the proceeds of or payments under a life or health insurance policy or annuity contract become payable in accordance with the terms of such policy or contract, or the exercise of any right or privilege thereunder, and the insurer makes payment thereof in accordance with the terms of the policy or contract or in accordance with any written assignment thereof, the person then designated in the policy or contract or by such assignment as being entitled thereto shall be entitled to receive such proceeds or payments and to give full acquittance therefor; and such payments shall fully discharge the insurer from all claims under the policy or contract unless, before payment is made, the insurer has received at its home office written notice by or on behalf of some other person that such other person claims to be entitled to such payment or some interest in the policy or contract.

History.--s. 472, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 373, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.4232  Health insurance out-of-hospital benefits.--No health insurance policy which provides coverage on a medical, hospital, or surgical expense-incurred basis shall be delivered or issued for delivery in this state unless coverage is provided for treatment performed outside a hospital for any accident or illness as defined in the policy, provided that such treatment would be covered on an inpatient basis and is provided by a health care provider whose services would be covered under the policy if the treatment were performed in a hospital and provided that treatment of the accident or illness is medically necessary and is provided as an alternative to inpatient treatment in a hospital. Reimbursement may be limited to amounts that are reasonable for the treatment or services provided and may be limited by any deductible and coinsurance provisions of the policy.

History.--ss. 6, 10, ch. 84-235; s. 114, ch. 92-318.

627.4233  Total disability defined.--

(1)  If an individual or group policy of disability income insurance provides for the waiver of premiums or payment of claims upon total disability:

(a)  The policy must, at a minimum, provide that for the first 12 months of the disability, a person is totally disabled if the person is unable to perform the material and substantial duties of the person's regular occupation, or must include a provision at least as favorable to the insured.

(b)  The policy may provide that after the first 12 months of disability as described in paragraph (a), the insurer may predicate the continuance of benefits on the person's ability to perform any work or occupation for which the person is reasonably qualified or trained.

(2)  If an individual or group policy of life insurance provides for the waiver of premiums or payment of claims upon total disability, the definition of total disability may not be more restrictive than the person's inability to perform any work or occupation for which the person is reasonably qualified or trained.

(3)  If an individual or group policy of medical expense insurance provides for extension of benefits for persons who are totally disabled on the date their insurance terminates, the definition of totally disabled may not be more restrictive than:

(a)  For an employee, the person's inability to perform any work or occupation for which the person is reasonably qualified or trained; or

(b)  For a dependent, the person's inability to engage in most normal activities of a person of like age and sex in good health.

History.--s. 119, ch. 92-33; s. 1, ch. 95-364.

627.4234  Health insurance cost containment provisions required.--A health insurance policy or health care services plan which provides medical, hospital, or surgical expense coverage delivered or issued for delivery in this state must contain one or more of the following procedures or provisions to contain health insurance costs or cost increases:

(1)  Coinsurance.

(2)  Deductible amounts.

(3)  Utilization review.

(4)  Audits of provider bills to verify that services and supplies billed were furnished and that proper charges were made.

(5)  Scheduled benefits.

(6)  Benefits for preadmission testing.

(7)  Any lawful measure or combination of measures for which the insurer provides to the office information demonstrating that the measure or combination of measures is reasonably expected to have an effect toward containing health insurance costs or cost increases.

History.--ss. 4, 10, ch. 84-235; ss. 40, 114, ch. 92-318; s. 1121, ch. 2003-261.

627.4235  Coordination of benefits.--

(1)  A group hospital, medical, or surgical expense policy, group health care services plan, or group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses delivered or issued for delivery in this state must contain a provision for coordinating its benefits with any similar benefits provided by any other group hospital, medical, or surgical expense policy, any group health care services plan, or any group-type self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses for the same loss.

(2)  A hospital, medical, or surgical expense policy, health care services plan, or self-insurance plan that provides protection or insurance against hospital, medical, or surgical expenses issued in this state or issued for delivery in this state may contain a provision whereby the insurer may reduce or refuse to pay benefits otherwise payable thereunder solely on account of the existence of similar benefits provided under insurance policies issued by the same or another insurer, health care services plan, or self-insurance plan which provides protection or insurance against hospital, medical, or surgical expenses only if, as a condition of coordinating benefits with another insurer, the insurers together pay 100 percent of the total reasonable expenses actually incurred of the type of expense within the benefits described in the policies and presented to the insurer for payment.

(3)  The standards provided in subsection (2) apply to coordination of benefits payable under Medicare, Title XVIII of the Social Security Act.

(4)  If a claim is submitted in accordance with any group hospital, medical, or surgical expense policy, or in accordance with any group health care service plan or group-type self-insurance plan, that provides protection, insurance, or indemnity against hospital, medical, or surgical expenses, and the policy or any other document that provides coverage includes a coordination-of-benefits provision and the claim involves another policy or plan which has a coordination-of-benefits provision, the following rules determine the order in which benefits under the respective health policies or plans will be determined:

(a)1.  The benefits of a policy or plan which covers the person as an employee, member, or subscriber, other than as a dependent, are determined before those of the policy or plan which covers the person as a dependent.

2.  However, if the person is also a Medicare beneficiary, and if the rule established under the Social Security Act of 1965, as amended, makes Medicare secondary to the plan covering the person as a dependent of an active employee, the order of benefit determination is:

a.  First, benefits of a plan covering a person as an employee, member, or subscriber.

b.  Second, benefits of a plan of an active worker covering a person as a dependent.

c.  Third, Medicare benefits.

(b)  Except as stated in paragraph (c), if two or more policies or plans cover the same child as a dependent of different parents:

1.  The benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls earlier in a year are determined before the benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls later in that year; but

2.  If both parents have the same birthday, the benefits of the policy or plan which covered the parent for a longer period of time are determined before those of the policy or plan which covered the parent for a shorter period of time.

However, if a policy or plan subject to the rule based on the birthdays of the parents coordinates with an out-of-state policy or plan which contains provisions under which the benefits of a policy or plan which covers a person as a dependent of a male are determined before those of a policy or plan which covers the person as a dependent of a female and if, as a result, the policies or plans do not agree on the order of benefits, the provisions of the other policy or plan determine the order of benefits.

(c)  If two or more policies or plans cover a dependent child of divorced or separated parents, benefits for the child are determined in this order:

1.  First, the policy or plan of the parent with custody of the child.

2.  Second, the policy or plan of the spouse of the parent with custody of the child.

3.  Third, the policy or plan of the parent not having custody of the child.

However, if the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child and if the entity obliged to pay or provide the benefits of the policy or plan of that parent has actual knowledge of those terms, the benefits of that policy or plan are determined first, except with respect to any claim determination period or plan or policy year during which any benefits are actually paid or provided before the entity has the actual knowledge.

(d)  The benefits of a policy or plan which covers a person as an employee who is neither laid off nor retired, or as that employee's dependent, are determined before those of a policy or plan which covers the person as a laid-off or retired employee or as the employee's dependent. If the other policy or plan is not subject to this rule, and if, as a result, the policies or plans do not agree on the order of benefits, this paragraph does not apply.

(e)  If none of the rules in paragraph (a), paragraph (b), paragraph (c), or paragraph (d) determine the order of benefits, the benefits of the policy or plan which covered an employee, member, or subscriber for a longer period of time are determined before those of the policy or plan which covered the person for the shorter period of time.

(5)  Coordination of benefits is not permitted against an indemnity-type policy, an excess insurance policy as defined in s. 627.635, a policy with coverage limited to specified illnesses or accidents, or a Medicare supplement policy.

(6)  If an individual is covered under a COBRA continuation plan as a result of the purchase of coverage as provided under the Consolidation Omnibus Budget Reconciliation Act of 1987 (Pub. L. No. 99-272), and also under another group plan, the following order of benefits applies:

(a)  First, the plan covering the person as an employee, or as the employee's dependent.

(b)  Second, the coverage purchased under the plan covering the person as a former employee, or as the former employee's dependent provided according to the provisions of COBRA.

History.--s. 1, ch. 74-367; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 374, 377, 809(2nd), ch. 82-243; ss. 52, 79, ch. 82-386; s. 5, ch. 84-235; s. 2, ch. 85-244; ss. 41, 114, ch. 92-318.

627.4236  Coverage for bone marrow transplant procedures.--

(1)  As used in this section, the term "bone marrow transplant" means human blood precursor cells administered to a patient to restore normal hematological and immunological functions following ablative therapy with curative intent. Human blood precursor cells may be obtained from the patient in an autologous transplant or from a medically acceptable related or unrelated donor, and may be derived from bone marrow, circulating blood, or a combination of bone marrow and circulating blood. If chemotherapy is an integral part of the treatment involving bone marrow transplantation, the term "bone marrow transplant" includes both the transplantation and the chemotherapy.

(2)  An insurer or a health maintenance organization may not exclude coverage for bone marrow transplant procedures recommended by the referring physician and the treating physician under a policy exclusion for experimental, clinical investigative, educational, or similar procedures contained in any individual or group health insurance policy or health maintenance organization contract issued, amended, delivered, or renewed in this state that covers treatment for cancer, if the particular use of the bone marrow transplant procedure is determined to be accepted within the appropriate oncological specialty and not experimental pursuant to subsection (3). Covered bone marrow transplant procedures must include costs associated with the donor-patient to the same extent and limitations as costs associated with the insured, except the reasonable costs of searching for the donor may be limited to immediate family members and the National Bone Marrow Donor Program.

(3)(a)  The Agency for Health Care Administration shall adopt rules specifying the bone marrow transplant procedures that are accepted within the appropriate oncological specialty and are not experimental for purposes of this section. The rules must be based upon recommendations of an advisory panel appointed by the secretary of the agency, composed of:

1.  One adult oncologist, selected from a list of three names recommended by the Florida Medical Association;

2.  One pediatric oncologist, selected from a list of three names recommended by the Florida Pediatric Society;

3.  One representative of the J. Hillis Miller Health Center at the University of Florida;

4.  One representative of the H. Lee Moffitt Cancer Center and Research Institute, Inc.;

5.  One consumer representative, selected from a list of three names recommended by the Chief Financial Officer;

6.  One representative of the Health Insurance Association of America;

7.  Two representatives of health insurers, one of whom represents the insurer with the largest Florida health insurance premium volume and one of whom represents the insurer with the second largest Florida health insurance premium volume; and

8.  One representative of the insurer with the largest Florida small group health insurance premium volume.

(b)  The director shall also appoint a member of the advisory panel to serve as chairperson.

(c)  The agency shall provide, within existing resources, staff support to enable the panel to carry out its responsibilities under this section.

(d)  In making recommendations and adopting rules under this section, the advisory panel and the director shall:

1.  Take into account findings, studies, or research of the federal Agency for Health Care Policy, National Cancer Institute, National Academy of Sciences, Health Care Financing Administration, and Congressional Office of Technology Assessment, and any other relevant information.

2.  Consider whether the federal Food and Drug Administration or National Cancer Institute is conducting or sponsoring assessment procedures to determine the safety and efficacy of the procedure or substantially similar procedures, or of any part of such procedures.

3.  Consider practices of providers with respect to requesting or requiring patients to sign a written acknowledgment that a bone marrow transplant procedure is experimental.

(e)  The advisory panel shall conduct, at least biennially, a review of scientific evidence to ensure that its recommendations are based on current research findings and that insurance policies offer coverage for the latest medically acceptable bone marrow transplant procedures.

(4)  Any rule adopted under this section applies only to claims filed under policies issued or renewed after the effective date of the rule.

History.--s. 42, ch. 92-318; s. 84, ch. 93-129; s. 5, ch. 95-188; s. 79, ch. 97-237; s. 2, ch. 99-299; s. 21, ch. 2000-305; s. 1122, ch. 2003-261.

627.4237  Sickness disability or disability due to sickness.--Notwithstanding any provision of law to the contrary, the term "sickness disability" or "disability due to sickness," as used in individual or group disability insurance policies ¹issued in this state on or after October 1, 1992, includes any restriction of a health care practitioner's ability to perform her or his ²occupation because of action taken by the state licensing board as a result of the practitioner's testing positive on a human immunodeficiency virus test. The provisions of this section do not require payment of disability income benefits under any policy without the insured experiencing an actual loss of income as may be required under the terms of the policy as a condition of receiving such benefits.

History.--s. 120, ch. 92-33; s. 1, ch. 92-171; s. 330, ch. 97-102.

¹Note.--Section 1, ch. 92-171, used the word "delivered" instead of the word "issued."

²Note.--Section 1, ch. 92-171, used the word "profession" instead of the word "occupation."

627.4238  Health insurer examinations.--The office may examine each authorized health insurer which transacts health insurance in this state. The purpose of the examination is to ascertain compliance by the insurer with the applicable provisions of this chapter. In lieu of the examination, the office may accept the report of a similar examination made by the insurance supervisory official of this state or another state. The reasonable cost of the examination shall be paid by the person examined, and such person is subject to the provisions of s. 624.320. Any examination is also subject to the applicable provisions of ss. 624.318, 624.319, 624.321, and 624.322. An examination under this section may not exceed 10 working days in length, may not be conducted more often than annually, and may not be conducted during the same calendar year as a market conduct examination conducted by the office, except in a case in which the office has prima facie evidence of a violation of this chapter or of chapter 626, which violation is of a nature so as to provide an immediate danger to the insurance-consuming public.

History.--ss. 3, 10, ch. 84-235; s. 114, ch. 92-318; s. 1123, ch. 2003-261.

627.4239  Coverage for use of drugs in treatment of cancer.--

(1)  DEFINITIONS.--As used in this section, the term:

(a)  "Medical literature" means scientific studies published in a United States peer-reviewed national professional journal.

(b)  "Standard reference compendium" means:

1.  The United States Pharmacopeia Drug Information;

2.  The American Medical Association Drug Evaluations; or

3.  The American Hospital Formulary Service Drug Information.

(2)  COVERAGE FOR TREATMENT OF CANCER.--

(a)  An insurer may not exclude coverage in any individual or group insurance policy issued, amended, delivered, or renewed in this state which covers the treatment of cancer for any drug prescribed for the treatment of cancer on the ground that the drug is not approved by the United States Food and Drug Administration for a particular indication, if that drug is recognized for treatment of that indication in a standard reference compendium or recommended in the medical literature.

(b)  Coverage for a drug required by this section also includes the medically necessary services associated with the administration of the drug.

(3)  APPLICABILITY AND SCOPE.--This section may not be construed to:

(a)  Alter any other law with regard to provisions limiting coverage for drugs that are not approved by the United States Food and Drug Administration.

(b)  Require coverage for any drug if the United States Food and Drug Administration has determined that the use of the drug is contraindicated.

(c)  Require coverage for a drug that is not otherwise approved for any indication by the United States Food and Drug Administration.

(d)  Affect the determination as to whether particular levels, dosages, or usage of a medication associated with bone marrow transplant procedures are covered under an individual or group health insurance policy or health maintenance organization contract.

(e)  Apply to specified disease or supplemental policies.

(4)  Nothing in this section is intended, expressly or by implication, to create, impair, alter, limit, modify, enlarge, abrogate, prohibit, or withdraw any authority to provide reimbursement for drugs used in the treatment of any other disease or condition.

History.--s. 1, ch. 95-268.

627.42395  Coverage for certain prescription and nonprescription enteral formulas.--Notwithstanding any other provision of law, any health insurance policy delivered or issued for delivery, to any person in this state or any group, blanket, or franchise health insurance policy delivered or issued for delivery in this state shall make available to the policyholder as part of the application, for an appropriate additional premium, coverage for prescription and nonprescription enteral formulas for home use which are physician prescribed as medically necessary for the treatment of inherited diseases of amino acid, organic acid, carbohydrate, or fat metabolism as well as malabsorption originating from congenital defects present at birth or acquired during the neonatal period. Coverage for inherited diseases of amino acids and organic acids shall include food products modified to be low protein, in an amount not to exceed $2,500 annually for any insured individual, through the age of 24. This section applies to any person or family notwithstanding the existence of any preexisting condition.

History.--s. 1, ch. 95-340.

Note.--Former s. 627.64195.

627.424  Minor may give acquittance.--

(1)  Any minor domiciled in this state who has attained the age of 16 years shall be deemed competent to receive and to give full acquittance and discharge for a payment or payments in aggregate amount not exceeding $3,000 in any one year made by a life insurer under the maturity, death, or settlement agreement provisions in effect or elected by such minor under a life insurance policy or annuity contract, if such policy, contract, or agreement provides for the payment to such minor. No such minor shall be deemed competent to alienate the right to or to anticipate or commute such payments. This section shall not be deemed to restrict the rights of minors set forth in s. 627.406.

(2)  If a guardian of the property of any such minor is duly appointed and written notice thereof is given to the insurer at its home office, any such payment thereafter falling due shall be paid to the guardian for the account of the minor, unless the policy or contract under which the payment is made expressly provides otherwise.

(3)  This section shall not be deemed to require any insurer making any such payment to determine whether any other insurer may be effecting a similar payment to the same minor.

History.--s. 473, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.425  Forms for proof of loss to be furnished.--An insurer shall furnish, upon written request of any person claiming to have a loss under an insurance contract issued by such insurer, forms of proof of loss for completion by such person, but such insurer shall not, by reason of the requirement so to furnish forms, have any responsibility for or with reference to the completion of such proof or the manner of any such completion or attempted completion.

History.--s. 474, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.426  Claims administration.--

(1)  Without limitation of any right or defense of an insurer otherwise, none of the following acts by or on behalf of an insurer shall be deemed to constitute a waiver of any provision of a policy or of any defense of the insurer thereunder:

(a)  Acknowledgment of the receipt of notice of loss or claim under the policy.

(b)  Furnishing forms for reporting a loss or claim, for giving information relative thereto, or for making proof of loss, or receiving or acknowledging receipt of any such forms or proofs completed or uncompleted.

(c)  Investigating any loss or claim under any policy or engaging in negotiations looking toward a possible settlement of any such loss or claim.

(2)  A liability insurer shall not be permitted to deny coverage based on a particular coverage defense unless:

(a)  Within 30 days after the liability insurer knew or should have known of the coverage defense, written notice of reservation of rights to assert a coverage defense is given to the named insured by registered or certified mail sent to the last known address of the insured or by hand delivery; and

(b)  Within 60 days of compliance with paragraph (a) or receipt of a summons and complaint naming the insured as a defendant, whichever is later, but in no case later than 30 days before trial, the insurer:

1.  Gives written notice to the named insured by registered or certified mail of its refusal to defend the insured;

2.  Obtains from the insured a nonwaiver agreement following full disclosure of the specific facts and policy provisions upon which the coverage defense is asserted and the duties, obligations, and liabilities of the insurer during and following the pendency of the subject litigation; or

3.  Retains independent counsel which is mutually agreeable to the parties. Reasonable fees for the counsel may be agreed upon between the parties or, if no agreement is reached, shall be set by the court.

History.--s. 475, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 375(1st), 377, 809(2nd), ch. 82-243; ss. 53, 79, ch. 82-386; s. 97, ch. 83-216; s. 114, ch. 92-318.

627.4265  Payment of settlement.--In any case in which a person and an insurer have agreed in writing to the settlement of a claim, the insurer shall tender payment according to the terms of the agreement no later than 20 days after such settlement is reached. The tender of payment may be conditioned upon execution by such person of a release mutually agreeable to the insurer and the claimant, but if the payment is not tendered within 20 days, or such other date as the agreement may provide, it shall bear interest at a rate of 12 percent per year from the date of the agreement; however, if the tender of payment is conditioned upon the execution of a release, the interest shall not begin to accrue until the executed release is tendered to the insurer.

History.--s. 12, ch. 83-288; s. 3, ch. 84-94; s. 114, ch. 92-318.

627.427  Payment of judgment by insurer; penalty for failure.--

(1)  Every judgment or decree for the recovery of money entered in any of the courts of this state against any authorized insurer shall be fully satisfied within 60 days from and after the entry thereof or, in the case of an appeal from such judgment or decree, within 60 days from and after the affirmance of the same by the appellate court.

(2)  If the judgment or decree is not satisfied as required under subsection (1), and proof of such failure to satisfy is made by filing with the office a certified transcript of the docket of the judgment or decree together with a certificate by the clerk of the court wherein the judgment or decree was entered that the judgment or decree remains unsatisfied, in whole or in part, after the time aforesaid, the office shall forthwith revoke the insurer's certificate of authority. The office shall not issue to such insurer any new certificate of authority until the judgment or decree is wholly paid and satisfied and proof thereof filed with the office under the official certificate of the clerk of the court wherein the judgment was recovered, showing that the same is satisfied of record, and until the expenses and fees incurred in the case are also paid by the insurer.

History.--s. 476, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 375(2nd), 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1124, ch. 2003-261.

627.428  Attorney's fee.--

(1)  Upon the rendition of a judgment or decree by any of the courts of this state against an insurer and in favor of any named or omnibus insured or the named beneficiary under a policy or contract executed by the insurer, the trial court or, in the event of an appeal in which the insured or beneficiary prevails, the appellate court shall adjudge or decree against the insurer and in favor of the insured or beneficiary a reasonable sum as fees or compensation for the insured's or beneficiary's attorney prosecuting the suit in which the recovery is had.

(2)  As to suits based on claims arising under life insurance policies or annuity contracts, no such attorney's fee shall be allowed if such suit was commenced prior to expiration of 60 days after proof of the claim was duly filed with the insurer.

(3)  When so awarded, compensation or fees of the attorney shall be included in the judgment or decree rendered in the case.

History.--s. 477, ch. 59-205; s. 1, ch. 67-400; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 376, 377, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.429  Medical tests for HIV infection and AIDS for insurance purposes.--

(1)  PURPOSE.--The purpose of this section is to prohibit unfair practices in the underwriting of insurance with respect to exposure to the human immunodeficiency virus infection and related matters, and thereby to reduce the possibility that a person may suffer unfair discrimination when purchasing insurance.

(2)  SCOPE.--

(a)  This section applies to all insurance policies, and the underwriting thereof, which are issued in this state or are issued outside this state pursuant to s. 627.5515 or s. 627.6515 covering residents of this state; to prepaid limited health organizations; and to multiple-employer welfare arrangements defined in s. 624.437. For the purposes of this section, "insurer" includes authorized multiple-employer welfare arrangements.

(b)  This section does not prohibit an insurer from contesting a policy or claim to the extent allowed by law.

(3)  DEFINITIONS.--As used in this section:

(a)  "AIDS" means acquired immune deficiency syndrome.

(b)  "ARC" means AIDS-related complex.

(c)  "HIV" means the human immunodeficiency virus identified as the causative agent of AIDS.

(4)  USE OF MEDICAL TESTS FOR UNDERWRITING.--

(a)  With respect to the issuance of or the underwriting of a policy regarding exposure to the HIV infection and sickness or medical conditions derived from HIV infection, the insurer may use only medical tests that are reliable predictors of risk. A test which is recommended by the Centers for Disease Control and Prevention or by the federal Food and Drug Administration is reliable for the purposes of this section. A test which is rejected or not recommended by the Centers for Disease Control and Prevention or the federal Food and Drug Administration is not reliable for the purposes of this section. If a specific test recommended by the Centers for Disease Control and Prevention or the federal Food and Drug Administration indicates the existence or potential existence of exposure to the HIV infection or a sickness or medical condition related to the HIV infection, the insurer shall, before relying on a single test result to deny or limit coverage or to rate the coverage, follow the applicable Centers for Disease Control and Prevention or federal Food and Drug Administration recommended test protocol and shall use any applicable followup tests or series of tests recommended by the Centers for Disease Control and Prevention or federal Food and Drug Administration to confirm the indication.

(b)  Prior to testing, the insurer shall disclose its intent to test the person for the HIV infection or for a specific sickness or medical condition derived therefrom and shall obtain the person's written informed consent to administer the test. The written informed consent required by this paragraph shall include a fair explanation of the test, including its purpose, potential uses, and limitations, and the meaning of its results and the right to confidential treatment of information. Use of a form approved by the office raises a conclusive presumption of informed consent.

(c)  An applicant shall be notified of a positive test result by a physician designated by the applicant or, in the absence of such designation, by the Department of Health. Notification must include all of the following:

1.  Face-to-face posttest counseling on the meaning of the test results, the possible need for additional testing, and the need to eliminate behavior which might spread the disease to others.

2.  The availability in the person's geographic area of any appropriate health care services, including mental health care, and appropriate social and support services.

3.  The benefits of locating and counseling any individual by whom the infected individual may have been exposed to human immunodeficiency virus and any individual whom the infected individual may have exposed to the virus.

4.  The availability, if any, of the services of public health authorities with respect to locating and counseling any individual described in subparagraph 3.

(d)  A medical test for exposure to the HIV infection or for a sickness or medical condition derived from such infection may be required of or given to a person only if the test is based on the person's current medical condition or medical history or if the test is triggered by threshold coverage amounts which apply to all persons within the risk class. Sexual orientation may not be used in the underwriting process or in the determination of which applicants shall be tested for exposure to the HIV infection. The marital status, living arrangements, occupation, gender, beneficiary designation, or zip code or other territorial classification of an applicant may not be used to establish the applicant's sexual orientation.

(e)  An insurer may inquire whether a person has been tested positive for exposure to the HIV infection or been diagnosed as having ARC or AIDS caused by the HIV infection or other sickness or condition derived from such infection. An insurer may not inquire whether the person has been tested for or has received a negative result from a specific test for exposure to the HIV infection or for a sickness or a medical condition derived from such infection.

(f)  Insurers shall maintain strict confidentiality regarding medical test results with respect to exposure to the HIV infection or a specific sickness or medical condition derived from such exposure. The insurer may not disclose information regarding specific test results outside of the insurance company or its employees, insurance affiliates, agents, or reinsurers, except to the person tested and to persons designated in writing by the person tested. The insurer may not furnish specific test results for exposure to the HIV infection to an insurer industry data bank if a review of the information would identify the individual and the specific test results.

(g)  A laboratory may be used by an insurer or insurance support organization for the processing of HIV-related tests only if it is certified by the United States Department of Health and Human Services under the Clinical Laboratories Improvement Act of 1967, permitting testing of specimens obtained in interstate commerce, and only if the laboratory subjects itself to ongoing proficiency testing by the College of American Pathologists, the American Association of Bio Analysts, or an equivalent program approved by the Centers for Disease Control and Prevention of the United States Department of Health and Human Services.

(5)  RESTRICTIONS ON COVERAGE EXCLUSIONS AND LIMITATIONS.--

(a)  An insurer of a group policy may not exclude coverage of an eligible individual because of a positive test result for exposure to the HIV infection or a specific sickness or medical condition derived from such exposure, either as a condition for or subsequent to the issuance of the policy. This paragraph does not apply to individuals applying for coverage where individual underwriting is otherwise allowed by law.

(b)  Subject to the total benefits limits in a health insurance policy, no health insurance policy shall contain an exclusion or limitation with respect to coverage for exposure to the HIV infection or a specific sickness or medical condition derived from such infection, except as provided in a preexisting condition clause. This paragraph does not prohibit the issuance of accident-only or specified disease health policies.

(c)  Except for preexisting conditions specifically applying to a sickness or medical condition of the insured, benefits under a life insurance policy shall not be denied or limited based on the fact that the insured's death was caused, directly or indirectly, by exposure to the HIV infection or a specific sickness or medical condition derived from such infection. This paragraph does not prohibit the issuance of accidental death only or specified disease policies.

(d)  Any major medical or comprehensive accident and health policy for which individual underwriting is authorized by law may contain a provision excluding coverage for expenses related to AIDS or ARC if, in the opinion of a legally qualified physician, the insured, prior to the first anniversary of the insured's coverage under the policy, first exhibited objective manifestations of AIDS or ARC, as defined by the Centers for Disease Control and Prevention, which objective manifestations are attributable to no other cause or was diagnosed as having AIDS or ARC if all of the following apply:

1.  The applicant for the policy is not required to submit to any medical test for HIV infection.

2.  The policy provision:

a.  Is set forth separately from the other exclusion and limitation provisions of the policy.

b.  Has an appropriate caption or heading.

c.  Is disclosed and referenced in a conspicuous manner on the policy data page.

d.  Contains a statement that the exclusion will not apply to any person if the insurer does not assert the defense before the person has been insured under the policy for 2 years.

3.  The insurer must notify the insured in writing of a determination that the insured would be subject to the effect of the exclusion within 90 days after the insurer first determines that an insured would be subject to the effect of the exclusion, even if there are no claims for AIDS or ARC. Failure to provide timely written notice under this subparagraph bars the insurer from using the exclusion.

4.  Objective manifestations of AIDS or ARC first exhibited after the 12-month manifestation period must be covered the same as any other illness.

History.--ss. 47, 53, ch. 88-380; s. 13, ch. 89-350; ss. 110, 114, ch. 92-318; s. 8, ch. 97-93; s. 259, ch. 99-8; s. 9, ch. 2000-370; s. 1125, ch. 2003-261.

627.4295  Dental procedures; anesthesia and hospitalization coverage.--For purposes of this section, dental treatment or surgery shall be considered necessary when the dental condition is likely to result in a medical condition if left untreated. Any individual health insurance policy issued or issued for delivery in this state which provides coverage for general anesthesia and hospitalization services to a covered person shall not preclude such coverage in assuring the safe delivery of necessary dental care provided to a covered person who:

(1)  Is under 8 years of age and is determined by a licensed dentist, and the child's physician licensed under chapter 458 or chapter 459, to require necessary dental treatment in a hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or

(2)  Has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center.

As provided herein, all terms and conditions of the covered person's health insurance policy shall apply to such services, and this section does not require coverage for the diagnosis or treatment of dental disease. An insurer may require prior authorization for general anesthesia and hospital services required under this section in the same manner the insurer requires prior authorization for hospitalization for other covered services. This section shall not apply to Medicare supplement, long-term care, disability, limited benefit, accident only, or specified disease policies.

History.--s. 1, ch. 98-312.

627.4301  Genetic information for insurance purposes.--

(1)  DEFINITIONS.--As used in this section, the term:

(a)  "Genetic information" means information derived from genetic testing to determine the presence or absence of variations or mutations, including carrier status, in an individual's genetic material or genes that are scientifically or medically believed to cause a disease, disorder, or syndrome, or are associated with a statistically increased risk of developing a disease, disorder, or syndrome, which is asymptomatic at the time of testing. Such testing does not include routine physical examinations or chemical, blood, or urine analysis, unless conducted purposefully to obtain genetic information, or questions regarding family history.

(b)  "Health insurer" means an authorized insurer offering health insurance as defined in s. 624.603, a self-insured plan as defined in s. 624.031, a multiple-employer welfare arrangement as defined in s. 624.437, a prepaid limited health service organization as defined in s. 636.003, a health maintenance organization as defined in s. 641.19, a prepaid health clinic as defined in s. 641.402, a fraternal benefit society as defined in s. 632.601, or any health care arrangement whereby risk is assumed.

(2)  USE OF GENETIC INFORMATION.--

(a)  In the absence of a diagnosis of a condition related to genetic information, no health insurer authorized to transact insurance in this state may cancel, limit, or deny coverage, or establish differentials in premium rates, based on such information.

(b)  Health insurers may not require or solicit genetic information, use genetic test results, or consider a person's decisions or actions relating to genetic testing in any manner for any insurance purpose.

(c)  This section does not apply to the underwriting or issuance of a life insurance policy, disability income policy, long-term care policy, accident-only policy, hospital indemnity or fixed indemnity policy, dental policy, or vision policy or any other actions of an insurer directly related to a life insurance policy, disability income policy, long-term care policy, accident-only policy, hospital indemnity or fixed indemnity policy, dental policy, or vision policy.

History.--s. 1, ch. 97-182; s. 43, ch. 2000-256; s. 10, ch. 2000-296.

627.4302  Identification cards for processing prescription drug claims.--

(1)  The purpose of this section is to improve patient care by minimizing confusion, eliminating unnecessary work, decreasing patient wait time, and improving business efficiencies.

(2)  Any health insurer or health maintenance organization and all state and local government entities entering into an agreement to provide coverage for prescription drugs on an outpatient basis shall provide a benefits-identification card containing the following information:

(a)  The name of the claim processor.

(b)  The electronic-claims payor identification number or the issuer identification number, also referred to as the Banking Identification Number or "BIN," assigned by the American National Standards Institute.

(c)  The insured's prescription group number.

(d)  The insured's identification number.

(e)  The insured's name.

(f)  The claims submission name and address.

(g)  The help desk telephone number.

(h)  Any other information that the entity finds will assist in the processing of the claim.

The information required in paragraphs (a), (b), (g), and (h) must be provided on the card, unless instruction is provided on the card for ready access to such information by electronic means.

(3)  The benefits-identification card must present the information in a manner readily identifiable or, alternatively, the information may be embedded in the card and available through magnetic stripe or smart card. The information may also be provided through other electronic technology.

(4)  Any entity providing a health-benefits-identification card containing all of the information required by this section shall not be required to provide a separate identification card for prescription drug benefits.

(5)  A benefits-identification card required under subsection (2) shall be issued no later than 60 days after any change in the information contained on the card becomes effective. An entity may issue a temporary sticker containing the new information in lieu of issuing a new card prior to the annual renewal date. Such sticker must be designed so that it can be attached to the existing card.

History.--s. 1, ch. 2002-245.

627.441  Commercial general liability policies; coverage to contractors for completed operations.--

(1)  As used in this section, the term:

(a)  "Contractor" means a contractor or subcontractor performing work on a public construction project under contract with a public agency, as described in s. 255.0517(2).

(b)  "Liability insurer" means an insurer issuing a commercial general liability insurance policy in this state to a contractor that provides coverage for liability arising out of completed operations performed by the contractor or on the contractor's behalf.

(2)  A liability insurer must offer coverage at an appropriate additional premium for liability arising out of current or completed operations under an owner-controlled insurance program for any period beyond the period for which the program provides liability coverage, as specified in s. 255.0517(2)(b). The period of such coverage must be sufficient to protect against liability arising out of an action brought within the time limits provided in s. 95.11(3)(c).

History.--s. 2, ch. 2004-377.

PART III

LIFE INSURANCE AND ANNUITY CONTRACTS

627.451  Scope of this part.

627.452  Standard provisions required.

627.453  Grace period.

627.454  Entire contract; statements in application.

627.455  Incontestability.

627.4554  Annuity investments by seniors.

627.4555  Secondary notice.

627.4556  Life insurance automatic policy loan provision.

627.456  Misstatement of age or sex.

627.457  Dividends.

627.458  Policy loan.

627.4585  Maximum rate of interest on policy loans.

627.459  Reinstatement.

627.460  Authority to alter contract.

627.461  Settlement on proof of death.

627.4615  Interest payable on death claim payments.

627.462  Table of installments.

627.463  Excluded or restricted coverage.

627.464  Annuity contracts, pure endowment contracts; standard provisions.

627.465  Annuity contracts, pure endowment contracts; grace period.

627.466  Annuity contracts, pure endowment contracts; incontestability.

627.467  Annuity contracts, pure endowment contracts; entire contract.

627.468  Annuity contracts, pure endowment contracts; misstatement of age or sex.

627.469  Annuity contracts, pure endowment contracts; dividends.

627.470  Annuity contracts, pure endowment contracts; reinstatement.

627.471  Reversionary annuities; standard provisions.

627.472  Incontestability after reinstatement.

627.473  Policy settlements.

627.474  Policy must contain entire contract.

627.475  Nonforfeiture benefits; certain interim policies.

627.476  Standard Nonforfeiture Law for Life Insurance.

627.479  Prohibited policy plans.

627.480  Cash payments of single-premium life policies.

627.481  Requirements for certain annuity agreements.

627.482  Interest payable on cash surrender of policy.

627.451  Scope of this part.--This part applies to life insurance and annuity contracts, other than reinsurance, group life insurance, group annuities, and industrial life insurance; except that ss. 627.463, 627.472, 627.476, and 627.479 also apply to industrial life insurance. This part does not apply to credit life insurance except as provided in part IX of chapter 627.

History.--s. 478, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 378, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.452  Standard provisions required.--

(1)  No policy of life insurance, except as stated in subsection (3), shall be delivered or issued for delivery in this state unless it contains in substance each of the provisions as required by ss. 627.453-627.462 inclusive and ss. 627.475 and 627.476, or provisions which in the opinion of the office are more favorable to the policyholder.

(2)  Any of such provisions or portions thereof not applicable to single-premium or term policies shall to that extent not be incorporated therein.

(3)  This section does not apply to annuity contracts, or to any provision of a life insurance policy or contract supplemental thereto relating to health benefits or to additional benefits in the event of death by accident or accidental means.

(4)  Except as otherwise required under this code or rules adopted pursuant thereto, the style, arrangement, and overall appearance of the policy shall give no undue prominence to any portion of the text. Every printed portion of the text of the policy and any endorsements or attached papers shall be plainly printed in lightfaced type of a style in general use, the size of which shall be uniform and not less than 10 points with a lowercase, unspaced alphabet length of not less than 120 points. As used in this subsection, "text" includes all printed matter except the name and address of the insurer, the name or title of the policy, the brief description of the coverage provided, if any, and captions and subcaptions.

History.--s. 479, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 379, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 4, ch. 91-296; s. 114, ch. 92-318; s. 1126, ch. 2003-261.

627.453  Grace period.--Every insurance contract shall provide that the insured is entitled to a grace period of not less than 30 days within which payment of any premium after the first may be made. The payment may, at the option of the insurer, be subject to an interest charge not in excess of 8 percent per year for the number of days of grace elapsing before the payment of the premium, during which period of grace the policy shall continue in force. If the policy becomes a claim during the grace period before the overdue premium is paid, or the deferred premiums of the current policy year, if any, are paid, the amount of such premium or premiums with interest not in excess of 8 percent per year thereon may be deducted in any settlement under the policy.

History.--s. 480, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 380, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.454  Entire contract; statements in application.--Every insurance contract shall provide that the policy, or the policy and the application therefor if a copy of such application is endorsed upon or attached to the policy when issued, shall constitute the entire contract between the parties, and that all statements contained in the application shall, in the absence of fraud, be deemed representations and not warranties.

History.--s. 481, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 381, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.455  Incontestability.--Every insurance contract shall provide that the policy shall be incontestable after it has been in force during the lifetime of the insured for a period of 2 years from its date of issue except for nonpayment of premiums and except, at the option of the insurer, as to provisions relative to benefits in event of disability and as to provisions which grant additional insurance specifically against death by accident or accidental means.

History.--s. 482, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 382, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.4554  Annuity investments by seniors.--

(1)  PURPOSE; CONSTRUCTION.--

(a)  The purpose of this section is to set forth standards and procedures for recommendations to senior consumers which result in a transaction involving annuity products to appropriately address the insurance needs and financial objectives of senior consumers at the time of the transaction.

(b)  Nothing in this section shall be construed to create or imply a private cause of action for a violation of this section.

(2)  APPLICATION.--This section applies to any recommendation to purchase or exchange an annuity made to a senior consumer by an insurance agent, or an insurer where no agent is involved, that results in the purchase or exchange recommended.

(3)  DEFINITIONS.--For purposes of this section:

(a)  "Annuity" means a fixed annuity or variable annuity that is individually solicited, whether the product is classified as an individual annuity or a group annuity.

(b)  "Recommendation" means advice provided by an insurance agent, or an insurer if no insurance agent is involved, to an individual senior consumer which results in a purchase or exchange of an annuity in accordance with that advice.

(c)  "Senior consumer" means a person 65 years of age or older. In the event of a joint purchase by more than one party, a purchaser is considered to be a senior consumer if any of the parties is age 65 or older.

(4)  DUTIES OF INSURERS AND INSURANCE AGENTS.--

(a)  In recommending to a senior consumer the purchase of an annuity or the exchange of an annuity that results in another insurance transaction or series of insurance transactions, an insurance agent, or an insurer if no insurance agent is involved, shall have reasonable grounds for believing that the recommendation is suitable for the senior consumer on the basis of the facts disclosed by the senior consumer as to his or her investments and other insurance products and as to his or her financial situation and needs.

(b)  Before executing a purchase or exchange of an annuity resulting from a recommendation to a senior consumer, an insurance agent, or an insurer if no insurance agent is involved, shall make reasonable efforts to obtain information concerning the senior consumer's financial status, tax status, and investment objectives and such other information used or considered to be reasonable by the insurance agent, or the insurer if no agent is involved, in making the recommendation.

(c)1.  Except as provided under subparagraph 2., an insurance agent, or an insurer if no insurance agent is involved, shall not have any obligation to a senior consumer under paragraph (a) related to any recommendation if the senior consumer:

a.  Refuses to provide relevant information requested by the insurer or insurance agent;

b.  Decides to enter into an insurance transaction that is not based on a recommendation of the insurer or insurance agent; or

c.  Fails to provide complete or accurate information.

2.  An insurer or insurance agent's recommendation subject to subparagraph 1. shall be reasonable under all the circumstances actually known to the insurer or insurance agent at the time of the recommendation.

(d)1.  An insurer or insurance agent shall ensure that a system to supervise recommendations which is reasonably designed to achieve compliance with this section is established and maintained by complying with subparagraphs 3., 4., and 5., or shall establish and maintain such a system, including, but not limited to:

a.  Maintaining written procedures.

b.  Conducting periodic reviews of its records that are reasonably designed to assist in detecting and preventing violations of this section.

2.  A managing general agent and an insurance agency shall adopt a system established by an insurer to supervise recommendations of its insurance agents which is reasonably designed to achieve compliance with this section or shall establish and maintain such a system, including, but not limited to:

a.  Maintaining written procedures.

b.  Conducting periodic reviews of records that are reasonably designed to assist in detecting and preventing violations of this section.

3.  An insurer may contract with a third party, including a managing general agent or an insurance agency, to establish and maintain a system of supervision as required by subparagraph 1. with respect to insurance agents under contract with or employed by the third party.

4.  An insurer shall make reasonable inquiry to ensure that such third party contracting under subparagraph 3. is performing the functions required under subparagraph 1. and shall take such action as is reasonable under the circumstances to enforce the contractual obligation to perform the functions. An insurer may comply with its obligation to make reasonable inquiry by:

a.  Annually obtaining a certification from a third party senior manager who has responsibility for the delegated functions that the manager has a reasonable basis to represent, and does represent, that the third party is performing the required functions.

b.  Based on reasonable selection criteria, periodically selecting third parties contracting under subparagraph 3. for a review to determine whether the third parties are performing the required functions. The insurer shall perform any procedures necessary to conduct the review which are reasonable under the circumstances.

5.  An insurer that contracts with a third party pursuant to subparagraph 3. and complies with the requirements specified in subparagraph 4. is deemed to have fulfilled its responsibilities under subparagraph 1.

6.  An insurer, managing general agent, or insurance agency is not required by subparagraph 1. or subparagraph 2. to:

a.  Review or provide for review of all transactions solicited by an insurance agent; or

b.  Include in its system of supervision an insurance agent's recommendations to senior consumers of products other than the annuities offered by the insurer, managing general agent, or insurance agency.

7.  A managing general agent or insurance agency contracting with an insurer pursuant to subparagraph 3. shall promptly, when requested by the insurer pursuant to subparagraph 4., provide a certification as described in subparagraph 4. or provide a clear statement that the managing general agent or insurance agency is unable to meet the certification criteria.

8.  A person may not provide a certification under sub-subparagraph 4.a. unless the person is a senior manager with responsibility for the delegated functions and has a reasonable basis for making the certification.

(5)  MITIGATION OF RESPONSIBILITY.--

(a)  The office may order an insurer to take reasonably appropriate corrective action for any senior consumer harmed by a violation of this section by the insurer or the insurer's insurance agent.

(b)  The department may order:

1.  An insurance agent to take reasonably appropriate corrective action for any senior consumer harmed by a violation of this section by the insurance agent.

2.  A managing general agency or insurance agency that employs or contracts with an insurance agent to sell or solicit the sale of annuities to senior consumers to take reasonably appropriate corrective action for any senior consumer harmed by a violation of this section by the insurance agent.

(c)  Any applicable penalty under the Florida Insurance Code for a violation of paragraph (4)(a), paragraph (4)(b), or subparagraph (4)(c)2. may be reduced or eliminated, according to a schedule adopted by the office or the department, as appropriate, if corrective action for the senior consumer was taken promptly after a violation was discovered.

(6)  RECORDKEEPING.--

(a)  Insurers, managing general agents, insurance agencies, and insurance agents shall maintain or be able to make available to the department or office, as appropriate, records of the information collected from the senior consumer and other information used in making the recommendations that were the basis for insurance transactions for 5 years after the insurance transaction is completed by the insurer. An insurer is permitted, but shall not be required, to maintain documentation on behalf of an insurance agent.

(b)  Records required to be maintained by this regulation may be maintained in paper, photographic, microprocess, magnetic, mechanical, or electronic media, or by any process that accurately reproduces the actual document.

(7)  EXEMPTIONS.--Unless otherwise specifically included, this section does not apply to recommendations involving:

(a)  Direct-response solicitations where there is no recommendation based on information collected from the senior consumer pursuant to this section.

(b)  Contracts used to fund:

1.  An employee pension or welfare benefit plan that is covered by the Employee Retirement and Income Security Act;

2.  A plan described by s. 401(a), s. 401(k), s. 403(b), s. 408(k), or s. 408(p) of the Internal Revenue Code of 1986, as amended, if established or maintained by an employer;

3.  A government or church plan defined in s. 414 of the Internal Revenue Code of 1986, as amended, a government or church welfare benefit plan, or a deferred compensation plan of a state or local government or tax-exempt organization under s. 457 of the Internal Revenue Code of 1986, as amended;

4.  A nonqualified deferred compensation arrangement established or maintained by an employer or plan sponsor;

5.  Settlements of or assumptions of liabilities associated with personal injury litigation or any dispute or claim resolution process; or

6.  Prepaid funeral contracts.

(8)  APPLICATION TO VARIABLE ANNUITIES.--Compliance with the National Association of Securities Dealers Conduct Rules in effect on January 1, 2004, shall satisfy the requirements under this section for the recommendation of variable annuities. This section does not limit the department's ability to enforce the provisions of this section with respect to insurance agents, insurance agencies, and managing general agents, or the office's ability to enforce the provisions of this section with respect to insurers.

History.--s. 146, ch. 2004-390.

627.4555  Secondary notice.--Except as provided in this section, a contract for life insurance issued or issued for delivery in this state on or after October 1, 1997, covering a natural person 64 years of age or older, which has been in force for at least 1 year, may not be lapsed for nonpayment of premium unless, after expiration of the grace period, and at least 21 days before the effective date of any such lapse, the insurer has mailed a notification of the impending lapse in coverage to the policyowner and to a specified secondary addressee if such addressee has been designated in writing by name and address by the policyowner. An insurer issuing a life insurance contract on or after October 1, 1997, shall notify the applicant of the right to designate a secondary addressee at the time of application for the policy, on a form provided by the insurer, and at any time the policy is in force, by submitting a written notice to the insurer containing the name and address of the secondary addressee. For purposes of any life insurance policy that provides a grace period of more than 51 days for nonpayment of premiums, the notice of impending lapse in coverage required by this section must be mailed to the policyowner and the secondary addressee at least 21 days before the expiration of the grace period provided in the policy. This section does not apply to any life insurance contract under which premiums are payable monthly or more frequently and are regularly collected by a licensed agent or are paid by credit card or any preauthorized check processing or automatic debit service of a financial institution.

History.--s. 1, ch. 95-142; s. 11, ch. 97-292.

627.4556  Life insurance automatic policy loan provision.--If an application for an individual life insurance policy provides an option to the applicant for an automatic policy loan against the cash value of the policy to pay the premium on the policy in the event of nonpayment of premium, such option shall be deemed to be elected by the applicant unless the applicant makes an affirmative election not to include this provision in the policy.

History.--s. 2, ch. 95-142.

627.456  Misstatement of age or sex.--Every insurance contract shall provide that if it is found that the age or sex of the insured, or of any other individual considered in determining the premium or benefit, has been misstated, the amount payable or benefit accruing under the policy shall be such as the premium would have purchased according to the correct age or sex. Such calculations shall be in accordance with the insurer's rate at date of issue, and at the option of the insurer this may be so specified in the policy.

History.--s. 483, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 383, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.457  Dividends.--

(1)  Every participating policy shall provide that, beginning not later than the end of the third policy year, the insurer shall annually ascertain and apportion the divisible surplus, if any, that will accrue on the policy anniversary or other dividend date specified in the policy provided the policy is in force and all premiums to that date are paid.

(2)  Except as provided in this section, any dividend so apportioned shall, at the option of the party entitled to elect such option, be either payable in cash or applied to any one of such other dividend options as may be provided by the policy. If any such other dividend options are provided, the policy shall further state which option shall be automatically effective if such party has not elected some other option. If the policy specifies a period within which such other option may be elected, such period shall be not less than 30 days following the date on which such dividend is due and payable.

(3)  The annually apportioned dividend shall be deemed to be payable in cash within the meaning of subsection (2) even though the policy provides that payment of such dividend is to be deferred for a specified period, provided such period does not exceed 6 years from the date of apportionment and that interest will be added to such dividend at a specified rate.

(4)  If a participating policy provides that the benefit under any paid-up nonforfeiture provision is to be participating, it may provide that any divisible surplus apportioned while the insurance is in force under such nonforfeiture provision be applied in the manner set forth in the policy.

History.--s. 484, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 384, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.458  Policy loan.--

(1)  There shall be a provision that after the policy has a cash surrender value and while no premium is in default, the insurer will advance, on proper assignment or pledge of the policy and on the sole security thereof, at a rate of interest not exceeding 10 percent per year, for policies issued prior to October 1, 1981, payable in advance, an amount equal to or, at the option of the party entitled thereto, less than the loan value of the policy. The loan value of the policy shall be at least equal to the cash surrender value at the end of the then-current policy year, except that the insurer may deduct, either from such loan value or from the proceeds of the loan, any existing indebtedness not already deducted in determining such cash surrender value, including any interest then accrued but not due, any unpaid balance of the premium for the current policy year, and interest on the loan to the end of the current policy year. However, as a condition for approval of a policy loan interest rate in excess of 6 percent per year, the office shall require the insurer to furnish such assurances as the office deems necessary that the interest rate on such loans will bear a reasonable relationship to other interest rates and that the holders of such policies will benefit through higher dividends or lower premiums, or both.

(2)  The policy may also provide that, if interest on any indebtedness is not paid when due, such interest shall then be added to the existing indebtedness and shall bear interest at the same rate and that, if and when the total indebtedness on the policy, including interest due or accrued, equals or exceeds the amount of loan value thereof, then the policy shall terminate and become void, but not until at least 30 days' notice has been mailed by the insurer to the last known address of the insured or policyowner and of any assignee of record at the home office of the insurer.

(3)  The policy shall reserve to the insurer the right to defer the granting of a loan, other than for the payment of any premium to the insurer, for 6 months after application therefor.

(4)  This section does not apply to term policies or to term insurance benefits provided by riders or supplemental policy provisions.

History.--s. 485, ch. 59-205; s. 3, ch. 76-168; ss. 1, 3, ch. 77-324; s. 1, ch. 77-457; ss. 2, 6, ch. 81-289; ss. 2, 3, ch. 81-318; ss. 385, 404, 809(2nd), 810, ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1127, ch. 2003-261.

627.4585  Maximum rate of interest on policy loans.--

(1)  For the purposes of this section, the "published monthly average" means the value of the interest rate index, as defined in s. 625.121(6)(e).

(2)  Policies issued on or after October 1, 1981, shall provide for policy loan interest rates through:

(a)  A provision permitting a maximum interest rate of not more than 10 percent a year; or

(b)  A provision permitting an adjustable maximum interest rate established from time to time by the life insurer as permitted by law.

(3)  The rate of interest charged on a policy loan made under paragraph (2)(b) shall not exceed the higher of the following:

(a)  The published monthly average for the calendar month ending 2 months before the date on which the rate is determined; or

(b)  The rate used to compute the cash surrender values under the policy during the applicable period plus 1 percent a year.

(4)  If the maximum rate of interest is determined pursuant to paragraph (2)(b), the policy shall contain a provision setting forth the frequency at which the rate is to be determined for that policy.

(5)  The maximum rate for each policy must be determined at regular intervals at least once every 12 months, but not more frequently than once in any 3-month period. At the intervals specified in the policy:

(a)  The rate being charged may be increased whenever such increase as determined under subsection (3) would increase that rate by 50 basis points or more a year.

(b)  The rate being charged must be reduced whenever such reduction as determined under subsection (3) would decrease that rate by 50 basis points or more a year.

(6)  The life insurer shall:

(a)  Notify the policyholder at the time a cash loan is made of the initial rate of interest on the loan.

(b)  Notify the policyholder with respect to premium loans of the initial rate of interest on the loan as soon as it is reasonably practicable to do so after making the initial loan. Notice need not be given to the policyholder when a further premium loan is added, except as provided in paragraph (c).

(c)  Send to policyholders with loans reasonable advance notice of any increase or decrease in the rate.

(d)  Include in the notices required in this section the substance of the pertinent provisions of subsections (2) and (4).

(7)  No policy shall terminate in a policy year as the sole result of a change in the interest rate during that policy year, and the life insurer shall maintain coverage during that policy year until the time at which it would otherwise have terminated if there had been no change during that policy year.

(8)  The substance of the pertinent provisions of subsections (2) and (4) shall be set forth in the policies to which they apply.

(9)  For purposes of this section:

(a)  The rate of interest on policy loans permitted under this section includes the interest rate charged on reinstatement of policy loans for the period during and after any lapse of a policy.

(b)  The term "policy loan" includes any premium loan made under a policy to pay one or more premiums that were not paid to the life insurer as they fell due.

(c)  The term "policyholder" includes the owner of the policy or the person designated to pay premiums as shown on the records of the life insurer.

(d)  The term "policy" includes certificates issued by a fraternal benefit society and annuity contracts which provide for policy loans.

(10)  No other provision of law shall apply to policy loan interest rates unless made specifically applicable to such rates.

History.--ss. 3, 6, ch. 81-289; ss. 386, 809(2nd), 810, ch. 82-243; s. 79, ch. 82-386; s. 65, ch. 91-108; s. 114, ch. 92-318.

627.459  Reinstatement.--Every contract shall provide that the policy may be reinstated upon written application therefor at any time within 3 years after the date of default in the payment of any premiums, unless the policy has been surrendered for its cash value or unless the paid-up term insurance, if any, has expired, upon evidence of insurability satisfactory to the insurer and the payment of all overdue premiums and payment (or, within the limits permitted by the then cash value of the policy, reinstatement) of any other indebtedness to the insurer upon the policy with interest as to both premiums and indebtedness at a rate not exceeding 6 percent per year compounded annually or, as to indebtedness for a policy issued on or after October 1, 1981, at an interest rate as provided for in s. 627.4585.

History.--s. 486, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 4, 6, ch. 81-289; ss. 2, 3, ch. 81-318; ss. 387, 404, 809(2nd), 810, ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.460  Authority to alter contract.--Every contract shall provide, at the option of the insurer, that no agent shall have the power or authority to waive, change, or alter any of the terms or conditions of any policy; except that, at the option of the insurer, the terms or conditions may be changed by an endorsement or rider signed by a duly authorized officer of the insurer.

History.--s. 487, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 388, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.461  Settlement on proof of death.--Every contract shall provide that, when a policy becomes a claim by the death of the insured, settlement shall be made upon receipt of due proof of death and surrender of the policy.

History.--s. 488, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 389, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 14, ch. 83-288; s. 114, ch. 92-318.

627.4615  Interest payable on death claim payments.--When a policy provides for payment of its proceeds in a lump sum upon the death of the insured, the payment must include interest, at an annual rate equal to or greater than the Moody's Corporate Bond Yield Average-Monthly Average Corporate as of the day the claim was received, from the date the insurer receives written due proof of death of the insured. If the method of calculating such index is substantially changed from the method of calculation in use on January 1, 1993, the rate must not be less than 8 percent.

History.--s. 15, ch. 83-288; s. 3, ch. 84-94; ss. 43, 114, ch. 92-318.

627.462  Table of installments.--If a policy provides for payment of its proceeds in installments, a table showing the amount and period of such installments shall be included in the policy; except that certain tables may be omitted from the policy if in the judgment of the office it is not practical to include them.

History.--s. 489, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1128, ch. 2003-261.

627.463  Excluded or restricted coverage.--A clause in any policy of life insurance providing that such policy shall be incontestable after a specified period shall preclude only a contest of the validity of the policy and shall not preclude the assertion at any time of defenses based upon provisions in the policy which exclude or restrict coverage, whether or not such restrictions or exclusions are excepted in such clause.

History.--s. 490, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.464  Annuity contracts, pure endowment contracts; standard provisions.--

(1)  No fixed-dollar annuity, variable annuity, or pure endowment contract, other than a reversionary annuity, survivorship annuity, or group annuity, shall be delivered or issued for delivery in this state unless it contains in substance each of the provisions set forth in ss. 627.465-627.470, inclusive, or provisions which in the opinion of the office are more favorable to the policyholder. Any of such provisions not applicable to single-premium annuities or single-premium pure endowment contracts shall not to that extent be incorporated therein.

(2)  This section does not apply to contracts for annuities included in or upon the lives of beneficiaries under life insurance policies.

History.--s. 491, ch. 59-205; s. 10, ch. 61-441; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1129, ch. 2003-261.

627.465  Annuity contracts, pure endowment contracts; grace period.--In a fixed-dollar annuity, variable annuity, or pure endowment contract, other than a reversionary, survivorship, or group annuity, the contract shall provide that there shall be a period of grace of 1 month but not less than 30 days, within which any stipulated payment to the insurer falling due after the first may be made, subject, at the option of the insurer, to an interest charge thereon at a rate to be specified in the contract but not exceeding 6 percent per year for the number of days of grace elapsing before such payment, during which period of grace the contract shall continue in full force. If a claim arises under the contract on account of death prior to expiration of the period of grace before the overdue payment to the insurer or the deferred payments of the current contract year, if any, are paid, the amount of such payments, with interest on any overdue payments, may be deducted from any amount payable under the contract in settlement.

History.--s. 492, ch. 59-205; s. 11, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 390, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.466  Annuity contracts, pure endowment contracts; incontestability.--If any statements, other than those relating to age, sex, and identity, are required as a condition to issuing a fixed-dollar annuity contract, variable annuity contract, or pure endowment contract, other than a reversionary, survivorship, or group annuity, and subject to s. 627.468, the contract shall provide that it shall be incontestable after it has been in force during the lifetime of the person, or of each of the persons as to whom such statements are required, for a period of 2 years from its date of issue except for nonpayment of stipulated payments to the insurer; and, at the option of the insurer, the contract may also except any provisions relative to benefits in the event of disability and any provisions which grant insurance specifically against death by accident or accidental means.

History.--s. 493, ch. 59-205; s. 12, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 391, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.467  Annuity contracts, pure endowment contracts; entire contract.--In a fixed-dollar annuity contract, variable annuity contract, or pure endowment contract, other than a reversionary, survivorship, or group annuity, the contract shall provide that it shall constitute the entire contract between the parties or, if a copy of the application is endorsed upon or attached to the contract when issued, that the contract and the application therefor shall constitute the entire contract between the parties.

History.--s. 494, ch. 59-205; s. 13, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 392, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.468  Annuity contracts, pure endowment contracts; misstatement of age or sex.--In a fixed-dollar annuity contract, variable annuity contract, or pure endowment contract, other than a reversionary, survivorship, or group annuity, the contract shall provide that if the age or sex of the person or persons upon whose life or lives the contract is made, or of any of them, has been misstated, the amount payable or benefits accruing under the contract shall be such as the stipulated payment or payments to the insurer would have purchased according to the correct age or sex; and that if the insurer shall make or has made any overpayment or overpayments on account of any such misstatement, the amount thereof, with interest at the rate to be specified in the contract but not exceeding 6 percent per year, may be charged against the current or next succeeding payment or payments to be made by the insurer under the contract.

History.--s. 495, ch. 59-205; s. 14, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 393, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.469  Annuity contracts, pure endowment contracts; dividends.--If a fixed-dollar annuity contract, variable annuity contract, or pure endowment contract is participating, the contract shall contain a provision that, beginning not later than the end of the third contract year, the insurer shall annually ascertain and apportion any divisible surplus accruing on the contract.

History.--s. 496, ch. 59-205; s. 15, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 394, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.470  Annuity contracts, pure endowment contracts; reinstatement.--In a fixed-dollar annuity contract, variable annuity contract, or pure endowment contract, other than a reversionary, survivorship, or group annuity, the contract shall provide that it may be reinstated upon written application therefor at any time within 1 year from the date of default in making stipulated payments to the insurer, unless the cash surrender value has been paid, but all overdue stipulated payments and any indebtedness to the insurer on the contract shall be paid or reinstated, with interest thereon at a rate to be specified in the contract but not exceeding 6 percent per year payable annually; and, when applicable, the insurer may also include a requirement of evidence of insurability satisfactory to the insurer.

History.--s. 497, ch. 59-205; s. 16, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 395, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.471  Reversionary annuities; standard provisions.--

(1)  Except as stated in this section, no contract for a reversionary annuity shall be delivered or issued for delivery in this state unless it contains in substance:

(a)  Those provisions specified in ss. 627.465-627.469, except that under s. 627.465 the insurer may at its option provide for an equitable reduction of the amount of the annuity payments in settlement of an overdue or deferred payment in lieu of providing for deduction of such payments from an amount payable upon settlement under the contract; and

(b)  A provision that the contract may be reinstated at any time within 3 years from the date of default in making stipulated payments to the insurer, upon production of evidence of insurability satisfactory to the insurer, and upon condition that all overdue payments and any indebtedness to the insurer on account of the contract are paid (or, within the limits permitted by the then cash value of the contract, reinstated) with interest as to both payments and indebtedness at a rate to be specified in the contract but not exceeding 8 percent per year compounded annually.

(2)  This section does not apply to group annuities or to annuities included in life insurance policies, and any of such provisions not applicable to single-premium annuities shall not to that extent be incorporated therein.

History.--s. 498, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 396, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.472  Incontestability after reinstatement.--A reinstated policy of life insurance, fixed-dollar annuity contract, or variable annuity contract may be contested on account of fraud or misrepresentation of facts material to the reinstatement only for the same period following reinstatement and with the same conditions and exceptions as the policy provides with respect to contestability after original issuance.

History.--s. 499, ch. 59-205; s. 17, ch. 61-441; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.473  Policy settlements.--Any life insurer shall have the power to hold under agreement the proceeds of any policy issued by it, upon such terms and restrictions as to revocation by the policyholder and control by beneficiaries and with such exemptions from the claims of creditors of beneficiaries other than the policyholder as set forth in the policy or as agreed to in writing by the insurer and the policyholder. Upon maturity of a policy, in the event the policyholder has made no such agreement, the insurer shall have the power to hold the proceeds of the policy under an agreement with the beneficiaries. The insurer shall not be required to segregate the funds so held but may hold them as part of its general assets.

History.--s. 500, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.474  Policy must contain entire contract.--No life insurer or its agent shall make any contract of insurance or agreement as to such contract other than as plainly expressed in the policy.

History.--s. 501, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 397, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.475  Nonforfeiture benefits; certain interim policies.--Each life insurance policy issued between the effective date of this code and the operative date of s. 627.476 shall provide:

(1)  That, in the event of default in any premium, the insurer will grant, upon proper request not later than 60 days after the due date of the premium in default, a paid-up nonforfeiture benefit on a plan stipulated in the policy.

(2)  That, upon surrender of the policy within 60 days after the due date of any premium payment in default after premiums have been paid for at least 3 full years, the insurer will pay, in lieu of any paid-up nonforfeiture benefit, a cash surrender value at least equal to the minimum cash surrender value hereinafter specified. The minimum cash surrender value shall be equal to:

(a)  The reserve on the date of default of the premium less a sum of not more than 2.5 percent of the face amount; or

(b)  An amount as defined in s. 627.476 but on the basis of the Commissioners' 1941 Standard Ordinary Mortality Table in lieu of the Commissioners' 1958 Standard Ordinary Mortality Table therein specified. The policy shall reserve to the insurer the right to defer the granting of any cash surrender value for 6 months after demand therefor with surrender of the policy.

(3)  That a specified paid-up nonforfeiture benefit, the present value of which shall be at least equal to the cash surrender value, shall become effective as specified in the policy unless the person entitled to make such election elects another available option not later than 60 days after the due date of the premium in default; however, when the mortality table used is the Commissioners' 1941 Standard Ordinary Mortality Table, the rates of mortality to be assumed in calculating any extended term insurance with accompanying pure endowment, if any, may be not more than 130 percent of the rates of mortality according to such table.

(4)  A statement of the mortality table and interest rate used in calculating the cash surrender values and the paid-up nonforfeiture benefits available under the policy, together with a table showing the cash surrender value, if any, and paid-up nonforfeiture benefit, if any, available under the policy on each policy anniversary either during the first 20 policy years or during the term of the policy, whichever is shorter.

This section does not apply to term policies of uniform amount of 15 years' duration or less, to increasing term policies of 15 years' duration or less, or to decreasing term policies.

History.--s. 502, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.476  Standard Nonforfeiture Law for Life Insurance.--

(1)  SHORT TITLE.--This section shall be known as the "Standard Nonforfeiture Law for Life Insurance."

(2)  NONFORFEITURE PROVISIONS.--In the case of policies issued on or after the operative date of this section as defined in subsection (14), no policy of life insurance, except as set forth in subsection (13), shall be delivered or issued for delivery in this state unless it contains in substance the following provisions, or corresponding provisions which in the opinion of the office are at least as favorable to the defaulting or surrendering policyholder as are the minimum requirements hereinafter specified and are essentially in compliance with subsection (12):

(a)  That in the event of default in any premium payment, after premiums have been paid for at least 1 full year in the case of ordinary insurance or 3 full years in the case of industrial insurance, the insurer will grant, upon proper request not later than 60 days after the due date of the premium in default, a paid-up nonforfeiture benefit on a plan stipulated in the policy, effective as of such due date, of such amount as may be hereinafter specified. In lieu of such stipulated paid-up nonforfeiture benefit, the company may substitute, upon proper request not later than 60 days after the due date of the premium in default, an actuarially equivalent alternative paid-up nonforfeiture benefit which provides a greater amount or longer period of death benefits or, if applicable, a greater amount or earlier payment of endowment benefits. With respect to all policy forms filed on or after October 1, 1990, the policy forms shall include, but not be limited to, a reduced paid-up nonforfeiture benefit. For the purposes of this subsection, the term "reduced paid-up nonforfeiture benefit" means a benefit whereby the policy may be continued at the option of the insured as reduced paid-up life insurance, the amount of which shall be as much as the surrender value of the policy will provide on the date of default, calculated using the surrender value of the policy as a net single premium on the due date of the first unpaid premium at the then-current age of the insured.

(b)  That upon surrender of the policy within 60 days after the due date of any premium payment in default after premiums have been paid for at least 3 full years in the case of ordinary insurance or 5 full years in the case of industrial insurance, the insurer will pay, in lieu of any paid-up nonforfeiture benefit, a cash surrender value of such amount as may be hereinafter specified.

(c)  That a specified paid-up nonforfeiture benefit shall become effective as specified in the policy unless the person entitled to make such election elects another available option not later than 60 days after the due date of the premium in default.

(d)  That if the policy becomes paid up by completion of all premium payments, or if it is continued under any paid-up nonforfeiture benefit which became effective on or after the third policy anniversary in the case of ordinary insurance or the fifth policy anniversary in the case of industrial insurance, the insurer will pay, upon surrender of the policy within 30 days after any policy anniversary, a cash surrender value of such amount as may be hereinafter specified.

(e)  In the case of a policy which causes on a basis guaranteed in the policy unscheduled changes in benefits or premiums, or which provides an option for changes in benefits or premiums other than a change to a new policy, a statement of the mortality table, interest rate, and method used in calculating cash surrender values and the paid-up nonforfeiture benefits available under the policy. In the case of any other policy, a statement of the mortality table and interest rate used in calculating the cash surrender values and the paid-up nonforfeiture benefits available under the policy, together with a table showing the cash surrender value, if any, and paid-up nonforfeiture benefit, if any, available under the policy on each policy anniversary, either during the first 20 policy years or during the term of the policy, whichever is shorter, such values and benefits to be calculated upon the assumption that there are no dividends or paid-up additions credited to the policy and that there is no indebtedness to the insurer on the policy.

(f)  A statement that the cash surrender values and the paid-up nonforfeiture benefits available under the policy are not less than the minimum values and benefits required by or pursuant to the insurance law of this state; an explanation of the manner in which the cash surrender values and the paid-up nonforfeiture benefits are altered by the existence of any paid-up additions credited to the policy or any indebtedness to the insurer on the policy; if a detailed statement of the method of computation of the values and benefits shown in the policy is not stated therein, a statement that such method of computation has been filed with the insurance supervisory official of the state in which the policy is delivered; and a statement of the method to be used in calculating the cash surrender value and paid-up nonforfeiture benefit available under the policy on any policy anniversary beyond the last anniversary for which such values and benefits are consecutively shown in the policy.

(3)  OMITTED PROVISIONS.--Any of the provisions or portions thereof set forth in paragraphs (2)(a)-(f) which are not applicable by reason of the plan of insurance may, to the extent inapplicable, be omitted from the policy. The insurer shall reserve the right to defer the payment of any cash surrender value for a period of 6 months after demand therefor with surrender of the policy.

(4)  CASH SURRENDER VALUE.--

(a)  Any cash surrender value available under the policy in the event of default in the premium payment due on any policy anniversary, whether or not required by subsection (2), shall be an amount not less than the excess, if any, of the present value on such anniversary of the future guaranteed benefits which would have been provided for by the policy, including any existing paid-up additions, if there had been no default, over the sum of:

1.  The then-present value of the adjusted premiums as defined in subsections (6) and (9), corresponding to premiums which would have fallen due on and after such anniversary, and

2.  The amount of any indebtedness to the insurer on account of or secured by the policy.

(b)  For any policy issued on or after the operative date of subsection (9), as defined therein, which provides supplemental life insurance or annuity benefits at the option of the insured and for an identifiable additional premium by rider or supplemental policy provision, the cash surrender value referred to in paragraph (a) shall be an amount not less than the sum of the cash surrender value as defined in such paragraph for an otherwise similar policy issued at the same age without such rider or supplemental policy provision and the cash surrender value as defined in such paragraph for a policy which provides only the benefits otherwise provided by such rider or supplemental policy provision. For any family policy issued on or after the operative date of subsection (9), as defined therein, which defines a primary insured and provides term insurance on the life of the spouse of the primary insured expiring before the spouse reaches age 71, the cash surrender value referred to in paragraph (a) shall be an amount not less than the sum of the cash surrender value as defined in such paragraph for an otherwise similar policy issued at the same age without such term insurance on the life of the spouse and the cash surrender value as defined in such paragraph for a policy which provides only the benefits otherwise provided by such term insurance on the life of the spouse.

(c)  Any cash surrender value available within 30 days after any policy anniversary under any policy paid up by completion of all premium payments, or any policy continued under any paid-up nonforfeiture benefits, whether or not required by subsection (2), shall be an amount not less than the present value, on such anniversary, of the future guaranteed benefits provided for by the policy, including any existing paid-up additions, decreased by any indebtedness to the insurer on account of or secured by the policy.

(5)  PAID-UP NONFORFEITURE BENEFITS.--Any paid-up nonforfeiture benefit available under the policy in the event of default in the premium payment due on any policy anniversary shall be such that its present value as of such anniversary shall be at least equal to the cash surrender value then provided for by the policy, or, if none is provided for, that cash surrender value which would have been required by this section in the absence of the condition that premiums shall have been paid for at least a specified period.

(6)  THE ADJUSTED PREMIUM.--This subsection shall not apply to policies issued on or after the operative date of subsection (9), as defined therein. The adjusted premiums for any policy shall be calculated on an annual basis and shall be such uniform percentage of the respective premiums specified in the policy for each policy year, excluding extra premiums on a substandard policy, that the present value, at the date of issue of the policy, of all such adjusted premiums shall be equal to the sum of:

(a)  The then-present value of the future guaranteed benefits provided for by the policy;

(b)  Two percent of the amount of the insurance if the insurance is uniform in amount, or of the equivalent uniform amount, as hereinafter defined, if the amount of insurance varies with the duration of the policy;

(c)  Forty percent of the adjusted premium for the first policy year; and

(d)  Twenty-five percent of either the adjusted premium for the first policy year or the adjusted premium for a whole life policy of the same uniform or equivalent uniform amount with uniform premiums for the whole of life issued at the same age for the same amount of insurance, whichever is less.

However, in applying the percentages specified in paragraphs (c) and (d), no adjusted premium shall be deemed to exceed 4 percent of the amount of insurance or uniform amount equivalent thereto. The date of issue of a policy for the purpose of this subsection shall be the date as of which the rated age of the insured is determined.

(7)  EQUIVALENT UNIFORM AMOUNT.--This subsection shall not apply to policies issued on or after the operative date of subsection (9), as defined therein. In the case of a policy providing an amount of insurance varying with the duration of the policy, the equivalent uniform amount thereof for the purpose of subsection (6) shall be deemed to be the uniform amount of insurance provided by an otherwise similar policy, containing the same endowment benefit or benefits, if any, issued at the same age and for the same term, the amount of which does not vary with duration and the benefits under which have the same present value at the date of issue as the benefits under the policy, except that, in the case of a policy for a varying amount of insurance issued on the life of a child under age 10, the equivalent uniform amount may be computed as though the amount of insurance provided by the policy prior to the attainment of age 10 were the amount provided by such policy at age 10.

(8)  MORTALITY TABLES; INTEREST.--This subsection shall not apply to policies issued on or after the operative date of subsection (9), as defined therein. All adjusted premiums and present values referred to in this section shall for all policies of ordinary insurance be calculated on the basis of the Commissioners' 1958 Standard Ordinary Mortality Table, except that, for any category of such policies issued on female risks, adjusted premiums and present values may be calculated according to an age not more than 6 years younger than the actual age of the insured. Such calculations for all policies of industrial insurance shall be made on the basis of the following tables:

(a)  For policies issued on and after the operative date of this section but before January 1, 1968, the 1941 Standard Industrial Mortality Table, unless the Commissioners' 1961 Standard Industrial Mortality Table is applicable according to subsection (14);

(b)  For policies issued on and after January 1, 1968, the Commissioners' 1961 Standard Industrial Mortality Table.

All calculations shall be made on the basis of the rate of interest specified in the policy for calculating cash surrender values and paid-up nonforfeiture benefits; however, such rate of interest shall not exceed 3.5 percent per year, except that a rate of interest not exceeding 4 percent per year may be used for policies issued on or after July 1, 1973, and prior to October 1, 1979, and a rate of interest not exceeding 4.5 percent per year may be used for policies issued on or after October 1, 1979, and a rate of interest not exceeding 5.5 percent per year may be used for policies issued on or after October 1, 1980. In calculating the present value of any paid-up term insurance with accompanying pure endowment, if any, offered as a nonforfeiture benefit, the rates of mortality assumed may be not more than those shown in the Commissioners' 1958 Extended Term Insurance Table, for ordinary policies. In the case of industrial policies:

(c)  For policies issued on and after the operative date of this section but before January 1, 1968, not more than 130 percent of the rates of mortality according to the 1941 Standard Industrial Mortality Table, unless the Commissioners' 1961 Industrial Extended Term Insurance Table is applicable according to subsection (14), in which case not more than those of the latter table;

(d)  For policies issued on and after January 1, 1968, not more than those of the Commissioners' 1961 Industrial Extended Term Insurance Table.

For insurance issued on a substandard basis, the calculation of any such adjusted premiums and present values may be based on such other table of mortality as may be specified by the insurer and approved by the office.

(9)  CALCULATION OF ADJUSTED PREMIUMS AND PRESENT VALUES FOR POLICIES ISSUED AFTER OPERATIVE DATE OF THIS SUBSECTION.--

(a)  This subsection shall apply to all policies issued on or after the operative date of this subsection, as defined herein. Except as provided in paragraph (g), the adjusted premiums for any policy shall be calculated on an annual basis and shall be such uniform percentage of the respective premiums specified in the policy for each policy year, excluding amounts payable as extra premiums to cover impairments or special hazards and also excluding any uniform annual contract charge or policy fee specified in the policy in a statement of the method to be used in calculating the cash surrender values and paid-up nonforfeiture benefits, that the present value, at the date of issue of the policy, of all adjusted premiums shall be equal to the sum of:

1.  The then-present value of the future guaranteed benefits provided for by the policy;

2.  One percent of either the amount of insurance, if the insurance is uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years; and

3.  One hundred and twenty-five percent of the nonforfeiture net-level premium as hereinafter defined.

However, in applying the percentage specified in subparagraph 3., no nonforfeiture net-level premium shall be deemed to exceed 4 percent of either the amount of insurance, if the insurance is uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years. The date of issue of a policy for the purpose of this subsection shall be the date as of which the rated age of the insured is determined.

(b)  The nonforfeiture net-level premium shall be equal to the present value, at the date of issue of the policy, of the guaranteed benefits provided for by the policy divided by the present value, at the date of issue of the policy, of an annuity of one per annum payable on the date of issue of the policy and on each anniversary of such policy on which a premium falls due.

(c)  In the case of a policy which causes on a basis guaranteed in the policy unscheduled changes in benefits or premiums, or which provides an option for changes in benefits or premiums other than a change to a new policy, the adjusted premiums and present values shall initially be calculated on the assumption that future benefits and premiums do not change from those stipulated at the date of issue of the policy. At the time of any such change in the benefits or premiums, the future adjusted premiums, nonforfeiture net-level premiums, and present values shall be recalculated on the assumption that future benefits and premiums do not change from those stipulated by the policy immediately after the change.

(d)  Except as otherwise provided in paragraph (g), the recalculated future adjusted premiums for any such policy shall be such uniform percentage of the respective future premiums specified in the policy for each policy year, excluding amounts payable as extra premiums to cover impairments and special hazards, and also excluding any uniform annual contract charge or policy fee specified in the policy in a statement of the method to be used in calculating the cash surrender values and paid-up nonforfeiture benefits, that the present value, at the time of change to the newly defined benefits or premiums, of all such future adjusted premiums shall be equal to the excess of the sum of the then-present value of the then future guaranteed benefits provided for by the policy and the additional expense allowance, if any, over the then cash surrender value, if any, or present value of any paid-up nonforfeiture benefit under the policy.

(e)  The additional expense allowance, at the time of the change to the newly defined benefits or premiums, shall be the sum of 1 percent of the excess, if positive, of the average amount of insurance at the beginning of each of the first 10 policy years subsequent to the change over the average amount of insurance prior to the change at the beginning of each of the first 10 policy years subsequent to the time of the most recent previous change, or, if there has been no previous change, the date of issue of the policy; and 125 percent of the increase, if positive, in the nonforfeiture net-level premium.

(f)  The recalculated nonforfeiture net-level premium shall be equal to the result obtained by dividing (A) and (B) where:

1.  (A) equals the sum of:

a.  The nonforfeiture net-level premium applicable prior to the change times the present value of an annuity of one per annum payable on each anniversary of the policy on or subsequent to the date of the change on which a premium would have fallen due had the change not occurred, and

b.  The present value of the increase in future guaranteed benefits provided for by the policy; and

2.  (B) equals the present value of an annuity of one per annum payable on each anniversary of the policy on or subsequent to the date of change on which a premium falls due.

(g)  Notwithstanding any other provisions of this subsection to the contrary, in the case of a policy issued on a substandard basis which provides reduced graded amounts of insurance so that, in each policy year, such policy has the same tabular mortality cost as an otherwise similar policy issued on the standard basis which provides higher uniform amounts of insurance, adjusted premiums and present values for such substandard policy may be calculated as if it were issued to provide such higher uniform amounts of insurance on the standard basis.

(h)  All adjusted premiums and present values referred to in this section shall for all policies of ordinary insurance be calculated on the basis of the Commissioners' 1980 Standard Ordinary Mortality Table or, at the election of the insurer for any one or more specified plans of life insurance, the Commissioners' 1980 Standard Ordinary Mortality Table with Ten-Year Select Mortality Factors; shall for all policies of industrial insurance be calculated on the basis of the Commissioners' 1961 Standard Industrial Mortality Table; and shall for all policies issued in a particular calendar year be calculated on the basis of a rate of interest not exceeding the nonforfeiture interest rate as defined in this subsection for policies issued in that calendar year. However:

1.  At the option of the insurer, calculations for all policies issued in a particular calendar year may be made on the basis of a rate of interest not exceeding the nonforfeiture interest rate, as defined in this subsection, for policies issued in the immediately preceding calendar year.

2.  Under any paid-up nonforfeiture benefit, including any paid-up dividend additions, any cash surrender value available, whether or not required by subsection (2), shall be calculated on the basis of the mortality table and rate of interest used in determining the amount of such paid-up nonforfeiture benefit and paid-up dividend additions, if any.

3.  An insurer may calculate the amount of any guaranteed paid-up nonforfeiture benefit, including any paid-up additions under the policy, on the basis of an interest rate no lower than that specified in the policy for calculating cash surrender values.

4.  In calculating the present value of any paid-up term insurance with accompanying pure endowment, if any, offered as a nonforfeiture benefit, the rates of mortality assumed may be not more than those shown in the Commissioners' 1980 Extended Term Insurance Table for policies of ordinary insurance and not more than the Commissioners' 1961 Industrial Extended Term Insurance Table for policies of industrial insurance.

5.  In lieu of the mortality tables specified in this section, at the option of the insurance company and subject to rules adopted by the commission, the insurance company may substitute:

a.  The 1958 CSO or CET Smoker and Nonsmoker Mortality Tables, whichever is applicable, for policies issued on or after the operative date of this subsection and before January 1, 1989;

b.  The 1980 CSO or CET Smoker and Nonsmoker Mortality Tables, whichever is applicable, for policies issued on or after the operative date of this subsection;

c.  A mortality table that is a blend of the sex-distinct 1980 CSO or CET mortality table standard, whichever is applicable, or a mortality table that is a blend of the sex-distinct 1980 CSO or CET smoker and nonsmoker mortality table standards, whichever is applicable, for policies that are subject to the United States Supreme Court decision in Arizona Governing Committee v. Norris to prevent unfair discrimination in employment situations.

6.  Ordinary mortality tables, adopted after 1980 by the National Association of Insurance Commissioners, adopted by rule by the commission for use in determining the minimum nonforfeiture standard may be substituted for the Commissioners' 1980 Standard Ordinary Mortality Table with or without Ten-Year Select Mortality Factors or for the Commissioners' 1980 Extended Term Insurance Table.

7.  For insurance issued on a substandard basis, the calculation of any such adjusted premiums and present values may be based on appropriate modifications of the aforementioned tables.

(i)  The nonforfeiture interest rate per year for any policy issued in a particular calendar year shall be equal to 125 percent of the calendar year statutory valuation interest rate for such policy as defined in the Standard Valuation Law, rounded to the nearest one-fourth of 1 percent.

(j)  Notwithstanding any other provision in this code to the contrary, any refiling of nonforfeiture values or their methods of computation for any previously approved policy form which involves only a change in the interest rate or mortality table used to compute nonforfeiture values shall not require refiling of any other provisions of that policy form.

(k)  After October 1, 1981, any insurer may file with the office a written notice of its election to comply with the provisions of this subsection after a specified date before January 1, 1989, which shall be the operative date of this subsection for that insurer. If an insurer makes no such election, the operative date of this subsection for the insurer shall be January 1, 1989.

(10)  INDETERMINATE PREMIUMS OR MINIMUM VALUES.--In the case of any plan of life insurance which provides for future premium determination, the amounts of which are to be determined by the insurer based on then estimates of future experience, or in the case of any plan of life insurance which is of such a nature that minimum values cannot be determined by the methods described in subsections (2)-(9):

(a)  The office must be satisfied that the benefits provided under the plan are substantially as favorable to policyholders and insureds as the minimum benefits otherwise required by subsections (2)-(9);

(b)  The office must be satisfied that the benefits and the pattern of premiums of that plan are not such as to mislead prospective policyholders or insureds; and

(c)  The cash surrender values and paid-up nonforfeiture benefits provided by such plan must not be less than the minimum values and benefits required for the plan computed by a method consistent with the principles of this Standard Nonforfeiture Law for Life Insurance, as determined by rules promulgated by the commission.

(11)  CALCULATION OF VALUES.--Any cash surrender value and any paid-up nonforfeiture benefit available under the policy in the event of default in a premium payment due at any time other than on the policy anniversary shall be calculated with allowance for the lapse of time and the payment of fractional premiums beyond the last preceding policy anniversary. All values referred to in subsections (4)-(9) may be calculated upon the assumption that any death benefit is payable at the end of the policy year of death. The net value of any paid-up additions, other than paid-up term additions, shall be not less than the amounts used to provide such additions. If term insurance benefits are provided by a rider or by a supplemental policy provision to which, if issued as a separate policy, this section would apply, additional cash surrender values and additional paid-up nonforfeiture benefits, if any, at least equal to those required if issued as a separate policy, may be provided by the insurer and shall be deemed to be in compliance with this section. Notwithstanding the provisions of subsection (4), additional benefits payable:

(a)  In the event of death or dismemberment by accident or accidental means,

(b)  In the event of total and permanent disability,

(c)  As reversionary annuity or deferred reversionary annuity benefits,

(d)  As term insurance benefits provided by a rider or supplemental policy provision to which, if issued as a separate policy, this section would not apply,

(e)  As term insurance on the life of a child or on the lives of children provided in a policy on the life of a parent of the child, if such term insurance expires before the child's age is 26, is uniform in amount after the child's age is 1, and has not become paid up by reason of the death of a parent of the child, and

(f)  As other policy benefits additional to life insurance by endowment benefits,

and premiums for all such additional benefits, shall be disregarded in ascertaining cash surrender values and nonforfeiture benefits required by this section; and no such additional benefits shall be required to be included in any paid-up nonforfeiture benefits.

(12)  CALCULATION OF VALUES FOR POLICIES ISSUED AFTER 1984.--This subsection, in addition to all other applicable subsections of this section, shall apply to all policies issued on or after January 1, 1985. Any cash surrender value available under the policy in the event of default in a premium payment due on any policy anniversary shall be in an amount which does not differ by more than 0.2 percent of either the amount of insurance, if the insurance is uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years, from the sum of the greater of zero and the basic cash value hereinafter specified and the present value of any existing paid-up additions less the amount of any indebtedness to the insurer under the policy. The basic cash value shall be equal to the present value, on such anniversary, of the future guaranteed benefits which would have been provided for by the policy, excluding any existing paid-up additions and before deduction of any indebtedness to the insurer, if there had been no default, less the then-present value of the nonforfeiture factors, as hereinafter defined, corresponding to premiums which would have fallen due on and after such anniversary. However, the effects on the basic cash value of supplemental life insurance or annuity benefits or of family coverage, as described in subsection (4), shall be the same as are the effects specified in subsection (4) on the cash surrender values defined in that subsection. The nonforfeiture factor for each policy year shall be an amount equal to a percentage of the adjusted premium for the policy year, as defined in subsection (6) or subsection (9), whichever is applicable. Except as is required by the next succeeding sentence of this paragraph, such percentage:

(a)  Must be the same percentage for each policy year between the second policy anniversary and the later of the fifth policy anniversary and the first policy anniversary at which there is available under the policy a cash surrender value in an amount, before including any paid-up additions and before deducting any indebtedness, of at least 0.2 percent of either the amount of insurance, if the insurance is uniform in amount, or the average amount of insurance at the beginning of each of the first 10 policy years; and

(b)  Must be such that no percentage after the later of the two policy anniversaries specified in paragraph (a) may apply to fewer than 5 consecutive policy years.

However, no basic cash value may be less than the value which would be obtained if the adjusted premiums for the policy, as defined in subsection (6) or subsection (9), whichever is applicable, were substituted for the nonforfeiture factors in the calculation of the basic cash value. All adjusted premiums and present values referred to in this subsection shall be calculated for a particular policy on the same mortality and interest bases as are used in demonstrating the compliance of the policy with the other subsections of this law. The cash surrender values referred to in this subsection shall include any endowment benefits provided for by the policy. Any cash surrender value available other than in the event of default in a premium payment due on a policy anniversary, and the amount of any paid-up nonforfeiture benefit available under the policy in the event of default in a premium payment, shall be determined in manners consistent with the manners specified for determining the analogous minimum amounts in subsections (2), (3), (4), (5), (9), and (11). The amounts of any cash surrender values and of any paid-up nonforfeiture benefits granted in connection with additional benefits such as those listed in paragraphs (11)(a)-(f) shall conform with the principles of this subsection.

(13)  EXCEPTIONS.--This section does not apply to any:

(a)  Reinsurance;

(b)  Group insurance;

(c)  Pure endowment contract;

(d)  Annuity or reversionary annuity contract;

(e)  Term policy of uniform amount which provides no guaranteed nonforfeiture or endowment benefits, or renewal thereof, of, 20 years or less expiring before age 71, for which uniform premiums are payable during the entire term of the policy;

(f)  Term policy of decreasing amount which provides no guaranteed nonforfeiture or endowment benefits, on which each adjusted premium calculated as specified in subsections (6)-(9) is less than the adjusted premium so calculated on a policy of uniform amount which provides no guaranteed nonforfeiture or endowment benefits, or renewal thereof, issued at the same age and for the same initial amount of insurance for a term of 20 years or less expiring before age 71, for which uniform premiums are payable during the entire term of the policy; or

(g)  Policy which provides no guaranteed nonforfeiture or endowment benefits for which no cash surrender value, if any, or present value of any paid-up nonforfeiture benefit, at the beginning of any policy year, calculated as specified in subsections (4)-(9) exceeds 2.5 percent of the amount of insurance at the beginning of the same policy year.

For purposes of determining the applicability of this section, the age at expiry for a joint term life insurance policy shall be the age at expiry of the oldest life.

(14)  OPERATIVE DATE.--After the effective date of this code, any insurer may file with the office a written notice or notices of its election to comply with the provisions of this section on and after a specified date or dates before January 1, 1966, as to either or both of its policies of ordinary and industrial insurance, in which case such specified date or dates shall be the operative date of this section with respect to such policies. The operative date of this section for policies of both ordinary and industrial insurance shall be the earlier of January 1, 1966, and any prior operative date or dates resulting from such previously filed written notices. With respect to policies of industrial insurance issued on and after the operative date of this section for such policies but before January 1, 1968, any insurer may file with the office written notice of its election to have the Commissioners' 1961 Standard Industrial Mortality Table and the Commissioners' 1961 Industrial Extended Term Insurance Table applicable with respect to subsection (8) for policies issued on and after the date specified in such election.

History.--s. 503, ch. 59-205; s. 3, ch. 61-106; ss. 2, 3, ch. 65-11; ss. 13, 35, ch. 69-106; s. 3, ch. 73-324; s. 3, ch. 76-168; s. 2, ch. 77-324; s. 1, ch. 77-457; ss. 2, 3, ch. 79-356; ss. 1, 2, ch. 80-137; ss. 5, 6, ch. 81-289; ss. 2, 3, ch. 81-318; ss. 398, 404, 809(2nd), 810, ch. 82-243; ss. 54, 79, ch. 82-386; s. 13, ch. 90-119; s. 114, ch. 92-318; s. 10, ch. 97-292; s. 1130, ch. 2003-261; s. 14, ch. 2004-370; s. 159, ch. 2004-390.

627.479  Prohibited policy plans.--

(1)  No insurer shall issue policies, certificates, or contracts to policyholders or members providing for the grouping of its policyholders or members into groups and divisions, classified according to age, and providing for payment of contingent endowment benefits, by whatever name called, from special funds created for such purpose to the oldest member in seniority of the group or division, or under any other similar plan.

(2)  No insurer shall issue policies containing annual endowments or other specialty-type policies such as founder's policies or coupon-bearing policies. The commission shall, by rule, define such prohibited policies.

(3)  The office shall revoke the certificate of authority of any insurer which violates this section.

History.--s. 506, ch. 59-205; ss. 13, 35, ch. 69-106; s. 1, ch. 74-50; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 401, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1131, ch. 2003-261.

627.480  Cash payments of single-premium life policies.--Premiums for single-premium life insurance policies shall be paid in cash. This section is not applicable to the use of dividends to purchase paid-up additional insurance or to such other usual and customary methods of paying for life insurance as may be permitted by rule of the commission.

History.--s. 1, ch. 70-66; s. 1, ch. 70-439; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 402, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1132, ch. 2003-261.

627.481  Requirements for certain annuity agreements.--

(1)  Any duly organized domestic or foreign nonstock corporation, or any unincorporated charitable trust, if such corporation or trust:

(a)  Has been in active operation for at least 5 years prior thereto and has qualified as an exempt organization under the Internal Revenue Code, 26 U.S.C. s. 501(c)(3), or

(b)  Has been wholly controlled for at least 10 years by a corporation or trust qualified under paragraph (a), if the subunit has been a corporation or trust for at least 2 years, and has engaged in the selling of annuity agreements authorized under this section in at least three other states without complaint,

may enter into annuity agreements with donors in accordance with this section. Such corporation or trust may receive gifts conditioned upon, or in return for, its agreement to pay an annuity to the donor or other designated beneficiary or beneficiaries and to make and carry out such annuity agreement. Annuity benefits under any such annuity agreement must be calculated to return to such corporation or trust upon the death of the annuitant a residue at least equal to one-half the original gift or other consideration for such annuity.

(2)(a)  Every such domestic corporation or such domestic or foreign trust shall have and maintain admitted assets at least equal to the sum of the reserves on its outstanding annuity agreements, and a surplus of 10 percent of such reserves, calculated using:

1.a.  The present value of future guaranteed benefits for individual annuities that have either commenced paying benefits or have fixed a future date of the first benefit payment.

b.  The commissioner's annuity reserve method, as set forth in s. 625.121(7)(c), for individual deferred annuities that have not fixed a date for the first benefit payment.

2.  The mortality tables used to value individual annuities, as defined in s. 625.121(5).

a.  For annuities issued prior to July 1, 1998:

(I)  The mortality tables described in s. 625.121(5)(h), for individual annuities;

(II)  At the option of the corporation or trust, the 1983 Individual Annuity Mortality Table; or

(III)  At the option of the corporation or trust, the 2000 Individual Annuity Mortality Table for annuities issued between January 1, 1998, and June 30, 1998, inclusive.

b.  For annuities issued on or after July 1, 1998:

(I)  The mortality tables set forth in s. 625.121(5)(i)3.;

(II)  Any other mortality tables required to be used by insurers in accordance with s. 625.121; or

(III)  At the option of the corporation or trust, any other mortality tables authorized to be used by insurers in accordance with s. 625.121.

3.  An interest rate not greater than the maximum interest rate permitted for the valuation of individual annuities issued during the same calendar year as the charitable gift annuity for individual annuities as set forth in s. 625.121(6)(b)-(f).

a.  The maximum statutory valuation interest rates for single-premium immediate annuities for 1992 may be used for annuities issued in 1992 or any prior year. The maximum statutory valuation interest rates for single-premium immediate annuities issued in 1992 through 2001 are as follows:

Year of Issue	Single Premium Immediate Annuity Interest Rate
1992	7.75 percent
1993	7.00 percent
1994	6.50 percent
1995	7.25 percent
1996	6.75 percent
1997	6.75 percent
1998	6.25 percent
1999	6.25 percent
2000	7.00 percent
2001	6.75 percent

b.  For 2002 and subsequent years, until an interest rate for a specified year can be determined in accordance with s. 625.121(6), the prior year's rate shall be used unless the office requires use of a lower rate.

(b)  In determining the reserves of any such corporation or trust, a deduction shall be made for all or any portion of an annuity risk which is reinsured by a life insurance company authorized to do business in this state.

(c)1.  The assets of such corporation or trust in an amount at least equal to the sum of such reserves and surplus shall be invested only in mutual funds or investments permitted under part II of chapter 625 for the investment of the reserves of authorized life insurance companies.

2.  For purposes of this section, the provisions of s. 625.305(2)(a) shall not apply. In lieu thereof, the fair market value of investments made by such corporation or trust in stock authorized by s. 625.324 may not exceed 50 percent of such corporation's or trust's required reserves and surplus. The fair market value in stock of any one corporation or mutual fund may not exceed 10 percent of such corporation's or trust's required reserves and surplus. All other provisions of s. 625.305 shall apply. Such assets shall be segregated as separate and distinct funds, independent of all other funds of such corporation or trust, and shall not be applied for the payment of the debts and obligations of the corporation or trust or for any purpose other than the annuity benefits specified in this section.

(3)  No such foreign corporation shall make these annuity agreements in this state unless it complies with all the requirements of this section imposed upon like domestic corporations, except that the corporation may invest its reserve and surplus funds in the kind of securities permitted by the laws of the state in which it was incorporated or organized.

(4)  Any corporation or trust that engages in the business of issuing these annuity agreements shall notify the office in writing by the later of 90 days after the effective date of this act or the date on which it enters into the first of these annuity agreements. The notice must:

(a)  Be signed by two or more officers or directors of the organization;

(b)  Identify the organization; and

(c)  Certify that the organization meets the requirements of this section.

(5)  Any annuity agreement entered into by a corporation or trust must contain the following clause: "This annuity is not issued by an insurance company, is subject only to limited regulation by the State of Florida and is not protected or otherwise guaranteed by any government agency."

(6)  If the office finds that any such corporation or trust has failed to comply with the requirements of this section, it may order such corporation or trust to cease making any new annuity agreements until such requirements have been satisfied. The office may, in its discretion, require annual statements by such corporation or trust and may accept in lieu thereof a sworn statement by two or more of the principal officers thereof, in such form as will satisfy the office that the requirements of this section are being complied with.

(7)  Except as provided in this section, every such corporation or trust shall be exempt from the provisions of this code in making annuity agreements issued under this section.

(8)  Any annuity agreement entered into by a corporation or trust the sole purpose of which is to support a state institution of higher learning shall contain the following clause:

"This agreement is the entire contract between the parties, with rights and responsibilities of each party to the other as set forth herein. The donor or annuitant shall not have recourse against any assets of the state other than any funds or assets donated by, or funds derived from any assets donated by, the donor as set forth herein."

(9)  Agreements in the form of a charitable remainder unitrust trust, charitable remainder annuity trust, charitable lead trust, pooled income fund or other similar charitable split interest trust arrangement (not including a charitable gift annuity), described in ss. 170(f)(2)(A) and (B), 664(d)(1) and (2), and 642(c)(5) of the Internal Revenue Code are exempt from the provisions of subsections (1), (2), (3), and (5).

(10)  The provisions of part IX of chapter 626 apply to issuers of annuity agreements under this section.

(11)  The commission shall adopt rules and forms for the filing of annual statements and agreements pertaining to donor annuity organizations.

History.--s. 1, ch. 74-149; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 21, ch. 78-95; ss. 2, 3, ch. 81-318; ss. 403, 404, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 44, 114, ch. 92-318; s. 16, ch. 96-168; s. 25, ch. 97-93; s. 15, ch. 99-307; s. 10, ch. 2000-370; s. 58, ch. 2001-63; s. 6, ch. 2002-247; s. 1133, ch. 2003-261.

627.482  Interest payable on cash surrender of policy.--

(1)  If an insured requests payment of the cash surrender value of a policy from its insurer, such payment shall include interest at the rate of interest specified in s. 625.121(6)(e), unless such payment is made by the insurer within 30 days of receipt of the insurance policy and request for cash surrender.

(2)  An insurer shall be exempt from the requirements of this section if, upon petition by the insurer to the office, it is determined by the office that payment of such interest threatens the solvency of the insurer.

History.--s. 1, ch. 89-360; s. 1, ch. 90-192; s. 66, ch. 91-108; s. 114, ch. 92-318; s. 1134, ch. 2003-261.

PART IV

INDUSTRIAL LIFE INSURANCE
POLICIES

627.501  Scope of this part.

627.502  "Industrial life insurance" defined; reporting.

627.503  Required provisions.

627.504  Grace period.

627.5045  Secondary notice.

627.505  Entire contract; statements in application.

627.506  Incontestability.

627.507  Misstatement of age or sex.

627.508  Dividends.

627.509  Reinstatement.

627.510  Settlement on proof of death.

627.511  Authority to alter contract.

627.512  Beneficiary.

627.513  Facility of payment.

627.514  Nonforfeiture benefits; certain interim policies.

627.515  Title of industrial life insurance policy.

627.516  Advance payment of premiums.

627.517  Conversion.

627.521  Disclosure statements.

627.522  Policy requirements and prohibitions.

627.501  Scope of this part.--The provisions of this part apply only to industrial life insurance policies. Sections 627.463, 627.472, 627.476, and 627.479 also apply to industrial life insurance policies.

History.--s. 507, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.502  "Industrial life insurance" defined; reporting.--

(1)  For the purposes of this code, "industrial life insurance" is that form of life insurance written under policies under which premiums are payable monthly or more often, bearing the words "industrial policy" or "weekly premium policy" or words of similar import imprinted upon the policies as part of the descriptive matter, and issued by an insurer which, as to such industrial life insurance, is operating under a system of collecting a debit by its agent.

(2)  Every life insurer transacting industrial life insurance shall report to the office all annual statement data regarding the exhibit of life insurance, including relevant information for industrial life insurance.

History.--s. 508, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 405, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1135, ch. 2003-261.

627.503  Required provisions.--

(1)  No policy of industrial life insurance shall be delivered or issued for delivery in this state unless it contains in substance each of the provisions as required in s. 627.476 and ss. 627.504-627.521, or provisions which in the opinion of the office are more favorable to the policyholder.

(2)  Any such provisions or portions not applicable to single-premium or term policies shall to that extent not be incorporated therein.

History.--s. 509, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 406, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1136, ch. 2003-261.

627.504  Grace period.--The policy shall provide that the insured is entitled to a grace period of 4 weeks within which the payment of any premiums due after the first premium payment may be made, except that in policies the premiums for which are payable monthly, the grace period shall be 1 month, but not less than 30 days; and that during the grace period the policy shall continue in full force, but if during the grace period there is a claim under the policy, then any premiums due and unpaid may be deducted from any settlement under the policy.

History.--s. 510, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 407, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.5045  Secondary notice.--Except as provided in this section, a contract for an industrial life insurance policy issued or issued for delivery in this state on or after October 1, 1997, for which premiums are paid monthly, covering a natural person 64 years of age or older or owned by a natural person 64 years of age or older, which has been in force for at least 1 year, may not be lapsed for nonpayment of premium unless, after expiration of the grace period, and at least 21 days before the effective date of such lapse, the insurer has mailed a notification of the impending lapse in coverage to the policyowner and to a specified secondary addressee if such addressee has been designated in writing by name and address by the policyowner. An insurer issuing an industrial life insurance contract on or after October 1, 1997, shall notify the applicant of the right to designate a secondary addressee at the time of application for the policy on a form provided by the insurer and at any time the policy is in force by submitting a written notice to the insurer containing the name and address of the secondary addressee. This section does not apply to any life insurance contract under which premiums are payable monthly or more frequently and are regularly collected by a licensed agent.

History.--s. 3, ch. 95-142; s. 12, ch. 97-292.

627.505  Entire contract; statements in application.--The policy shall provide that the policy shall constitute the entire contract between the parties or, if a copy of the application is endorsed upon or attached to the policy when issued, that the policy and the application therefor shall constitute the entire contract. If the application is so made a part of the contract, the policy shall also provide that all statements made by the applicant in such application shall, in the absence of fraud, be deemed to be representations and not warranties.

History.--s. 511, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 408, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.506  Incontestability.--The policy shall provide that the policy shall be incontestable after it has been in force during the lifetime of the insured for a period of 2 years from its date of issue except for nonpayment of premiums and except, at the option of the insurer, as to provisions providing benefits for disability or specifically for death by accident or accidental means.

History.--s. 512, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 409, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.507  Misstatement of age or sex.--The policy shall provide that if it is found that the age or sex of the insured, or of any other individual considered in determining the premium, has been misstated, any amount payable or benefit accruing under the policy shall be such as the premium would have purchased according to the correct sex or age. The calculations shall be in accordance with the insurer's rate at the date of issue, and at the insurer's option this may be so specified in the policy.

History.--s. 513, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 410, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.508  Dividends.--Every participating policy shall provide that the insurer shall annually ascertain and apportion any divisible surplus accruing on the policy. This provision shall not prohibit the payment of additional dividends on default of payment of premiums or termination of the policy.

History.--s. 514, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 411, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.509  Reinstatement.--The policy shall provide that the policy may be reinstated at any time within 3 years after the date of default in the payment of any premium, unless the policy has been surrendered for its cash value or unless the paid-up term insurance, if any, has expired, upon evidence of insurability satisfactory to the insurer and the payment of all overdue premiums and payment (or, within the limits permitted by the then cash value of the policy, reinstatement) of any other indebtedness to the insurer upon the policy with interest as to both premiums and indebtedness at a rate not exceeding 6 percent per year compounded annually.

History.--s. 515, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 412, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.510  Settlement on proof of death.--

(1)  The policy shall provide that when the policy becomes a claim by the death of the insured, settlement shall be made upon surrender of the policy and receipt of due proof of death or after a specified period not exceeding 60 days after such surrender and receipt of such proof. At the insurer's option, surrender of the premium receipt book may also be required.

(2)  Insurers transacting industrial life insurance business in the state who require a claim form to be filed by a claimant for settlement of a policy shall allow the claimant to file the claim using the uniform life insurance claim form developed by the commission. The commission shall establish by rule a uniform life insurance claim form to be used by claimants for settlement of any industrial life insurance policy issued by an insurer transacting life insurance business in this state.

History.--s. 516, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 413, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 87-37; s. 114, ch. 92-318; s. 1137, ch. 2003-261.

627.511  Authority to alter contract.--The policy shall provide that no agent shall have the power or authority to waive, change, or alter any of the terms or conditions of any policy; except that, at the option of the insurer, the terms or conditions may be changed by an endorsement or rider signed by a duly authorized officer of the insurer.

History.--s. 517, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 414, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.512  Beneficiary.--The policy shall provide a space for the name of the beneficiary designated with a reservation of the right to designate or change the beneficiary after the issuance of the policy. The policy may also provide that no designation or change of beneficiary shall be binding on the insurer until endorsed on the policy by the insurer and that the insurer may refuse to endorse the name of any proposed beneficiary who does not appear to the insurer to have an insurable interest in the life of the insured.

History.--s. 518, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 415, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.513  Facility of payment.--The policy may also provide that if the beneficiary designated in the policy does not make a claim under the policy or does not surrender the policy with due proof of death within the period stated in the policy, which shall not be less than 30 days after the death of the insured, or if the beneficiary is the estate of the insured or is a minor, or dies before the insured or is not legally competent to give valid release, then the insurer may make payment to the executor or administrator of the insured; to any of the insured's relatives by blood or legal adoption or connection by marriage; to any person appearing to the insurer to be equitably entitled thereto; or to any person who has incurred expense for the maintenance, medical attention, or burial of the insured. The policy may also include a similar provision applicable to any other payment due under the policy.

History.--s. 519, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 416, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.514  Nonforfeiture benefits; certain interim policies.--Each industrial life insurance policy delivered or issued for delivery between the effective date of this code and the operative date of s. 627.476 shall provide:

(1)  That, in the event of default in any premiums, the insurer will grant, upon proper request not later than 13 weeks or 3 months after the due date of the premium in default, a paid-up nonforfeiture benefit on a plan stipulated in the policy.

(2)  That, upon surrender of the policy within 13 weeks or 3 months after the due date of any premium payment in default after premiums have been paid for at least 5 full years, the insurer will pay, in lieu of any paid-up nonforfeiture benefit, a cash surrender value at least equal to the minimum cash surrender value hereinafter specified. The minimum cash surrender value shall be equal to:

(a)  The reserve on the date of default of the premium less a sum of not more than 2.5 percent of the face amount; or

(b)  An amount as defined in s. 627.476. The policy shall reserve to the insurer the right to defer the granting of any cash surrender value for 6 months after demand therefor with surrender of the policy.

(3)  That a specified paid-up nonforfeiture benefit, the present value of which shall be at least equal to the cash surrender value, shall become effective as specified in the policy unless the person entitled to make such election elects another available option not later than 13 weeks or 3 months after the due date of the premium in default; however, when the mortality table used is the 1941 Standard Industrial Mortality Table, the rates of mortality to be assumed in calculating any extended term insurance with accompanying pure endowment, if any, may be not more than 130 percent of the rates of mortality according to such table.

(4)  A statement of the mortality table and interest rate used in calculating the cash surrender values and the paid-up nonforfeiture benefits available under the policy, together with a table showing the cash surrender value, if any, and paid-up nonforfeiture benefits, if any, available under the policy on each policy anniversary either during the first 20 policy years or during the term of the policy, whichever is shorter.

This section does not apply to term policies of uniform amount of 15 years' duration or less, to increasing term policies of 15 years' duration or less, or to decreasing term policies.

History.--s. 520, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 417, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.515  Title of industrial life insurance policy.--There shall be a title on the face of each such policy briefly describing its form.

History.--s. 521, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.516  Advance payment of premiums.--Each insurer shall allow a refund or discount on advance premiums paid for an industrial life insurance policy if such premiums are paid in a single sum covering a period of at least 13 weeks. Such refund or discount shall reflect the difference in costs between weekly or monthly premium payment and the advance premiums being paid, with an interest factor used to reflect the time value of money.

History.--s. 522, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 2, ch. 80-156; ss. 2, 3, ch. 81-318; ss. 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.517  Conversion.--Each industrial life insurance policy delivered or issued for delivery on or after January 1, 1981, shall provide that if, upon the sale of any new industrial life insurance policy, the combined face value of all industrial life insurance policies, including the new policy, issued by any one insurer, insuring any one life and owned by any one person, would exceed $3,000, then the owner shall have the option of merging and converting such industrial life insurance policies into one regularly offered ordinary life insurance policy with the same insurer with no further evidence of insurability required.

History.--s. 523, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 3, ch. 80-156; ss. 2, 3, ch. 81-318; ss. 418, 420, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.521  Disclosure statements.--Each industrial life insurance premium receipt book delivered in this state on or after January 1, 1983, shall contain the following disclosure statement: "You are entitled to a discount or refund from the company if you make your premium payment 13 weeks in advance."

History.--ss. 419, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.522  Policy requirements and prohibitions.--

(1)  An industrial life insurance policy may not exclude or restrict the payment of the face amount by reason of the fact that the death of the insured occurred due to the act of another.

(2)  Each of the optional benefits and charges provided under an industrial life insurance policy must be separately priced. The prices must be set forth in the policy in a clear, conspicuous, and understandable manner.

(3)  This section does not limit the rights of any assignee of any industrial life insurance policy to enforce any assignment pursuant to its terms and does not prohibit an insurer from recognizing any such assignment pursuant to its terms.

History.--s. 45, ch. 92-318.

PART V

GROUP LIFE INSURANCE POLICIES

627.551  Group contracts and plans of self-insurance must meet group requirements.

627.5515  Out-of-state groups.

627.552  Employee groups.

627.553  Debtor groups.

627.554  Labor union groups.

627.555  Trustee groups.

627.556  Credit union groups.

627.5565  Additional groups.

627.5567  Group life insurance; association groups.

627.5575  Group life insurance for dependents.

627.558  Provisions required in group contracts.

627.559  Grace period.

627.560  Incontestability.

627.561  Application; statements deemed representations.

627.562  Insurability.

627.563  Misstatement of age.

627.564  Payment of benefits.

627.565  Certificate.

627.566  Conversion on termination of eligibility.

627.567  Conversion on termination of policy.

627.568  Death pending conversion.

627.5685  Continuance of coverage during disability.

627.5686  Waiver of premium for disabled insured.

627.569  Use of dividends, refunds, rate reductions, commissions, service fees.

627.570  Premium rates.

627.571  Assignment of incidents of ownership in group life insurance policies, including conversion privileges.

627.5725  Notification to insureds of cancellation or expiration.

627.573  Replacement or termination of group life insurance; liability of prior insurer.

627.574  Liability of succeeding insurer on replacement of group policy.

627.575  Extension of benefits.

627.551  Group contracts and plans of self-insurance must meet group requirements.--

(1)(a)  A life insurance policy insuring the lives of more than one individual may be delivered or issued for delivery in this state only if the policy is issued to one of the groups specified in ss. 627.552-627.5575, and only if the policy complies with the other applicable provisions of this part.

(b)  A plan of self-insurance providing benefits in the event of death to residents of this state may be established or maintained only if the plan complies with the applicable provisions of this part relating to the rights of individuals to specified benefits and coverages.

(2)  Subsection (1) does not apply to life insurance policies or plans of self-insurance:

(a)  Insuring or providing benefits only to individuals related by blood, marriage, or legal adoption.

(b)  Insuring or providing benefits only to individuals who have a common interest through ownership of a business enterprise, or a substantial legal interest or equity therein, and who are actively engaged in the management of the business enterprise.

(c)  Insuring or providing benefits only to individuals otherwise having an insurable interest in each other's lives.

(3)  As used in this part:

(a)  "Policy," "insurance policy," and "group life insurance policy" include plans of self-insurance providing death benefits.

(b)  "Amount of insurance" and "insurance" include the death benefits provided under a plan of self-insurance.

(c)  "Insurer" includes any person or governmental unit providing a plan of self-insurance.

(4)  A nongovernmental self-insurance plan providing life insurance may not be contributory by participants.

(5)  This section does not apply to any plan which is established or maintained by an individual employer in accordance with the Employee Retirement Income Security Act of 1974. This subsection does not allow an authorized insurer to issue a group life insurance policy or certificate which does not comply with this part.

History.--s. 524, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 3, 10, ch. 80-341; ss. 2, 3, ch. 81-318; ss. 421, 448, 809(2nd), ch. 82-243; ss. 55, 79, ch. 82-386; s. 5, ch. 83-203; s. 16, ch. 83-288; ss. 46, 114, ch. 92-318.

627.5515  Out-of-state groups.--

(1)  Any group life insurance policy issued or delivered outside this state under which a resident of this state is provided coverage shall comply with the provisions of this part in the same manner as group life policies issued in this state.

(2)  This part does not apply to a group life insurance policy issued or delivered outside this state under which a resident of this state is provided coverage if:

(a)  The policy is issued to an employee group the composition of which is substantially as described in s. 627.552; a labor union group the composition of which is substantially as described in s. 627.554; a trustee group the composition of which is substantially as described in s. 627.555; a credit union group the composition of which is substantially as described in s. 627.556; an additional group complying with s. 627.5565; an association group the composition of which is substantially as described in s. 627.5567; an association group to cover persons associated in any other common group, which common group is formed primarily for purposes other than providing insurance; a group which is established primarily for the purpose of providing group insurance, provided the benefits are reasonable in relation to the premiums charged thereunder and issuance of the group policy has resulted, or will result, in economies of administration; or a group of insurance agents of an insurer, which insurer is the policyholder;

(b)  Certificates evidencing coverage under the policy are issued to residents of this state and contain in contrasting color and not less than 10-point type the following statement:  "The benefits of the policy providing your coverage are governed primarily by the law of a state other than Florida."; and

(c)  The policy provides the benefits specified in s. 627.566.

(3)  Section 624.428 is not applicable when residents of this state are enrolled for coverage under a policy or certificate issued in accordance with subsection (2).

(4)  Prior to solicitation in this state, a copy of the master policy and a copy of the form of the certificate evidencing coverage that will be issued to residents of this state shall be filed with the office for informational purposes.

(5)  Prior to solicitation in this state, an officer of the insurer shall truthfully certify to the office that the policy and certificates evidencing coverage have been reviewed and approved by the state in which the group policy is issued.

(6)  Any insurer who provides coverage under certificates of insurance issued to residents of this state shall designate one Florida-licensed resident agent as agent of record for the service of such certificates, unless the policy is issued to a group substantially as described in s. 627.552, s. 627.554, s. 627.555, s. 627.556, s. 627.5565, or s. 627.5567.

History.--ss. 422, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 98, ch. 83-216; s. 114, ch. 92-318; s. 30, ch. 99-3; s. 1138, ch. 2003-261.

627.552  Employee groups.--Subject to all of the requirements of this section, the lives of a group of individual employees of an employer may be insured, for the benefit of persons other than the employer, under a policy issued to the employer or to the trustees of a fund established by an employer, which employer or board of trustees is deemed to be the policyholder.

(1)(a)  The employees eligible for insurance under the policy shall be all of the employees of the employer, or all of any class or classes of employees determined by conditions pertaining to their employment.

(b)  The policy may provide that the term "employees" includes the employees of one or more subsidiary corporations, and includes the employees, individual proprietors, and partners of one or more affiliated corporations, proprietors, or partnerships if the business of the employer and of the affiliated corporations, proprietors, or partnerships is under common control. The policy may provide that the term "employees" includes the individual proprietor or partners if the employer is an individual proprietor or a partnership. The policy may provide that the term "employees" includes directors of a corporate employer, former employees, or retired employees.

(c)  A policy issued to insure the employees of a public body may provide that the term "employees" includes elected or appointed officials.

(2)  The premium for the policy shall be paid by the policyholder, either from the employer's funds or from funds contributed by the insured employees, or from both. A policy on which no part of the premium is derived from funds contributed by the insured employees must insure all eligible employees, or all except any as to whom evidence of individual insurability is not satisfactory to the insurer, except those employees who reject coverage in writing.

(3)  The amounts of insurance under the policy must be based upon some plan precluding individual selection either by the employees or by the employer or trustees.

This section does not affect the provisions of ss. 112.08-112.14.

History.--s. 525, ch. 59-205; s. 1, ch. 63-187; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 423, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 47, 114, ch. 92-318.

627.553  Debtor groups.--The lives of a group of individuals may be insured under a policy issued to a creditor or its parent holding company, or to a trustee or trustees or agent designated by two or more creditors, which creditor, holding company, affiliate, trustee or trustees, or agent shall be deemed the policyholder, to insure debtors of the creditor or creditors, subject to the following requirements:

(1)  The debtors eligible for insurance under the policy shall be all of the debtors of the creditor or creditors or all of any class or classes thereof. The policy may provide that the term "debtors" includes:

(a)  Borrowers of money or purchasers or lessees of goods, services, or property for which payment is arranged through a credit transaction;

(b)  The debtors of one or more subsidiary corporations; and

(c)  The debtors of one or more affiliated corporations, proprietorships, or partnerships if the business of the policyholder and of such affiliated corporations, proprietorships, or partnerships is under common control.

(2)  The premium for the policy shall be paid either from the creditor's funds or from charges collected from the insured debtors, or from both. A policy on which part or all of the premium is to be derived from the collection from the insured debtors of identifiable charges not required of uninsured debtors shall not include, in the class or classes of debtors eligible for insurance, debtors under obligations outstanding at its date of issue without evidence of individual insurability unless at least 75 percent of the then eligible debtors elect to pay the required charges. A policy on which no part of the premium is to be derived from the collection of such identifiable charges must insure all eligible debtors, or all except any as to whom evidence of individual insurability is not satisfactory to the insurer. The policy may be issued only if the group of eligible debtors is then receiving new entrants at the rate of at least 100 persons yearly, or may reasonably be expected to receive at least 100 new entrants during the first policy year, and only if the policy reserves to the insurer the right to require evidence of individual insurability if less than 75 percent of the new entrants become insured. The policy may exclude from the classes eligible for insurance classes of debtors determined by age.

(3)  The amount of insurance on the life of any debtor shall at no time exceed the amount owed by her or him which is repayable in installments to the creditor or $50,000, whichever is less, except that loans not exceeding 1 year's duration shall not be subject to such limits. However, on such loans not exceeding 1 year's duration, the limit of coverage shall not exceed $50,000 with any one insurer.

(4)  The policy shall provide that the insurer will furnish to the policyholder, for delivery to each insured debtor under the policy, a certificate of insurance describing the coverage and specifying that the death benefit shall first be applied to reduce or extinguish the indebtedness. The remainder, if any, shall be paid to the designated second beneficiary or the insured's estate.

History.--s. 526, ch. 59-205; s. 1, ch. 67-131; s. 3, ch. 76-168; s. 1, ch. 77-246; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 424, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 89-75; s. 114, ch. 92-318; s. 331, ch. 97-102.

627.554  Labor union groups.--Subject to all of the requirements of this section, the lives of a group of individual labor union members or labor union members and their dependents may be insured, for the benefit of persons other than the union or any of its officials, representatives, or agents, under a policy issued to the labor union or to the trustees of a fund established in this state by the labor union, which labor union or board of trustees is deemed to be the policyholder.

(1)  The individuals eligible for insurance under the policy shall be all of the members of the union, or all of the members of any class or classes of union members determined by conditions pertaining to their employment or to membership in the union, or to both. A policy issued to the trustees of a fund established in this state by a labor union may provide that the trustees or their employees, or both, may be insured under the policy if their duties are principally connected with such trusteeship.

(2)  The premium for the policy shall be paid by the policyholder either wholly from the policyholder's funds or from funds contributed by the employer or employers of the insured persons or by the labor union, or by both, or partly from such funds and partly from funds contributed by the insured members specifically for their insurance. A policy on which no part of the premium is to be derived from funds contributed by the insured members specifically for their insurance must insure all eligible members, or all except any as to whom evidence of individual insurability is not satisfactory to the insurer or except as to those who reject the coverage in writing.

(3)  The amounts of insurance under the policy must be based upon some plan precluding individual selection either by the members or by the union.

History.--s. 527, ch. 59-205; s. 1, ch. 61-107; s. 2, ch. 63-187; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 425, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 48, 114, ch. 92-318.

627.555  Trustee groups.--Subject to all of the requirements of this section, the lives of a group of individual employees of employers or members of labor unions may be insured, for the benefit of persons other than the employers or unions, under a policy issued to the trustees of a fund established by two or more employers in the same industry or by two or more labor unions, or to the trustees of a fund established by one or more employers in the same industry and one or more labor unions or by one or more employers and one or more labor unions whose members are in the same or related occupations or trades, which board of trustees is deemed to be the policyholder.

(1)  A policy may not be issued under this section:

(a)  To insure employees of any employer whose eligibility to participate in the fund as an employer arises out of considerations directly related to the employer being a commercial correspondent or business client or patron of another employer, regardless of whether the other employer is or is not participating in the fund.

(b)  To insure employees of any employer not located in this state, unless the majority of the employers whose employees are to be insured are located in this state, or unless the employer has assumed obligations through a collective bargaining agreement and is participating in the fund either pursuant to those obligations with regard to one or more classes of employees encompassed in the collective bargaining agreement or as a method of providing insurance benefits for other classes of employees, or unless the policy is issued to the trustees of a fund established by two or more labor unions.

(2)(a)  The persons eligible for insurance shall be all of the employees of the employers or all of the members of the unions, or all of the members of any class or classes of employees or union members determined by conditions pertaining to their employment or to membership in the unions, or both. The policy may provide that the term "employees" includes retired employees, former employees, directors of a corporate employer, and the individual proprietor or partners if an employer is an individual proprietor or a partnership. The policy may provide that the term "employees" includes the employees of one or more subsidiary corporations, and the employees, individual proprietors, and partners of one or more affiliated corporations, proprietorships, or partnerships if the business of the employer and of the affiliated corporations, proprietorships, or partnerships is under common control.

(b)  Except as provided in paragraph (a) as to retired employees, an individual proprietor or partner is not eligible for insurance under the policy as an employee unless she or he is actively engaged in and devotes a substantial part of her or his time to the conduct of the business of the proprietor or partnership. The policy may provide that the term "employees" includes the trustees or their employees, or both, if their duties are principally connected with such trusteeship.

(3)  The premium for the policy shall be paid by the policyholder either wholly from the policyholder's funds or from funds contributed by the employer or employers of the insured persons or by the union or unions, or by both, or partly from such funds and partly from funds contributed by the insured persons. A policy may not be issued if the entire gross premium charged for the insurance by the insurer is derived from funds contributed by the insured employees or members specifically for their insurance. A policy on which no part of the premium is to be derived from funds contributed by the insured persons specifically for their insurance must insure all eligible persons, or all except any who reject the coverage in writing or as to whom evidence of individual insurability is not satisfactory to the insurer. For the purpose of determining the number of eligible persons who must be covered under a policy, dependents may not be included as eligible persons.

(4)  The policy must cover at date of issue not less than five individuals, other than individual proprietors or partners, from each employer unit unless:

(a)  The policy is issued to the trustees of a fund established by employers that have assumed obligations through a collective bargaining agreement and are participating in the fund either pursuant to those obligations with regard to one or more classes of their employees which are encompassed in the collective bargaining agreement or as a method of providing insurance benefits for other classes of their employees.

(b)  The employer unit is a subsidiary corporation of an employer in the group or is an affiliated corporation, proprietorship, or partnership of an employer in the group whose business and that of such employer is under common control.

(c)  The policy is issued to the trustees of a fund established by two or more labor unions.

(5)  In addition to the requirements of subsection (4), if the fund is established by the members of a group of employers, the policy may be issued only if the participating employers constitute at the date of issue at least 60 percent of those employer members whose employees are not already covered for group life insurance or if the total number of persons covered at date of issue exceeds 600. The policy may not require that if a participating employer discontinues membership in the group of employers, the insurance of the employer's employees ceases solely by reason of the discontinuance.

(6)  The amounts of insurance under the policy must be based upon some plan precluding individual selection either by the insured persons or by the policyholder, employers, or unions.

History.--s. 528, ch. 59-205; s. 2, ch. 61-107; s. 1, ch. 65-19; s. 1, ch. 67-96; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 426, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 49, 114, ch. 92-318; s. 332, ch. 97-102.

627.556  Credit union groups.--The lives of a group of individual credit union members may be insured under a policy issued to the credit union, which is deemed to be the policyholder. The premium shall be paid by the credit union insuring all of its eligible members for the amounts of insurance, not in excess of the share balance, as to each member. The policy shall be for the benefit of the share account of the member or some person or persons other than the credit union or its officials. All eligible members of a credit union may be insured.

History.--s. 529, ch. 59-205; s. 1, ch. 63-6; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 427, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 50, 114, ch. 92-318.

627.5565  Additional groups.--

(1)  An insurer may afford coverage under a group policy issued under this subsection if all of the following conditions are satisfied:

(a)  The issuance of the group policy is not contrary to the best interests of the public.

(b)  Coverage under the group policy is afforded on an actuarially sound basis.

(c)  The group policy results in economies of acquisition or administration of a magnitude comparable to other group policies under this part.

(d)  The premium for the policy is paid by the policyholder either from policyholder funds or from funds contributed by the covered persons, or from both.

(e)  The group consists at all times of not less than five persons.

(f)  Eligibility for participation in the group is not based on the health of an individual participant.

(g)  The group was organized and exists primarily for purposes other than the procurement of insurance.

(h)  The composition of the group to which the policy is to be issued is not substantially similar to one of the groups specified in ss. 627.5515-627.5567.

(2)  An insurer shall inform the office of the effectuation of any coverage under this section within 30 days after effectuation of coverage. The insurer is responsible for establishing that the criteria of subsection (1) have been satisfied.

History.--ss. 428, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 51, 114, ch. 92-318; s. 1139, ch. 2003-261.

627.5567  Group life insurance; association groups.--Subject to all of the requirements of this section, the lives of a group of individual members of an association or members and their employees or dependents may be insured, for the benefit of persons other than the association or any of its official representatives or agents, under a policy issued to the association or to the board of trustees of a fund established in this state for the association, if the members of the association are engaged in a particular profession and are licensed to engage in the profession in this state and if the association has been in existence for at least 2 years and holds regular meetings not less than annually to further the purposes of the association members. The association or board of trustees is deemed to be the policyholder of the group life insurance policy.

(1)  The members eligible for insurance under the policy shall be all of the members of the association, or all of any class or classes of members of the association determined by conditions pertaining to their profession or to membership in the association, or to both. A policy issued to the trustees of a fund established in this state by an association may provide that the trustees or their employees, or both, may be insured under the policy if their duties are principally connected with the trusteeship.

(2)  The premium for the policy shall be paid by the policyholder either wholly from the policyholder's funds or funds contributed by the insured persons or by the association, or by both, or partly from such funds and partly from funds contributed by the insured members specifically for their insurance, subject to the following:

(a)  A policy on which part of the premium is derived from funds contributed by the insured members specifically for their insurance may be placed in force only if at least 100 of the then eligible members elect to make the required contributions. The policy may contain a provision requiring evidence of insurability of individual members.

(b)  A policy on which no part of the premium is derived from funds contributed by the insured members specifically for their insurance must insure all eligible members.

(3)  The association must have been in existence for at least 2 years prior to the issuance of the policy; its annual dues must actually be collected from its members; and it must not have been organized for the sole and exclusive purpose of qualifying for insurance under this section.

(4)  If a dividend, premium refund, rate reduction, commission, or service fee is received by any association or by the trustees of a fund established in whole or in part by an association, under any group insurance policy issued for delivery in this state, with respect to which they are the policyholder, covering the members of the association, to which the members contribute to the cost of the premiums for the insurance, the excess, if any, of the aggregate of the dividends, premium refunds, rate reductions, commissions, and service fees over the aggregate expenditure of the association or trustees towards the cost of such insurance, including its administration, for the current and preceding 2 years, to the extent that they were not defrayed by dividends, premium refunds, rate reductions, commissions, and service fees, shall be applied by the policyholder for the sole benefit of insured members on a basis which precludes individual selection and unfair discrimination.

History.--s. 1, ch. 72-57; s. 164, ch. 73-333; s. 1, ch. 74-283; s. 1, ch. 75-141; s. 3, ch. 76-168; s. 212, ch. 77-104; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 445, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 52, 114, ch. 92-318.

Note.--Former s. 627.572.

627.5575  Group life insurance for dependents.--Except for a policy issued under s. 627.553, a group life insurance policy may be extended to insure the employees or members against loss due to the deaths of their spouses and dependent children or any class or classes thereof, subject to the following:

(1)  The premium for the insurance shall be paid either from funds contributed by the employer, union, association, or other person to whom the policy has been issued or from funds contributed by the covered persons, or from both. Except as provided in subsection (2), a policy on which no part of the premium for the spouse's and dependent child's coverage is to be derived from funds contributed by the covered persons shall insure all eligible employees or members with respect to their spouses and dependent children or any class or classes thereof.

(2)  An insurer may exclude or limit the coverage on any spouse or dependent child as to whom evidence of individual insurability is not satisfactory to the insurer.

(3)  The amounts of insurance for any covered spouse or dependent child under the policy may not exceed 50 percent of the amount of insurance for which the employee or member is insured.

History.--ss. 429, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.558  Provisions required in group contracts.--No policy of group life insurance shall be delivered in this state unless it contains in substance the provisions set forth in ss. 627.559-627.568 or provisions which in the opinion of the office are more favorable to the persons insured, or at least as favorable to the persons insured and more favorable to the policyholder; except that:

(1)  Sections 627.564-627.568 inclusive do not apply to policies issued to a creditor to insure debtors of such creditor;

(2)  The standard provisions required for individual life insurance policies do not apply to group life insurance policies; and

(3)  If the group life insurance policy is on a plan of insurance other than the term plan, it shall contain a nonforfeiture provision or provisions which in the opinion of the office is or are equitable to the insured persons and to the policyholder, but nothing in this section shall be construed to require that group life insurance policies contain the same nonforfeiture provisions as are required for individual life insurance policies.

History.--s. 531, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 430, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1140, ch. 2003-261.

627.559  Grace period.--A group life insurance policy shall provide that the policyholder is entitled to a grace period of 31 days for the payment of any premium due except the first, during which grace period the death benefit coverage shall continue in force, unless the policyholder has given the insurer written notice of discontinuance in advance of the date of discontinuance and in accordance with the terms of the policy. The policy may provide that the policyholder is liable to the insurer for the payment of a pro rata premium for the time the policy was in force during such grace period.

History.--s. 532, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 431, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.560  Incontestability.--A group life insurance policy shall provide that the validity of the policy shall not be contested, except for nonpayment of premium, after it has been in force for 2 years from its date of issue. No statement made by any person insured under the policy relating to that person's insurability shall be used in contesting the validity of the insurance with respect to which the statement was made after the insurance has been in force prior to the contest for a period of 2 years during that person's lifetime nor unless it is contained in a written instrument signed by her or him.

History.--s. 533, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 432, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 333, ch. 97-102.

627.561  Application; statements deemed representations.--A group life insurance policy shall provide that a copy of the application, if any, of the policyholder be attached to the policy when issued, that all statements made by the policyholder or by the persons insured be deemed representations and not warranties, and that no statement made by any person insured be used in any contest unless a copy of the instrument containing the statement is or has been furnished to such person or to her or his beneficiary.

History.--s. 534, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 433, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 334, ch. 97-102.

627.562  Insurability.--A group life insurance policy shall contain a provision setting forth the conditions, if any, under which the insurer reserves the right to require a person eligible for insurance to furnish evidence of individual insurability satisfactory to the insurer as a condition to part or all of her or his coverage.

History.--s. 535, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 335, ch. 97-102.

627.563  Misstatement of age.--A group life insurance policy shall contain a provision specifying an equitable adjustment of premiums or of benefits, or of both, to be made in the event the age of a person insured has been misstated. The provision shall contain a clear statement of the method of adjustment to be used.

History.--s. 536, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 434, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.564  Payment of benefits.--A group life insurance policy shall provide that any sum becoming due by reason of the death of the person insured be payable to the beneficiary designated by the person insured, except that, when the policy contains conditions pertaining to family status, the beneficiary may be the family member specified by the policy terms, subject to the provisions of the policy in the event there is no designated beneficiary living at the time of death of the person insured; all or any part of such sum shall be subject to any right reserved by the insurer in the policy and set forth in the certificate to pay at its option a part of the sum not exceeding $2,000 to any person appearing to the insurer to be equitably entitled thereto by reason of having incurred funeral or other expenses incident to the last illness or death of the person insured.

History.--s. 537, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 435, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 99, ch. 83-216; s. 114, ch. 92-318.

627.565  Certificate.--A group life insurance policy shall provide that the insurer will issue to the policyholder for delivery to each person insured an individual certificate containing the group number and describing the insurance protection to which the certificateholder is entitled, those to whom the insurance benefits are payable, any dependent's coverage included in the certificate, the rights and conditions set forth in ss. 627.566, 627.567, and 627.568, the person to whom the insurance benefits are payable, and the person insured; except that for employee groups as defined in s. 627.552 the certificate may, in lieu of including the name of the person insured and the person to whom benefits are payable, contain the following statement prominently displayed in 10-point type or larger and in a contrasting color: "This certificate provides life insurance for the employees and dependents, if applicable, of (employer's name and address) under (group contract number). The employee shall be given a copy of the group enrollment application. The benefits are payable to the beneficiaries of record designated by the employee." Current records shall be maintained by the employer and the insurer of all insured persons and beneficiaries.

History.--s. 538, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 436, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 86-43; s. 114, ch. 92-318.

627.566  Conversion on termination of eligibility.--A group life insurance policy shall provide that, if the insurance, or any portion of it, on a person covered under the policy or on the dependent of a person covered ceases because of termination of employment or of membership in the class or classes eligible for coverage under the policy, such person is entitled to have issued to her or him by the insurer, without evidence of insurability, an individual policy of life insurance without health or other supplementary benefits, provided application for the individual policy is made, and the first premium is paid, to the insurer within 31 days after such termination, and provided further that:

(1)  The individual policy shall, at the option of such person, be on any one of the forms then customarily issued by the insurer at the age and for the amount applied for, except that the group policy may exclude the option to elect term insurance;

(2)  The individual policy shall be in an amount not in excess of the amount of life insurance which ceases because of such termination, less, in the case of a person whose membership in the class or classes eligible for coverage terminates but who continues in employment in another class, the amount of any life insurance for which such person is or becomes eligible under any other group policy within 31 days after such termination, provided that any amount of insurance which has matured on or before the date of such termination as an endowment payable to the person insured, whether in one sum or in installments or in the form of an annuity, shall not, for the purposes of this provision, be included in the amount which is considered to cease because of such termination; and

(3)  The premium on the individual policy shall be at the insurer's then customary rate applicable to the form and amount of the individual policy, to the class of risk to which such person then belongs, and to such person's age attained on the effective date of the individual policy. A conversion privilege shall be available to a surviving dependent, if any, at the death of the employee or member, with respect to the coverage under the group policy which terminates by reason of such death, and to the dependent of the employee or member upon termination of coverage of the dependent, while the employee or member remains insured under the group policy, by reason of the dependent ceasing to be a qualified family member under the group policy.

History.--s. 539, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 437, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 336, ch. 97-102.

627.567  Conversion on termination of policy.--A group life insurance policy shall provide that, if the group policy terminates or is amended so as to terminate the insurance of any class of insured persons, every person insured thereunder at the date of such termination whose insurance terminates, including the insured dependent of a covered person, and who has been so insured for at least 5 years prior to such termination date is entitled to have issued to her or him by the insurer an individual policy of life insurance, subject to the same conditions and limitations as are provided by s. 627.566, except that the group policy may provide that the amount of such individual policy shall not exceed the smaller of:

(1)  The amount of the person's life insurance protection ceasing because of the termination or amendment of the group policy, less the amount of any life insurance for which she or he is or becomes eligible under any group policy issued or reinstated by the same or another insurer within 31 days after such termination; or

(2)  Ten thousand dollars.

History.--s. 540, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 438, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 337, ch. 97-102.

627.568  Death pending conversion.--A group life insurance policy shall provide that, if a person insured under the policy dies during the period within which she or he would have been entitled to have an individual policy issued in accordance with s. 627.566 or s. 627.567 and before such an individual policy has become effective, the amount of life insurance which she or he would have been entitled to have issued under the individual policy shall be payable as a claim under the group policy, whether or not application for the individual policy or the payment of the first premium therefor has been made.

History.--s. 541, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 439, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 338, ch. 97-102.

627.5685  Continuance of coverage during disability.--When active employment is a condition of group life insurance, the policy shall provide that an insured may continue coverage during the insured's total disability by timely payment to the policyholder of that portion, if any, of the premium that would have been required from the insured had total disability not occurred. The continuation shall be for a period of at least 6 months from the date on which the total disability started.

History.--ss. 440, 809(2nd), ch. 82-243; ss. 56, 79, ch. 82-386; s. 114, ch. 92-318.

627.5686  Waiver of premium for disabled insured.--A waiver of premium for any insured who is totally disabled for a period of at least 6 months shall be made available to the policyholder as a part of the application for any group life insurance policy.

History.--ss. 441, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.569  Use of dividends, refunds, rate reductions, commissions, service fees.--If a dividend, premium refund, rate reduction, commission, or service fee is received by any employer, labor union, or association, under any and all group insurance policies whenever issued and delivered in this state, with respect to which the employer, labor union, or association is the policyholder, or an affiliate or subsidiary of the policyholder, covering the employees of one or more employers or the members of one or more labor unions or associations, or any combination thereof, to which such employees or members contribute to the cost of the premiums for such insurance, the excess, if any, of the aggregate of such dividends, premium refunds, rate reductions, commissions, and service fees over the aggregate expenditure of such employer, labor union, or association towards the cost of such insurance, including its administration, for the current and preceding 2 years to the extent that they were not defrayed by dividends, premium refunds, rate reductions, commissions, and service fees, shall be applied by the policyholder for the sole benefit of insured employees or members on a basis which precludes individual selection and unfair discrimination. If such dividend, premium refund, rate reduction, commission, or service fee is received by a trusteed fund, it shall be applied by the trustees for the sole purposes of the trust.

History.--s. 542, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 442, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.570  Premium rates.--A life insurer may issue insurance policies under the provisions of this part at premium rates less than the usual rates or premiums for individual insurance policies.

History.--s. 543, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 443, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.571  Assignment of incidents of ownership in group life insurance policies, including conversion privileges.--

(1)  Nothing in this code or in any other law shall be construed to prohibit any person insured under a group life insurance policy from making an assignment of all or any part of her or his incidents of ownership under such policy, including, but not limited to, the privilege of having issued to the person an individual policy of life insurance pursuant and subject to the provisions of ss. 627.566 and 627.567 and the right to name a beneficiary. Subject to the terms of the policy, agreement, or arrangement among the insured, the group policyholder, and the insurer, relating to assignment of incidents of ownership thereunder, such an assignment by an insured, whenever made, is valid for the purpose of vesting in the assignee, in accordance with any provisions included therein as to the time at which it is to be effective, all of such incidents of ownership so assigned, but without prejudice to the insurer on account of any payment it may make or individual policy it may issue in accordance with ss. 627.566 and 627.567 prior to receipt of notice of the assignment.

(2)  The purpose of subsection (1) is to declare and codify existing rights under policies of the types described therein.

History.--ss. 1, 3, ch. 70-10; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 444, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 339, ch. 97-102.

627.5725  Notification to insureds of cancellation or expiration.--Every insurer delivering or issuing for delivery a group life insurance policy under the provisions of this part shall notify each certificateholder when the master policy has expired or when the master policy has been canceled. The insurer may take such action through the policyholder; and, if the insurer elects to take such action through the policyholder, the insurer shall be deemed to have complied with the provisions of this section upon notifying the policyholder of the requirements of this section and requesting the policyholder to forward to the certificateholders the notice required in this section. Upon receipt of such a request, the policyholder shall forward, as soon as practicable, the notice of expiration or cancellation to each certificateholder covered under the policy.

History.--ss. 1, 3, ch. 83-157; s. 114, ch. 92-318.

627.573  Replacement or termination of group life insurance; liability of prior insurer.--When an insurance purchaser replaces or terminates an existing group life contract, the prior insurer remains liable only to the extent of its accrued liabilities and extensions of benefits as required by s. 627.575.

History.--s. 1, ch. 74-72; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 1, 3, ch. 79-179; ss. 2, 3, ch. 81-318; ss. 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.574  Liability of succeeding insurer on replacement of group policy.--

(1)  Each person who is eligible for coverage in accordance with the succeeding insurer's plan of benefits shall be covered by that insurer's plan of benefits unless such coverage would result in duplication of benefits payable under the prior insurer's plan.

(2)  Each person not covered under the succeeding insurer's plan of benefits in accordance with subsection (1) must be covered by the succeeding insurer in accordance with the following provisions if such individual was validly covered, including benefit extensions, under the prior plan on the date of discontinuance of the prior plan and if such individual is a member of the class or classes of individuals eligible for coverage under the succeeding insurer's plan.

(a)  The minimum level of benefits to be provided by the succeeding insurer shall be the applicable level of benefits of the prior insurer's plan reduced by any benefits payable by the prior plan.

(b)  Coverage must be provided by the succeeding insurer until at least the earliest of the following dates:

1.  The date the individual becomes eligible under the succeeding insurer's plan as described in subsection (1).

2.  The date the individual's coverage would terminate in accordance with the succeeding insurer's plan provisions applicable to individual termination of coverage, for example, at termination of employment.

3.  When an individual was totally disabled immediately prior to the date the succeeding insurer's coverage became effective and the policy of the prior insurer did not conform to s. 627.575, the date of the end of any period of extension or accrued liability which would have been required of the prior insurer by s. 627.575, had s. 627.575 been applicable.

History.--ss. 2, 3, ch. 79-179; s. 2, ch. 81-318; ss. 446, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 100, ch. 83-216; s. 114, ch. 92-318.

627.575  Extension of benefits.--

(1)  Every group life policy which is delivered or issued for delivery in this state or under which benefits are altered, modified, or amended shall provide a reasonable provision for extension of benefits for those individuals who become totally disabled while insured under the policy and who continue to be totally disabled at the date of discontinuance of the policy, as required by subsection (2).

(2)  A reasonable provision for extension of benefits in the case of a group life plan is either premium waiver extension, extended death benefit for a period of at least 12 months in the event of total disability, or payment of income for a specified period during total disability. The discontinuance of the group policy shall not operate to terminate such extension.

History.--ss. 2, 3, ch. 79-179; s. 2, ch. 81-318; ss. 447, 448, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

PART VI

HEALTH INSURANCE POLICIES

627.601  Scope of this part.

627.602  Scope, format of policy.

627.603  Death benefits.

627.604  Nonresident insured.

627.6041  Handicapped children; continuation of coverage.

627.6043  Notification of cancellation, nonrenewal, or change in rates.

627.6044  Use of a specific methodology for payment of claims.

627.6045  Preexisting condition.

627.605  Required provisions; captions, omissions, substitutions.

627.6056  Coverage for ambulatory surgical center service.

627.606  Entire contract; changes.

627.607  Time limit on certain defenses.

627.608  Grace period.

627.609  Reinstatement.

627.610  Notice of claim.

627.611  Claim forms.

627.612  Proof of loss.

627.613  Time of payment of claims.

627.6131  Payment of claims.

627.614  Payment of claims.

627.6141  Denial of claims.

627.615  Physical examination, autopsy.

627.616  Legal actions.

627.617  Change of beneficiary.

627.618  Optional policy provisions.

627.619  Change of occupation.

627.620  Misstatement of age or sex.

627.621  Other insurance with this insurer.

627.622  Insurance with other insurers.

627.623  Insurance with other insurers; other benefits.

627.624  Relation of earnings to insurance.

627.625  Unpaid premiums.

627.6265  Cancellation or nonrenewal prohibited.

627.627  Conformity with statutes.

627.628  Illegal occupation.

627.629  Intoxicants and narcotics.

627.630  Order of certain provisions.

627.631  Third-party ownership.

627.632  Requirements of other jurisdictions.

627.633  Other policy provisions.

627.634  Age limit.

627.635  Excess insurance.

627.636  Industrial health insurance.

627.637  Construction of noncomplying contracts.

627.638  Direct payment for hospital, medical services.

627.639  Application signed by agent.

627.640  Filing of classifications and rates.

627.6401  Refunds for persons age 64.

627.6402  Insurance rebates for healthy lifestyles.

627.6403  Payment of acupuncture benefits to certified acupuncturists.

627.6405  Decreasing inappropriate utilization of emergency care.

627.6406  Maternity care.

627.6407  Massage.

627.6408  Diabetes treatment services.

627.6409  Coverage for osteoporosis screening, diagnosis, treatment, and management.

627.641  Coverage for newborn children.

627.6415  Coverage for natural-born, adopted, and foster children; children in insured's custodial care.

627.6416  Coverage for child health supervision services.

627.6417  Coverage for surgical procedures and devices incident to mastectomy.

627.64171  Coverage for length of stay and outpatient postsurgical care.

627.64172  Requirements with respect to breast cancer and routine followup care.

627.6418  Coverage for mammograms.

627.6419  Requirements with respect to breast cancer.

627.64193  Required coverage for cleft lip and cleft palate.

627.642  Outline of coverage.

627.6425  Renewability of individual coverage.

627.643  Uniform minimum standards.

627.644  Discrimination against handicapped prohibited.

627.645  Denial of health insurance claims restricted.

627.646  Conversion on termination of eligibility.

627.647  Standard health claim form.

627.6471  Contracts for reduced rates of payment; limitations; coinsurance and deductibles.

627.6472  Exclusive provider organizations.

627.64725  Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.

627.6473  Combined preferred provider and exclusive provider policies.

627.6474  Provider contracts.

627.6475  Individual reinsurance pool.

627.648  Florida Comprehensive Health Association Act.

627.6482  Definitions.

627.6484  Termination of enrollment; availability of other coverage.

627.6486  Eligibility.

627.6487  Guaranteed availability of individual health insurance coverage to eligible individuals.

627.64871  Certification of coverage.

627.64872  Florida Health Insurance Plan.

627.6488  Florida Comprehensive Health Association.

627.6489  Disease Management Program.

627.649  Administrator.

627.6492  Participation of insurers.

627.6494  Assessments; deferment, limitation.

627.6496  Issuing of policies.

627.6498  Minimum benefits coverage; exclusions; premiums; deductibles.

627.6499  Reporting by insurers and third-party administrators.

627.601  Scope of this part.--Nothing in this part applies to or affects:

(1)  Any policy of liability insurance or workers' compensation insurance, with or without supplementary expense coverage.

(2)  Any group or blanket policy, except as provided in ss. 627.648-627.6499.

(3)  Life insurance, endowment, or annuity contracts, or contracts supplemental thereto, which contain only provisions relating to health insurance that:

(a)  Provide additional benefits in case of death or dismemberment or loss of sight by accident or accidental means; or

(b)  Operate to safeguard the contract against lapse, or to give a special surrender value or special benefit or an annuity if the insured or annuitant becomes totally and permanently disabled, as defined by the contract or supplemental contract.

(4)  Reinsurance.

History.--s. 544, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 109, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 449, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 11, ch. 90-334; ss. 53, 114, ch. 92-318.

627.602  Scope, format of policy.--

(1)  Each health insurance policy delivered or issued for delivery to any person in this state must comply with all applicable provisions of this code and all of the following requirements:

(a)  The monetary and other considerations shall be expressed in the policy.

(b)  The time when the insurance takes effect and terminates shall be expressed in the policy.

(c)  The policy may purport to insure only one person, except that upon the application of an adult member of a family, who is deemed to be the policyholder, a policy may insure, either originally or by subsequent amendment, any eligible members of that family, including husband, wife, any children or any person dependent upon the policyholder.

(d)  The style, arrangement, and overall appearance of the policy may not give any undue prominence to any portion of the text. Every printed portion of the text of the policy and of any endorsements or attached papers shall be plainly printed in lightfaced type of a style in general use, the size of which is uniform and is not less than 10 points with a lowercase, unspaced alphabet length of not less than 120 points. As used in this paragraph, "text" includes all printed matter except the name and address of the insurer, the name or title of the policy, the brief description of the coverage provided, if any, and captions and subcaptions.

(e)  The exceptions and reductions of indemnity shall be set forth in the policy and, other than those contained in ss. 627.606-627.629, shall be printed, at the insurer's option, either included with the benefit provisions to which they apply, or under an appropriate caption such as "Exceptions," or "Exceptions and Reductions." However, if an exception or reduction specifically applies only to a particular benefit of the policy, a statement of such exception or reduction shall be included with the benefit provision to which it applies.

(f)  Each form, including outlines of coverage, applications, riders, and endorsements, shall be identified by a form identification number in the lower left-hand corner of the first page of the form.

(g)  The policy may not contain any provision purporting to make any portion of the charter, rules, constitution, or bylaws of the insurer a part of the policy unless the portion is set forth in full in the policy, except in the case of the incorporation of, or reference to, a statement of rates, statement of classification of risks, or short-rate table filed with the office.

(2)  The office may require any health insurance policy or certificate containing a provision commonly known as a "deductible provision" to have printed or stamped on such policy or certificate: "This policy or certificate contains a deductible provision."; or appropriate words of similar import approved by the office. The statement shall appear on the first page of the policy or certificate in at least 18-point type and may be printed or stamped either as an overprint or by means of a rubber stamp impression.

History.--s. 545, ch. 59-205; s. 1, ch. 61-423; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 57, ch. 77-121; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 450, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 101, ch. 83-216; ss. 121, 149, ch. 92-33; s. 114, ch. 92-318; s. 1141, ch. 2003-261.

627.603  Death benefits.--Any health insurance policy may contain a provision for paying a benefit for death from any cause in an amount not exceeding $1,000, which benefit shall not relieve such policy from the requirements of this chapter. This provision shall not limit benefits for death by accident.

History.--s. 546, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 451, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.604  Nonresident insured.--If any health insurance policy is issued by an insurer domiciled in this state for delivery to a person residing in another state, and if the official having responsibility for the administration of the insurance laws of such other state has advised the office that any such policy is not subject to approval or disapproval by such official, the commission may by rule require that such policy meet the standards set forth in this part.

History.--s. 547, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 452, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1142, ch. 2003-261.

627.6041  Handicapped children; continuation of coverage.--A hospital or medical expense insurance policy or health care services plan contract that is delivered or issued for delivery in this state and that provides that coverage of a dependent child will terminate upon attainment of the limiting age for dependent children specified in the policy or contract shall also provide in substance that attainment of the limiting age does not terminate the coverage of the child while the child continues to be both:

(1)  Incapable of self-sustaining employment by reason of mental retardation or physical handicap; and

(2)  Chiefly dependent upon the policyholder or subscriber for support and maintenance.

If a claim is denied under a policy or contract for the stated reason that the child has attained the limiting age for dependent children specified in the policy or contract, the notice of denial must state that the policyholder has the burden of establishing that the child continues to meet the criteria specified in subsections (1) and (2).

History.--s. 1, ch. 70-187; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 453, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 18, ch. 83-288; ss. 122, 149, ch. 92-33; s. 114, ch. 92-318.

Note.--Former s. 627.6055.

627.6043  Notification of cancellation, nonrenewal, or change in rates.--

(1)  Any insurer delivering or issuing an individual health insurance policy subject to this part shall give the policyholder at least 45 days' advance written notice of cancellation, nonrenewal, or a change in rates. Such notice shall be mailed to the policyholder's last address as shown by the records of the insurer. However, if cancellation is for nonpayment of premium, at least 10 days' written notice accompanied by the reason therefor shall be given. Written notice of cancellation for nonpayment of premium shall not be required for health insurance policies under which premiums are payable monthly or more frequently and regularly collected by a licensed agent.

(2)  In the event of cancellation, the insurer will return promptly the unearned portion of any premium paid. If the insured cancels, the earned premium shall be computed by the use of the short-rate table last filed with the state official having supervision of insurance in the state where the insured resided when the policy was issued. If the insurer cancels, the earned premium shall be computed pro rata. Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.

(3)  If the insurer fails to provide the 45 days' notice required by this section, the coverage shall remain in effect at the existing premium until 45 days after the notice is given or until the effective date of replacement coverage obtained by the insured, whichever occurs first.

History.--s. 569, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 476, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 89-222; s. 12, ch. 90-249; s. 1, ch. 91-106; ss. 54, 114, ch. 92-318.

Note.--Former s. 627.626; s. 627.6085.

627.6044  Use of a specific methodology for payment of claims.--

(1)  Each insurance policy that provides for payment of claims based on a specific methodology, including, but not limited to, usual and customary charges, reasonable and customary charges, or charges based upon the prevailing rate in the community, shall specify the formula or criteria used by the insurer in determining the amount to be paid.

(2)  Each insurer issuing a policy that provides for payment of claims based on a specific methodology shall provide to an insured, upon her or his written request, an estimate of the amount the insurer will pay for a particular medical procedure or service. The estimate may be in the form of a range of payments or an average payment. The insurer may require the insured to provide detailed information regarding the procedure or service to be performed, including the procedure or service code number provided by the health care provider and the health care provider's estimated charge. An insurer that provides an insured with a good faith estimate is not bound by the estimate. However, a pattern of providing estimates that vary significantly from the ultimate insurance payment constitutes a violation of this code.

History.--ss. 9, 12, ch. 91-296; ss. 55, 114, ch. 92-318; s. 340, ch. 97-102.

Note.--Former s. 627.6145.

627.6045  Preexisting condition.--A health insurance policy must comply with the following:

(1)  A preexisting condition provision may not exclude coverage for a period beyond 24 months following the individual's effective date of coverage and may relate only to:

(a)  Conditions that, during the 24-month period immediately preceding the effective date of coverage, had manifested themselves in such a manner as would cause an ordinarily prudent person to seek medical advice, diagnosis, care, or treatment or for which medical advice, diagnosis, care, or treatment was recommended or received; or

(b)  A pregnancy existing on the effective date of coverage.

(2)  In determining whether a preexisting condition provision applies to an eligible insured or dependent, credit must be given for the time the person was covered under previous coverage if the previous coverage was similar to or exceeded the coverage provided under the new policy and if the previous coverage was continuous to a date not more than 62 days before the effective date of the new coverage, exclusive of any applicable waiting period under the plan.

(3)  This section does not apply to short-term, nonrenewable health insurance policies of no more than a 6-month policy term, provided that it is clearly disclosed to the applicant in the advertising and application, in 10-point contrasting type, that "This policy does not meet the definition of qualifying previous coverage or qualifying existing coverage as defined in ¹s. 627.6699. As a result, if purchased in lieu of a conversion policy or other group coverage, you may have to meet a preexisting condition requirement when renewing or purchasing other coverage."

(4)  This section does not apply to disability income insurance or income replacement insurance coverage.

History.--s. 1, ch. 96-223.

¹Note.--Former s. 627.6699(3)(r), which defined the terms "qualifying previous coverage" and "qualifying existing coverage," was deleted by s. 15, ch. 97-179.

627.605  Required provisions; captions, omissions, substitutions.--

(1)  Except as provided in subsection (2), each such policy delivered or issued for delivery to any person in this state shall contain the provisions specified in ss. 627.606-627.617, inclusive, in the words in which the same appear; except that the insurer may, at its option, substitute for one or more of such provisions corresponding provisions of different wording approved by the office which are in each instance not less favorable in any respect to the insured or the beneficiary. Each such provision shall be preceded individually by the applicable caption shown or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the office may approve.

(2)  If any such provision is in whole or in part inapplicable to or inconsistent with the coverage provided by a particular form of policy, the insurer, with the approval of the office, shall omit from such policy any inapplicable provision or part of a provision and shall modify any inconsistent provision or part of a provision in such manner as to make the provision as contained in the policy consistent with the coverage provided by the policy.

History.--s. 548, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1143, ch. 2003-261.

627.6056  Coverage for ambulatory surgical center service.--No individual health insurance policy providing coverage on an expense-incurred basis or individual service or indemnity-type contract issued by a nonprofit corporation, of any kind or description, shall be issued unless coverage provided for any service performed in an ambulatory surgical center, as defined in s. 395.002, is provided if such service would have been covered under the terms of the policy or contract as an eligible inpatient service.

History.--s. 12, ch. 77-24; s. 2, ch. 81-318; ss. 26, 30, ch. 82-182; ss. 454, 809(2nd), ch. 82-243; ss. 57, 79, ch. 82-386; s. 102, ch. 83-216; s. 114, ch. 92-318.

Note.--Former s. 395.22.

627.606  Entire contract; changes.--The contract shall include the following provision:

"Entire Contract; Changes: This policy, with the application and attached papers, is the entire contract between the insured and the insurer. No change in this policy will be effective until approved by an officer of the insurer. This approval must be noted on or attached to this policy. No agent may change this policy or waive any of its provisions."

History.--s. 549, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 455, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.607  Time limit on certain defenses.--

(1)  The contract shall include the following provision:

"Time Limit on Certain Defenses: After 2 years from the issue date, only fraudulent misstatements in the application may be used to void the policy or deny any claim for loss incurred or disability starting after the 2-year period."

(2)  A policy may, in place of the provision set forth in subsection (1), include the following provision:

"Incontestable:

(a)  Misstatements in the Application: After this policy has been in force for 2 years during the insured's lifetime (excluding any period during which the insured is disabled), the insurer cannot contest the statements in the application.

(b)  Preexisting Conditions: No claim for loss incurred or disability starting after 2 years from the issue date will be reduced or denied because a sickness or physical condition, not excluded by name or specific description before the date of loss, had existed before the effective date of coverage."

History.--s. 550, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 456, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 56, 114, ch. 92-318.

627.608  Grace period.--

(1)  If the insurer reserves the right to refuse renewal, the contract shall include the following provision:

"Grace Period: This policy has a  (insert a number not less than '7' for a weekly premium policy, '10' for a monthly premium policy, or '31' for all other policies)  day grace period. This provision means that if a renewal premium is not paid on or before the date it is due, it may be paid during the following grace period. The grace period will not apply if, at least 30 days before the premium due date, the insurer has delivered or mailed to the insured's last address shown in the insurer's records written notice of the insurer's intent not to renew this policy. During the grace period, the policy will stay in force."

(2)  If the insurer does not reserve the right to refuse renewal, the contract shall include the following provision:

"Grace Period: This policy has a  (insert a number not less than '7' for a weekly premium policy, '10' for a monthly premium policy, or '31' for all other policies)  day grace period. This provision means that if a renewal premium is not paid on or before the date it is due, it may be paid during the following grace period. During the grace period, the policy will stay in force."

History.--s. 551, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 457, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.609  Reinstatement.--

(1)  The contract shall include the following provision:

"Reinstatement: If the renewal premium is not paid before the grace period ends, the policy will lapse. Later acceptance of the premium by the insurer, or by an agent authorized to accept payment without requiring an application for reinstatement, will reinstate this policy. If the insurer or its agent requires an application, the insured will be given a conditional receipt for the premium. If the application is approved, the policy will be reinstated as of the approval date. Lacking such approval, the policy will be reinstated on the 45th day after the date of the conditional receipt unless the insurer has previously written the insured of its disapproval. The reinstated policy will cover only loss that results from an injury sustained after the date of reinstatement or sickness that starts more than 10 days after such date. In all other respects, the rights of the insured and the insurer will remain the same, subject to any provisions noted on or attached to the reinstated policy. Any premiums the insurer accepts for a reinstatement will be applied to a period for which premiums have not been paid. No premiums will be applied to any period more than 60 days before the reinstatement date."

(2)  The last two sentences of the above provision may be omitted from any policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age 50 or, in the case of a policy issued after age 44, for at least 5 years from its date of issue.

History.--s. 552, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 458, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.610  Notice of claim.--

(1)  The contract shall include the following provision:

"Notice of Claim: Written notice of claim must be given within 20 days after a covered loss starts or as soon as reasonably possible. The notice may be given to the insurer at its home office or to the insurer's agent. Notice should include the name of the insured and the policy number."

(2)  The contract may include the following provision:

"If the insured has a disability for which benefits may be payable for at least 2 years, at least once every 6 months after the insured has given notice of claim, the insured must give the insurer notice that the disability has continued. The insured need not do this if legally incapacitated. The first 6 months after any filing of proof by the insured or any payment or denial of a claim by the insurer will not be counted in applying this provision. If the insured delays in giving this notice, the insured's right to any benefits for the 6 months before the date which the insured gives notice will not be impaired."

History.--s. 553, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 459, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.611  Claim forms.--The contract shall include the following provision:

"Claim Forms: When the insurer receives the notice of claim, it will send the claimant forms for filing proof of loss. If these forms are not given to the claimant within 15 days, the claimant may meet the proof of loss requirements by giving the insurer a written statement of the nature and extent of the loss within the time limit stated in the 'Proof of Loss' provision."

History.--s. 554, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 460, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.612  Proof of loss.--The contract shall include the following provision:

"Proof of Loss: If the policy provides for periodic payment for a continuing loss, written proof of loss must be given the insurer within 90 days after the end of each period for which the insurer is liable. For any other loss, written proof must be given within 90 days after such loss. If it was not reasonably possible to give written proof in the time required, the insurer shall not reduce or deny the claim for this reason if the proof is filed as soon as reasonably possible. In any event, the proof required must be given no later than 1 year from the time specified unless the claimant was legally incapacitated."

History.--s. 555, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 461, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.613  Time of payment of claims.--

(1)  The contract shall include the following provision:

"Time of Payment of Claims: After receiving written proof of loss, the insurer will pay monthly all benefits then due for  (type of benefit) . Benefits for any other loss covered by this policy will be paid as soon as the insurer receives proper written proof."

(2)  Health insurers shall reimburse all claims or any portion of any claim from an insured or an insured's assignees, for payment under a health insurance policy, within 45 days after receipt of the claim by the health insurer. If a claim or a portion of a claim is contested by the health insurer, the insured or the insured's assignees shall be notified, in writing, that the claim is contested or denied, within 45 days after receipt of the claim by the health insurer. The notice that a claim is contested shall identify the contested portion of the claim and the reasons for contesting the claim.

(3)  A health insurer, upon receipt of the additional information requested from the insured or the insured's assignees shall pay or deny the contested claim or portion of the contested claim, within 60 days.

(4)  An insurer shall pay or deny any claim no later than 120 days after receiving the claim.

(5)  Payment shall be treated as being made on the date a draft or other valid instrument which is equivalent to payment was placed in the United States mail in a properly addressed, postpaid envelope or, if not so posted, on the date of delivery.

(6)  All overdue payments shall bear simple interest at the rate of 10 percent per year.

(7)  Upon written notification by an insured, an insurer shall investigate any claim of improper billing by a physician, hospital, or other health care provider. The insurer shall determine if the insured was properly billed for only those procedures and services that the insured actually received. If the insurer determines that the insured has been improperly billed, the insurer shall notify the insured and the provider of its findings and shall reduce the amount of payment to the provider by the amount determined to be improperly billed. If a reduction is made due to such notification by the insured, the insurer shall pay to the insured 20 percent of the amount of the reduction up to $500.

History.--s. 556, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 462, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 2, ch. 90-85; s. 5, ch. 91-296; s. 114, ch. 92-318.

627.6131  Payment of claims.--

(1)  The contract shall include the following provision:

"Time of Payment of Claims: After receiving written proof of loss, the insurer will pay monthly all benefits then due for  (type of benefit) . Benefits for any other loss covered by this policy will be paid as soon as the insurer receives proper written proof."

(2)  As used in this section, the term "claim" for a noninstitutional provider means a paper or electronic billing instrument submitted to the insurer's designated location that consists of the HCFA 1500 data set, or its successor, that has all mandatory entries for a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463, or psychologists licensed under chapter 490 or any appropriate billing instrument that has all mandatory entries for any other noninstitutional provider. For institutional providers, "claim" means a paper or electronic billing instrument submitted to the insurer's designated location that consists of the UB-92 data set or its successor with entries stated as mandatory by the National Uniform Billing Committee.

(3)  All claims for payment or overpayment, whether electronic or nonelectronic:

(a)  Are considered received on the date the claim is received by the insurer at its designated claims-receipt location or the date the claim for overpayment is received by the provider at its designated location.

(b)  Must be mailed or electronically transferred to the primary insurer within 6 months after the following have occurred:

1.  Discharge for inpatient services or the date of service for outpatient services; and

2.  The provider has been furnished with the correct name and address of the patient's health insurer.

All claims for payment, whether electronic or nonelectronic, must be mailed or electronically transferred to the secondary insurer within 90 days after final determination by the primary insurer. A provider's claim is considered submitted on the date it is electronically transferred or mailed.

(c)  Must not duplicate a claim previously submitted unless it is determined that the original claim was not received or is otherwise lost.

(4)  For all electronically submitted claims, a health insurer shall:

(a)  Within 24 hours after the beginning of the next business day after receipt of the claim, provide electronic acknowledgment of the receipt of the claim to the electronic source submitting the claim.

(b)  Within 20 days after receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the insurer's action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

(c)1.  Notification of the health insurer's determination of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim.

2.  A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health insurer may not request duplicate documents.

(d)  For purposes of this subsection, electronic means of transmission of claims, notices, documents, forms, and payments shall be used to the greatest extent possible by the health insurer and the provider.

(e)  A claim must be paid or denied within 90 days after receipt of the claim. Failure to pay or deny a claim within 120 days after receipt of the claim creates an uncontestable obligation to pay the claim.

(5)  For all nonelectronically submitted claims, a health insurer shall:

(a)  Effective November 1, 2003, provide acknowledgment of receipt of the claim within 15 days after receipt of the claim to the provider or provide a provider within 15 days after receipt with electronic access to the status of a submitted claim.

(b)  Within 40 days after receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the insurer's action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

(c)1.  Notification of the health insurer's determination of a contested claim must be accompanied by an itemized list of additional information or documents the insurer can reasonably determine are necessary to process the claim.

2.  A provider must submit the additional information or documentation, as specified on the itemized list, within 35 days after receipt of the notification. Additional information is considered submitted on the date it is electronically transferred or mailed. The health insurer may not request duplicate documents.

(d)  For purposes of this subsection, electronic means of transmission of claims, notices, documents, forms, and payments shall be used to the greatest extent possible by the health insurer and the provider.

(e)  A claim must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny a claim within 140 days after receipt of the claim creates an uncontestable obligation to pay the claim.

(6)  If a health insurer determines that it has made an overpayment to a provider for services rendered to an insured, the health insurer must make a claim for such overpayment to the provider's designated location. A health insurer that makes a claim for overpayment to a provider under this section shall give the provider a written or electronic statement specifying the basis for the retroactive denial or payment adjustment. The insurer must identify the claim or claims, or overpayment claim portion thereof, for which a claim for overpayment is submitted.

(a)  If an overpayment determination is the result of retroactive review or audit of coverage decisions or payment levels not related to fraud, a health insurer shall adhere to the following procedures:

1.  All claims for overpayment must be submitted to a provider within 30 months after the health insurer's payment of the claim. A provider must pay, deny, or contest the health insurer's claim for overpayment within 40 days after the receipt of the claim. All contested claims for overpayment must be paid or denied within 120 days after receipt of the claim. Failure to pay or deny overpayment and claim within 140 days after receipt creates an uncontestable obligation to pay the claim.

2.  A provider that denies or contests a health insurer's claim for overpayment or any portion of a claim shall notify the health insurer, in writing, within 35 days after the provider receives the claim that the claim for overpayment is contested or denied. The notice that the claim for overpayment is denied or contested must identify the contested portion of the claim and the specific reason for contesting or denying the claim and, if contested, must include a request for additional information. If the health insurer submits additional information, the health insurer must, within 35 days after receipt of the request, mail or electronically transfer the information to the provider. The provider shall pay or deny the claim for overpayment within 45 days after receipt of the information. The notice is considered made on the date the notice is mailed or electronically transferred by the provider.

3.  The health insurer may not reduce payment to the provider for other services unless the provider agrees to the reduction in writing or fails to respond to the health insurer's overpayment claim as required by this paragraph.

4.  Payment of an overpayment claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest at the rate of 12 percent per year. Interest on an overdue payment for a claim for an overpayment begins to accrue when the claim should have been paid, denied, or contested.

(b)  A claim for overpayment shall not be permitted beyond 30 months after the health insurer's payment of a claim, except that claims for overpayment may be sought beyond that time from providers convicted of fraud pursuant to s. 817.234.

(7)  Payment of a claim is considered made on the date the payment was mailed or electronically transferred. An overdue payment of a claim bears simple interest of 12 percent per year. Interest on an overdue payment for a claim or for any portion of a claim begins to accrue when the claim should have been paid, denied, or contested. The interest is payable with the payment of the claim.

(8)  For all contracts entered into or renewed on or after October 1, 2002, a health insurer's internal dispute resolution process related to a denied claim not under active review by a mediator, arbitrator, or third-party dispute entity must be finalized within 60 days after the receipt of the provider's request for review or appeal.

(9)  A provider or any representative of a provider, regardless of whether the provider is under contract with the health insurer, may not collect or attempt to collect money from, maintain any action at law against, or report to a credit agency an insured for payment of covered services for which the health insurer contested or denied the provider's claim. This prohibition applies during the pendency of any claim for payment made by the provider to the health insurer for payment of the services or internal dispute resolution process to determine whether the health insurer is liable for the services. For a claim, this pendency applies from the date the claim or a portion of the claim is denied to the date of the completion of the health insurer's internal dispute resolution process, not to exceed 60 days. This subsection does not prohibit the collection by the provider of copayments, coinsurance, or deductible amounts due the provider.

(10)  The provisions of this section may not be waived, voided, or nullified by contract.

(11)  A health insurer may not retroactively deny a claim because of insured ineligibility more than 1 year after the date of payment of the claim.

(12)  A health insurer shall pay a contracted primary care or admitting physician, pursuant to such physician's contract, for providing inpatient services in a contracted hospital to an insured if such services are determined by the health insurer to be medically necessary and covered services under the health insurer's contract with the contract holder.

(13)  Upon written notification by an insured, an insurer shall investigate any claim of improper billing by a physician, hospital, or other health care provider. The insurer shall determine if the insured was properly billed for only those procedures and services that the insured actually received. If the insurer determines that the insured has been improperly billed, the insurer shall notify the insured and the provider of its findings and shall reduce the amount of payment to the provider by the amount determined to be improperly billed. If a reduction is made due to such notification by the insured, the insurer shall pay to the insured 20 percent of the amount of the reduction up to $500.

(14)  A permissible error ratio of 5 percent is established for insurer's claims payment violations of paragraphs (4)(a), (b), (c), and (e) and (5)(a), (b), (c), and (e). If the error ratio of a particular insurer does not exceed the permissible error ratio of 5 percent for an audit period, no fine shall be assessed for the noted claims violations for the audit period. The error ratio shall be determined by dividing the number of claims with violations found on a statistically valid sample of claims for the audit period by the total number of claims in the sample. If the error ratio exceeds the permissible error ratio of 5 percent, a fine may be assessed according to s. 624.4211 for those claims payment violations which exceed the error ratio. Notwithstanding the provisions of this section, the office may fine a health insurer for claims payment violations of paragraphs (4)(e) and (5)(e) which create an uncontestable obligation to pay the claim. The office shall not fine insurers for violations which the office determines were due to circumstances beyond the insurer's control.

(15)  This section is applicable only to a major medical expense health insurance policy as defined in s. 627.643(2)(e) offered by a group or an individual health insurer licensed pursuant to chapter 624, including a preferred provider policy under s. 627.6471 and an exclusive provider organization under s. 627.6472 or a group or individual insurance contract that only provides direct payments to dentists for enumerated dental services.

(16)  Notwithstanding paragraph (4)(b), where an electronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health insurer, the pharmacy benefits manager shall, within 30 days of receipt of the claim, pay the claim or notify a provider or designee if a claim is denied or contested. Notice of the insurer's action on the claim and payment of the claim is considered to be made on the date the notice or payment was mailed or electronically transferred.

(17)  Notwithstanding paragraph (5)(a), effective November 1, 2003, where a nonelectronic pharmacy claim is submitted to a pharmacy benefits manager acting on behalf of a health insurer, the pharmacy benefits manager shall provide acknowledgment of receipt of the claim within 30 days after receipt of the claim to the provider or provide a provider within 30 days after receipt with electronic access to the status of a submitted claim.

History.--s. 5, ch. 2002-389; s. 1144, ch. 2003-261.

627.614  Payment of claims.--

(1)  The contract shall include the following provision:

"Payment of Claims: Benefits will be paid to the insured. Loss-of-life benefits are payable in accordance with the beneficiary designation in effect at the time of payment. If none is then in effect, the benefits will be paid to the insured's estate. Any other benefits unpaid at death may be paid, at the insurer's option, either to the insured's beneficiary or estate."

(2)  The following provisions, or either of them, may be included with the foregoing provision at the option of the insurer:

(a)  "If benefits are payable to the insured's estate or a beneficiary who cannot execute a valid release, the insurer can pay benefits up to $3,000 to someone related to the insured or beneficiary by blood or marriage whom the insurer considers to be entitled to the benefits. The insurer will be discharged to the extent of any such payment made in good faith."

(b)  "The insurer may pay all or a portion of any indemnities provided for health care services to the provider, unless the insured directs otherwise in writing by the time proofs of loss are filed. The insurer cannot require that the services be rendered by a particular provider."

History.--s. 557, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 463, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.6141  Denial of claims.--Each claimant, or provider acting for a claimant, who has had a claim denied as not medically necessary must be provided an opportunity for an appeal to the insurer's licensed physician who is responsible for the medical necessity reviews under the plan or is a member of the plan's peer review group. The appeal may be by telephone, and the insurer's licensed physician must respond within a reasonable time, not to exceed 15 business days.

History.--s. 7, ch. 96-223.

627.615  Physical examination, autopsy.--The contract shall include the following provision:

"Physical Examinations and Autopsy: The insurer at its expense has the right to have the insured examined as often as reasonably necessary while a claim is pending. It may also have an autopsy made unless prohibited by law."

History.--s. 558, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 464, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.616  Legal actions.--The contract shall include the following provision:

"Legal Actions: No legal action may be brought to recover on this policy within 60 days after written proof of loss has been given as required by this policy. No such action may be brought after the expiration of the applicable statute of limitations from the time written proof of loss is required to be given."

History.--s. 559, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 465, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.617  Change of beneficiary.--The contract shall include the following provision:

"Change of Beneficiary: The insured can change the beneficiary at any time by giving the insurer written notice. The beneficiary's consent is not required for this or any other change in the policy, unless the designation of the beneficiary is irrevocable."

History.--s. 560, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 466, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.618  Optional policy provisions.--Except as provided in s. 627.605(2), no health insurance policy delivered or issued for delivery to any person in this state shall contain any provision respecting the matters set forth in ss. 627.619-627.629, inclusive, unless such provision is in the words in which the same appears in the applicable section, except that the insurer may, at its option, use in lieu of any such provision a corresponding provision of different wording approved by the office which is not less favorable in any respect to the insured or the beneficiary. Any such provision contained in the policy shall be preceded individually by the appropriate caption or, at the option of the insurer, by such appropriate individual or group captions or subcaptions as the office may approve.

History.--s. 561, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 468, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1145, ch. 2003-261.

627.619  Change of occupation.--There may be a provision as follows:

"Change of Occupation: If the insured is injured or contracts sickness after having changed his or her occupation to one classified by the insurer as more hazardous than that stated in this policy or while doing for compensation anything pertaining to an occupation so classified, the insurer will pay only such portion of the indemnities provided in this policy as the premium paid would have purchased at the rates and within the limits fixed by the insurer for such more hazardous occupation. If the insured changes his or her occupation to one classified by the insurer as less hazardous than that stated in this policy, the insurer, upon receipt of proof of such change of occupation, will reduce the premium rate accordingly, and will return the excess pro rata unearned premium from the date of change of occupation or from the policy anniversary date immediately preceding receipt of such proof, whichever is the more recent. In applying this provision, the classification of occupational risk and the premium rates shall be such as have been last filed by the insurer prior to the occurrence of the loss for which the insurer is liable or prior to date of proof of change in occupation with the state official having supervision of insurance in the state where the insured resided at the time this policy was issued; but if such filing was not required, then the classification of occupational risk and the premium rates shall be those last made effective by the insurer in such state prior to the occurrence of the loss or prior to the date of proof of change in occupation."

History.--s. 562, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 341, ch. 97-102.

627.620  Misstatement of age or sex.--The contract may include the following provision:

"Misstatement of Age or Sex: If the age or sex of the insured has been misstated, all amounts payable under this policy shall be such as the premium paid would have purchased according to the correct age or sex."

History.--s. 563, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 469, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.621  Other insurance with this insurer.--The contract may include the following provision:

"Other Insurance with This Insurer: If two or more health insurance policies, exclusive of guaranteed-issue policies, are issued by the insurer covering the same insured, the insurer shall pay the total benefits payable under all policies issued; provided that when guaranteed-issue policies are in force concurrently either with or without other health insurance policies, resulting in coverage in excess of covered claims, the excess insurance provided under such guaranteed-issue policies shall be void and all premiums paid for such excess shall be returned to the insured or to the insured's estate; provided further that full payment of all covered claims is made."

History.--s. 564, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 470, 497, 809(2nd), ch. 82-243; ss. 59, 79, ch. 82-386; s. 114, ch. 92-318; s. 342, ch. 97-102.

627.622  Insurance with other insurers.--

(1)  The contract may include the following provision:

"Insurance with Other Insurers: If there is other valid coverage, not with this insurer, providing benefits for the same loss on a provision-of-service basis or on an expense-incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability under any expense-incurred or service coverage of this policy shall be for such proportion of the loss as the amount which would otherwise have been payable plus the total of the like amounts under all such other valid coverages for the same loss of which this insurer had notice bears to the total like amounts under all valid coverages for such loss, and for the return of such portion of the premiums paid as shall exceed the pro rata portion for the amount so determined. For the purpose of applying this provision when other coverage is on a provision-of-service basis, the 'like amount' of such other coverage shall be taken as the amount which the services rendered would have cost in the absence of such coverage."

(2)  If the foregoing policy provision is included in a policy which also contains the policy provision set out in s. 627.623, there shall be added to the caption of the foregoing provision the phrase: "--Expense-incurred Benefits." The insurer may, at its option, include in this provision a definition of "other valid coverage," approved as to form by the office, which definition shall be limited to coverage provided by organizations subject to regulation by the insurance law of any jurisdiction. In the absence of such definition, such term does not include group insurance, automobile medical payments insurance, or coverage provided by health care services plans or by union welfare plans or employer or employee benefit organizations. Any benefit provided for an insured pursuant to any compulsory benefit statute shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision, no third-party liability coverage shall be included as "other valid coverage."

History.--s. 565, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 110, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 471, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1146, ch. 2003-261.

627.623  Insurance with other insurers; other benefits.--

(1)  The contract may include the following provision:

"Insurance With Other Insurers: If there is other valid coverage, not with this insurer, providing benefits for the same loss on other than an expense-incurred basis and of which this insurer has not been given written notice prior to the occurrence or commencement of loss, the only liability for such benefits under this policy shall be for such proportion of the indemnities otherwise provided hereunder for such loss as the like indemnities of which the insurer had notice (including the indemnities under this policy) bear to the total amount of all like indemnities for such loss, and for the return of such portion of the premium paid as shall exceed the pro rata portion for the indemnities thus determined."

(2)  If the foregoing policy provision is included in a policy which also contains the policy provision set out in s. 627.622, there shall be added to the caption of the foregoing provision the phrase: "--Other Benefits." The insurer may, at its option, include in this provision a definition of "other valid coverage," approved as to form by the office, which definition shall be limited to coverage provided by organizations subject to regulation by the insurance law of any jurisdiction. In the absence of such definition, such term does not include group insurance, or benefits provided by union welfare plans or by employer or employee benefit organizations. Any benefit provided for an insured pursuant to any compulsory benefit statute shall in all cases be deemed to be "other valid coverage" of which the insurer has had notice. In applying the foregoing policy provision, no third-party liability coverage shall be included as "other valid coverage."

History.--s. 566, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 111, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 473, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1147, ch. 2003-261.

627.624  Relation of earnings to insurance.--

(1)  The contract may include the following provision:

"Relation of Earnings to Insurance: If the total monthly amount of loss-of-time benefits promised for the same loss under all valid loss-of-time coverage upon the insured, whether payable on a weekly or monthly basis, exceeds the monthly earnings of the insured at the time disability commenced or his or her average monthly earnings for the period of 2 years immediately preceding a disability for which claim is made, whichever is the greater, the insurer will be liable only for such proportionate amount of such benefits under this policy as the amount of such monthly earnings or such average monthly earnings of the insured bears to the total amount of monthly benefits for the same loss under all such coverage upon the insured at the time such disability commences and for the return of such part of the premiums paid during such 2 years as exceeds the pro rata amount of the premiums for the benefits actually paid hereunder; but this provision shall not operate to reduce the total monthly amount of benefits payable under all such coverage upon the insured below the sum of $500 or the sum of the monthly benefits specified in such coverages, whichever is the lesser, nor shall it operate to reduce benefits other than those payable for loss of time."

(2)  The foregoing policy provision may be inserted only in a policy which the insured has the right to continue in force subject to its terms by the timely payment of premiums until at least age 50 or, in the case of a policy issued after age 44, for at least 5 years from its date of issue. The insurer may, at its option, include in this provision a definition of "valid loss-of-time coverage," approved as to form by the office, which definition shall be limited to coverage provided by governmental agencies or by organizations subject to regulation by insurance law, or any combination of such coverages. In the absence of such definition, such term does not include any coverage provided for such insured pursuant to any compulsory benefit statute or benefits provided by union welfare plans or by employer or employee benefit organizations.

History.--s. 567, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; s. 112, ch. 79-40; ss. 2, 3, ch. 81-318; ss. 474, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 343, ch. 97-102; s. 1148, ch. 2003-261.

627.625  Unpaid premiums.--The contract may include the following provision:

"Unpaid Premium: Upon the payment of a claim under this policy, any premium then due and unpaid or covered by any note or written order may be deducted therefrom."

History.--s. 568, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 475, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.6265  Cancellation or nonrenewal prohibited.--Notwithstanding any other provision of law to the contrary, no insurer shall cancel or nonrenew the health insurance policy of any insured because of diagnosis or treatment of human immunodeficiency virus infection or acquired immune deficiency syndrome.

History.--ss. 49, 53, ch. 88-380; s. 114, ch. 92-318.

627.627  Conformity with statutes.--The contract may include the following provision:

"Conformity with State Statutes: Any provision of this policy which, on its effective date, is in conflict with the statutes of the state in which the insured resides on such date is hereby amended to conform to the minimum requirements of such statutes."

History.--s. 570, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 477, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.628  Illegal occupation.--The contract may include the following provision:

"Illegal Occupation: The insurer will not be liable for any loss which results from the insured committing or attempting to commit a felony or from the insured engaging in an illegal occupation."

History.--s. 571, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 478, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.629  Intoxicants and narcotics.--The contract may include the following provision:

"Intoxicants and Narcotics: The insurer will not be liable for any loss resulting from the insured being drunk or under the influence of any narcotic unless taken on the advice of a physician."

History.--s. 572, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 479, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.630  Order of certain provisions.--The provisions which are the subject of ss. 627.606-627.629, inclusive, shall be printed in the consecutive order of the provisions in such sections; or, at the option of the insurer, any such provision may appear as a unit in any part of the policy, with other provisions to which it may be logically related, provided that the resulting policy shall not be in whole or in part unintelligible, uncertain, ambiguous, abstruse, or likely to mislead a person to whom the policy is offered, delivered, or issued.

History.--s. 573, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 480, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.631  Third-party ownership.--The word "insured," as used in this part, shall not be construed as preventing a person other than the insured with a proper insurable interest from making application for and owning a policy covering the insured or from being entitled under such a policy to any indemnities, benefits, and rights provided therein.

History.--s. 574, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 481, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.632  Requirements of other jurisdictions.--

(1)  Any policy of a foreign or alien insurer, when delivered or issued for delivery to any person in this state, may contain any provision which is not less favorable to the insured or the beneficiary than the provisions of this chapter and which is prescribed or required by the law of the state or country under which the insurer is organized.

(2)  Any policy of a domestic insurer may, when issued for delivery in any other state or country, contain any provision permitted or required by the laws of such other state or country.

History.--s. 575, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.633  Other policy provisions.--No policy provision which is not subject to this part shall be less favorable in any respect to the insured or the beneficiary than the policy provisions which are subject to this chapter.

History.--s. 576, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 482, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.634  Age limit.--If any health insurance policy contains a provision establishing, as an age limit or otherwise, a date after which the coverage provided by the policy will not be effective, and if such date falls within a period for which a premium is accepted by the insurer or if the insurer accepts a premium after such date, the coverage provided by the policy will continue in force subject to any right of cancellation until the end of the period for which the premium has been accepted. In the event the age of the insured has been misstated and if, according to the correct age of the insured, the coverage provided by the policy would not have become effective, or would have ceased prior to the acceptance of such premium or premiums, then the liability of the insurer shall, upon discovery of the error, be limited to the refund of all premiums paid for the period not covered by the policy.

History.--s. 577, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 483, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.635  Excess insurance.--

(1)  No provision of this chapter shall be deemed to prohibit an insurer from issuing a health insurance policy as, or including in a policy a provision providing for, excess insurance; that is, to the effect that the insurer's liability for benefits payable on account of expense incurred for any hospitalization, medical, surgical, and other services resulting from covered sickness or injury of the insured shall be limited to that part of that expense, if any, which is in excess of all benefits payable on account thereof by the same insurer under any other policy or policies covering the same insured and by all other insurers and service organizations by whom benefits are payable as to the same such expense.

(2)  Any excess insurance policy, or any policy containing any excess insurance provision, shall have imprinted or stamped conspicuously upon the face thereof the designation "excess insurance" or appropriate words of similar import approved by the office.

History.--s. 578, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 484, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1149, ch. 2003-261.

627.636  Industrial health insurance.--Industrial health insurance is that form of individual health insurance for which the premium is payable weekly. No policy of industrial health insurance may be delivered or issued for delivery in this state unless it has printed thereon the words "industrial policy" or "weekly premium policy" or words of similar import. Each policy shall be subject to the provisions of this chapter except that:

(1)  Any policy may contain a provision requiring proof of continuance of disability. If such provision is used, it shall be in the following words: "Affirmative proof of continuance of disability must be furnished at the expiration of each period for which a claim is filed."

(2)  The insurer may refuse to endorse the name of any proposed beneficiary who does not appear to the insurer to have an insurable interest in the life of the insured.

History.--s. 579, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 485, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.637  Construction of noncomplying contracts.--If any insurer writes or issues in this state any health insurance contract, as contemplated by this chapter, and the form of such contract is not authorized by or in conformity with the provisions of this chapter, the contract shall nevertheless be a valid and binding contract of the insurer, and shall be construed as though its terms and provisions were in conformity with those required by this chapter, any provision in the contract to the contrary notwithstanding.

History.--s. 580, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 486, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.638  Direct payment for hospital, medical services.--

(1)  Any health insurance policy insuring against loss or expense due to hospital confinement or to medical and related services may provide for payment of benefits directly to any recognized hospital, doctor, or other person who provided the services, in accordance with the provisions of the policy. To comply with this section, the words "or to the hospital, doctor, or person rendering services covered by this policy," or similar words appropriate to the terms of the policy, shall be added to applicable provisions of the policy.

(2)  Whenever, in any health insurance claim form, an insured specifically authorizes payment of benefits directly to any recognized hospital or physician, the insurer shall make such payment to the designated provider of such services, unless otherwise provided in the insurance contract.

History.--s. 581, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 487, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 85-160; s. 114, ch. 92-318.

627.639  Application signed by agent.--If the application for a health insurance policy is to be made a part of the contract of insurance, the insurer's agent who completed the application shall sign the same in the capacity of soliciting agent.

History.--s. 582, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 488, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.640  Filing of classifications and rates.--An insurer shall not deliver or issue for delivery in this state any health insurance policy until it has filed with the office a copy of any applicable classification of risks and premium rates.

History.--s. 583, ch. 59-205; ss. 13, 35, ch. 69-106; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 489, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 1150, ch. 2003-261.

627.6401  Refunds for persons age 64.--If an insured who has reached his or her 64th birthday but who is not yet 65 years of age pays an annual or semiannual premium that would otherwise pay for coverage beyond his or her 65th birthday, such person shall be entitled to an appropriate refund of unearned premium from the insurer in the event that coverage terminates or is reduced upon the insured's attainment of age 65.

History.--s. 1, ch. 85-136; s. 1, ch. 86-286; s. 114, ch. 92-318; s. 344, ch. 97-102.

627.6402  Insurance rebates for healthy lifestyles.--

(1)  Any rate, rating schedule, or rating manual for an individual health insurance policy filed with the office shall provide for an appropriate rebate of premiums paid in the last calendar year when the individual covered by such plan is enrolled in and maintains participation in any health wellness, maintenance, or improvement program approved by the health plan. The individual must provide evidence of demonstrative maintenance or improvement of the individual's health status as determined by assessments of agreed-upon health status indicators between the individual and the health insurer, including, but not limited to, reduction in weight, body mass index, and smoking cessation. Any rebate provided by the health insurer is presumed to be appropriate unless credible data demonstrates otherwise, but shall not exceed 10 percent of paid premiums.

(2)  The premium rebate authorized by this section shall be effective for an insured on an annual basis, unless the individual fails to maintain or improve his or her health status while participating in an approved wellness program, or credible evidence demonstrates that the individual is not participating in the approved wellness program.

History.--s. 33, ch. 2004-297.

627.6403  Payment of acupuncture benefits to certified acupuncturists.--Any policy of individual health insurance that provides coverage for acupuncture shall cover the services of an acupuncturist certified pursuant to chapter 457 under the same conditions that apply to services of a licensed physician.

History.--ss. 1, 3, ch. 87-176; s. 114, ch. 92-318.

627.6405  Decreasing inappropriate utilization of emergency care.--

(1)  The Legislature finds and declares it to be of vital importance that emergency services and care be provided by hospitals and physicians to every person in need of such care, but with the double-digit increases in health insurance premiums, health care providers and insurers should encourage patients and the insured to assume responsibility for their treatment, including emergency care. The Legislature finds that inappropriate utilization of emergency department services increases the overall cost of providing health care and these costs are ultimately borne by the hospital, the insured patients, and, many times, by the taxpayers of this state. Finally, the Legislature declares that the providers and insurers must share the responsibility of providing alternative treatment options to urgent care patients outside of the emergency department. Therefore, it is the intent of the Legislature to place the obligation for educating consumers and creating mechanisms for delivery of care that will decrease the overutilization of emergency service on health insurers and providers.

(2)  Health insurers shall provide on their websites information regarding appropriate utilization of emergency care services which shall include, but not be limited to, a list of alternative urgent care contracted providers, the types of services offered by these providers, and what to do in the event of a true emergency.

(3)  Health insurers shall develop community emergency department diversion programs. Such programs may include, at the discretion of the insurer, but not be limited to, enlisting providers to be on call to insurers after hours, coordinating care through local community resources, and providing incentives to providers for case management.

(4)  As a disincentive for insureds to inappropriately use emergency department services for nonemergency care, health insurers may require higher copayments for urgent care or primary care provided in an emergency department and higher copayments for use of out-of-network emergency departments. Higher copayments may not be charged for the utilization of the emergency department for emergency care. For the purposes of this section, the term "emergency care" has the same meaning as provided in s. 395.002 and shall include services provided to rule out an emergency medical condition.

History.--s. 25, ch. 2004-297.

627.6406  Maternity care.--

(1)  Any policy of health insurance that provides coverage for maternity care must also cover the services of certified nurse-midwives and midwives licensed pursuant to chapter 467, and the services of birth centers licensed under ss. 383.30-383.335.

(2)  An insurer issuing a health insurance policy that provides maternity and newborn coverage may not limit coverage for the length of a maternity and newborn stay in a hospital or for followup care outside of a hospital to any time period that is less than that determined to be medically necessary, in accordance with prevailing medical standards and consistent with guidelines for perinatal care of the American Academy of Pediatrics or the American College of Obstetricians and Gynecologists, by the treating obstetrical care provider or the pediatric care provider.

(3)  This section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and this section does not prohibit appropriate utilization review or case management by an insurer.

(4)  Any policy of health insurance that provides coverage, benefits, or services for maternity or newborn care must provide coverage for postdelivery care for a mother and her newborn infant. The postdelivery care must include a postpartum assessment and newborn assessment and may be provided at the hospital, at the attending physician's office, at an outpatient maternity center, or in the home by a qualified licensed health care professional trained in mother and baby care. The services must include physical assessment of the newborn and mother, and the performance of any medically necessary clinical tests and immunizations in keeping with prevailing medical standards.

(5)  An insurer subject to subsection (1) shall communicate active case questions and concerns regarding postdelivery care directly to the treating physician or hospital in written form, in addition to other forms of communication. Such insurers shall also use a process that includes a written protocol for utilization review and quality assurance.

(6)  An insurer subject to subsection (1) may not:

(a)  Deny to a mother or her newborn infant eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section.

(b)  Provide monetary payments or rebates to a mother to encourage the mother to accept less than the minimum protections available under this section.

(c)  Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an individual participant or beneficiary in accordance with this section.

(d)  Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an individual participant or beneficiary in a manner inconsistent with this section.

(e)  Subject to paragraph (7)(c), restrict benefits for any portion of a period within a hospital length of stay required under subsection (2) in a manner that is less favorable than the benefits provided for any preceding portion of such stay.

(7)(a)  This section does not require a mother who is a participant or beneficiary to:

1.  Give birth in a hospital.

2.  Stay in the hospital for a fixed period of time following the birth of her infant.

(b)  This section does not apply with respect to any health insurance coverage that does not provide benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant.

(c)  This section does not prevent a policy from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits for hospital lengths of stay in connection with childbirth for a mother or her newborn infant, except that such coinsurance or other cost-sharing for any portion of a period within a hospital length of stay required under subsection (2) may not be greater than such coinsurance or cost-sharing for any preceding portion of such stay.

History.--s. 20, ch. 83-288; s. 3, ch. 84-94; s. 1, ch. 89-190; s. 114, ch. 92-318; s. 1, ch. 96-195; s. 1, ch. 97-179.

627.6407  Massage.--Any policy of health insurance that provides coverage for massage shall also cover the services of persons licensed to practice massage pursuant to chapter 480, where the massage, as defined in chapter 480, has been prescribed by a physician licensed under chapter 458, chapter 459, chapter 460, or chapter 461, as being medically necessary and the prescription specifies the number of treatments.

History.--s. 57, ch. 92-318; s. 241, ch. 98-166.

627.6408  Diabetes treatment services.--

(1)  A health insurance policy or group health insurance policy sold in this state must provide coverage for all medically appropriate and necessary equipment, supplies, and diabetes outpatient self-management training and educational services used to treat diabetes, if the patient's treating physician or a physician who specializes in the treatment of diabetes certifies that such services are necessary.

(2)  The policy may require that diabetes outpatient self-management training and educational services be provided under the direct supervision of a certified diabetes educator or a board-certified endocrinologist. The policy may further require that nutrition counseling be provided by a licensed dietitian.

(3)  The Agency for Health Care Administration shall adopt standards for diabetes outpatient self-management training and educational services, taking into consideration standards approved by the American Diabetes Association.

History.--s. 3, ch. 95-268; s. 1, ch. 96-279.

627.6409  Coverage for osteoporosis screening, diagnosis, treatment, and management.--Any health insurance policy that covers a resident of this state and that is issued, amended, delivered, or renewed in this state after October 1, 1996, must provide coverage for the medically necessary diagnosis and treatment of osteoporosis for high-risk individuals, including, but not limited to, estrogen-deficient individuals who are at clinical risk for osteoporosis, individuals who have vertebral abnormalities, individuals who are receiving long-term glucocorticoid (steroid) therapy, individuals who have primary hyperparathyroidism, and individuals who have a family history of osteoporosis. This section does not apply to specified-accident, specified-disease, hospital-indemnity, Medicare supplement, or long-term-care health insurance policies or to the state employee health insurance program.

History.--s. 2, ch. 96-282.

627.641  Coverage for newborn children.--

(1)  A health insurance policy that provides coverage on an expense-incurred basis for a member of the family of the insured or subscriber shall, as to the family member's coverage, also provide that the health insurance benefits applicable for children will be payable with respect to a newborn child of the insured or subscriber, or covered family member of the insured or subscriber, from the moment of birth. However, with respect to a newborn child of a covered family member other than the spouse of the insured or subscriber, the coverage for the newborn child terminates 18 months after the birth of the newborn child.

(2)  The coverage for newborn children required by this section consists of coverage for injury or sickness, including the necessary care or treatment of medically diagnosed congenital defects, birth abnormalities, or prematurity, and transportation costs of the newborn to and from the nearest available facility appropriately staffed and equipped to treat the newborn's condition, when such transportation is certified by the attending physician as necessary to protect the health and safety of the newborn child. The coverage of such transportation costs may not exceed the usual and customary charges, up to $1,000.

(3)  This section does not apply to disability income or hospital indemnity policies or to normal maternity policy provisions applicable to the mother.

(4)  A policy may require the insured, subscriber, or covered family member to notify the insurer of the birth of a child within a time period, as specified in the policy, of not less than 30 days after the birth. If timely notice is given, the insurer may not charge an additional premium for coverage of the newborn child for the duration of the notice period. If timely notice is not given, the insurer may charge an additional premium from the date of birth. The insurer may not deny coverage for a child due to the failure of the insured to timely notify the insurer of the birth of the child.

(5)  If the policy does not require the insured to notify the insurer of the birth of a child within a specified time period, the insurer may not deny coverage for such child or retroactively charge the insured an additional premium for such child. However, the insurer may prospectively charge the insured an additional premium for the child if the insurer provides at least 45 days' notice of the additional premium required.

History.--s. 1, ch. 72-82; s. 1, ch. 74-8; s. 3, ch. 76-168; s. 1, ch. 77-174; s. 1, ch. 77-457; s. 1, ch. 80-177; ss. 2, 3, ch. 81-318; ss. 490, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 84-202; ss. 123, 149, ch. 92-33; s. 114, ch. 92-318.

627.6415  Coverage for natural-born, adopted, and foster children; children in insured's custodial care.--

(1)  A health insurance policy that provides coverage for a member of the family of the insured shall, as to the family member's coverage, provide that the health insurance benefits applicable to children of the insured also apply to an adopted child or a foster child of the insured placed in compliance with chapter 63, prior to the child's 18th birthday, from the moment of placement in the residence of the insured. Except in the case of a foster child, the policy may not exclude coverage for any preexisting condition of the child. In the case of a newborn child, coverage begins at the moment of birth if a written agreement to adopt the child has been entered into by the insured prior to the birth of the child, whether or not the agreement is enforceable. This section does not require coverage for an adopted child who is not ultimately placed in the residence of the insured in compliance with chapter 63.

(2)  A policy may require the insured to notify the insurer of the birth or placement of an adopted child within a specified time period of not less than 30 days after the birth or placement in the residence of a child adopted by the insured. If timely notice is given, the insurer may not charge an additional premium for coverage of the child for the notice period. If timely notice is not given, the insurer may charge an additional premium from the date of birth or placement. If notice is given within 60 days of the birth or placement of the child, the insurer may not deny coverage for the child due to the failure of the insured to timely notify the insurer of the birth or placement of the child.

(3)  If the policy does not require the insured to notify the insurer of the birth or placement of an adopted child within a specified time period, the insurer may not deny coverage for such child or retroactively charge the insured an additional premium for such child. However, the insurer may prospectively charge the insured an additional premium for the child if the insurer provides at least 45 days' notice of the additional premium required.

(4)  In order to increase access to postnatal, infant, and pediatric health care for all children placed in court-ordered custody, including foster children, all health insurance policies that provide coverage for a member of the family of the insured shall, as to such family member's coverage, also provide that the health insurance benefits applicable for children shall be payable with respect to a foster child or other child in court-ordered temporary or other custody of the insured, prior to the child's 18th birthday.

History.--ss. 3, 5, ch. 85-189; s. 1, ch. 88-269; s. 1, ch. 91-185; ss. 124, 149, ch. 92-33; s. 5, ch. 92-278; s. 114, ch. 92-318; s. 9, ch. 98-159.

627.6416  Coverage for child health supervision services.--

(1)  All health insurance policies providing coverage on an expense-incurred basis which provide coverage for a member of a family of the insured or subscriber must, as to such family member's coverage, also provide that the health insurance benefits applicable for children include coverage for child health supervision services from the moment of birth to age 16 years. Such services must be exempt from any deductible provisions that are in force in such policies or contracts.

(2)  As used in this section, the term "child health supervision services" means physician-delivered or physician-supervised services that include, at a minimum, services delivered at the intervals and scope stated in this section.

(a)  Child health supervision services must include periodic visits which shall include a history, a physical examination, a developmental assessment and anticipatory guidance, and appropriate immunizations and laboratory tests. Such services and periodic visits shall be provided in accordance with prevailing medical standards consistent with the Recommendations for Preventive Pediatric Health Care of the American Academy of Pediatrics.

(b)  Minimum benefits may be limited to one visit payable to one provider for all of the services provided at each visit cited in this section.

(3)  This section does not apply to disability income, specified disease, Medicare supplement, or hospital indemnity policies.

History.--ss. 2, 6, ch. 86-122; s. 1, ch. 88-329; s. 114, ch. 92-318; s. 1, ch. 97-166.

627.6417  Coverage for surgical procedures and devices incident to mastectomy.--

(1)  Any health insurance policy that provides coverage for mastectomies must also provide coverage for prosthetic devices and breast reconstructive surgery incident to the mastectomy. The insurer may charge an appropriate additional premium for the coverage required by this subsection. The coverage for prosthetic devices and breast reconstructive surgery shall be subject to any deductible and coinsurance conditions and all other terms and conditions applicable to other benefits. Breast reconstructive surgery must be in a manner chosen by the treating physician, consistent with prevailing medical standards, and in consultation with the patient.

(2)  As used in this section, the term "mastectomy" means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician, and the term "breast reconstructive surgery" means surgery to reestablish symmetry between the two breasts.

(3)  This section does not apply to disability income, specified disease other than cancer, or hospital indemnity policies.

History.--ss. 2, 4, ch. 87-262; s. 4, ch. 88-269; ss. 58, 114, ch. 92-318; s. 1, ch. 97-48.

627.64171  Coverage for length of stay and outpatient postsurgical care.--

(1)  Any health insurance policy that is issued, amended, delivered, or renewed in this state which provides coverage for breast cancer treatment may not limit inpatient hospital coverage for mastectomies to any period that is less than that determined by the treating physician to be medically necessary in accordance with prevailing medical standards and after consultation with the insured patient.

(2)  Any health insurance policy that provides coverage for mastectomies under subsection (1) must also provide coverage for outpatient postsurgical followup care in keeping with prevailing medical standards by a licensed health care professional qualified to provide postsurgical mastectomy care. The treating physician, after consultation with the insured patient, may choose that the outpatient care be provided at the most medically appropriate setting, which may include the hospital, treating physician's office, outpatient center, or home of the insured patient.

(3)  An insurer subject to subsection (1) may not:

(a)  Deny to an insured eligibility, or continued eligibility, to enroll or to renew coverage under the terms of the policy for the purpose of avoiding the requirements of this section;

(b)  Provide monetary payments or rebates to an insured patient to accept less than the minimum protections available under this section;

(c)  Penalize or otherwise reduce or limit the reimbursement of an attending provider solely because the attending provider provided care to an insured patient under this section;

(d)  Provide incentives, monetary or otherwise, to an attending provider solely to induce the provider to provide care to an insured patient in a manner inconsistent with this section; or

(e)  Subject to the other provisions of this section, restrict benefits for any portion of a period within a hospital length of stay or outpatient care as required by this section in a manner that is less than favorable than the benefits provided for any preceding portion of such stay.

(4)(a)  This section does not require an insured patient to have the mastectomy in the hospital or stay in the hospital for a fixed period of time following the mastectomy.

(b)  This section does not prevent a policy from imposing deductibles, coinsurance, or other cost-sharing in relation to benefits under this section, except that such cost-sharing may not exceed cost-sharing with other benefits.

(5)  Except as provided in subsection (3), this section does not affect any agreement between an insurer and a hospital or other health care provider with respect to reimbursement for health care services provided, rate negotiations with providers, or capitation of providers, and does not prohibit appropriate utilization review or case management by the insurer.

(6)  This section does not apply to disability income, specified diseases other than cancer, or hospital indemnity policies.

(7)  As used in this section, the term "mastectomy" means the removal of all or part of the breast for medically necessary reasons as determined by a licensed physician.

History.--s. 2, ch. 97-48.

627.64172  Requirements with respect to breast cancer and routine followup care.--Routine followup care to determine whether a breast cancer has recurred in a person who has been previously determined to be free of breast cancer does not constitute medical advice, diagnosis, care, or treatment for purposes of determining preexisting conditions, unless evidence of breast cancer is found during or as a result of the followup care.

History.--s. 3, ch. 97-48.

627.6418  Coverage for mammograms.--

(1)  An accident or health insurance policy issued, amended, delivered, or renewed in this state must provide coverage for at least the following:

(a)  A baseline mammogram for any woman who is 35 years of age or older, but younger than 40 years of age.

(b)  A mammogram every 2 years for any woman who is 40 years of age or older, but younger than 50 years of age, or more frequently based on the patient's physician's recommendation.

(c)  A mammogram every year for any woman who is 50 years of age or older.

(d)  One or more mammograms a year, based upon a physician's recommendation, for any woman who is at risk for breast cancer because of a personal or family history of breast cancer, because of having a history of biopsy-proven benign breast disease, because of having a mother, sister, or daughter who has or has had breast cancer, or because a woman has not given birth before the age of 30.

It is the intent of the Legislature that, when practice parameters for the delivery of mammography services are developed pursuant to ¹s. 408.02(7), the Legislature review the requirements of this section and conform to the practice parameters.

(2)  Except as provided in paragraph (1)(b), for mammograms done more frequently than every 2 years for women 40 years of age or older but younger than 50 years of age, the coverage required by subsection (1) applies, with or without a physician prescription, if the insured obtains a mammogram in an office, facility, or health testing service that uses radiological equipment registered with the Department of Health for breast cancer screening. The coverage is subject to the deductible and coinsurance provisions applicable to outpatient visits, and is also subject to all other terms and conditions applicable to other benefits. This section does not affect any requirements or prohibitions relating to who may perform, analyze, or interpret a mammogram or the persons to whom the results of a mammogram may be furnished or released.

(3)  This section does not apply to disability income, specified disease, or hospital indemnity policies.

(4)  Every insurer subject to the requirements of this section shall make available to the policyholder as part of the application, for an appropriate additional premium, the coverage required in this section without such coverage being subject to the deductible or coinsurance provisions of the policy.

History.--s. 4, ch. 88-269; s. 125, ch. 92-33; s. 6, ch. 95-188; s. 260, ch. 99-8.

¹Note.--Repealed by s. 42, ch. 2004-297.

627.6419  Requirements with respect to breast cancer.--

(1)  An insurer may not deny the issuance or renewal of, or cancel, a policy of accident insurance or health insurance, nor include any exception or exclusion of benefits in a policy solely because the insured has been diagnosed as having a fibrocystic condition or a nonmalignant lesion that demonstrates a predisposition, or solely due to the family history of the insured related to breast cancer, or solely due to any combination of these factors, unless the condition is diagnosed through a breast biopsy that demonstrates an increased disposition to developing breast cancer.

(2)  An insurer may not deny the issuance or renewal of, or cancel, a policy of accident insurance or health insurance, nor include any exception or exclusion of benefits in a policy solely due to breast cancer, if the insured has been free from breast cancer for more than 2 years before the applicant's request for health insurance coverage.

(3)  This section also applies to a policy of group, blanket, or franchise accident or health insurance and to a contract or evidence of coverage issued by a health maintenance organization.

History.--s. 59, ch. 92-318; s. 7, ch. 95-188; s. 4, ch. 97-48; s. 2, ch. 97-182.

627.64193  Required coverage for cleft lip and cleft palate.--A health insurance policy that covers a child under the age of 18 must provide coverage for treatment of cleft lip and cleft palate for the child. The coverage must include medical, dental, speech therapy, audiology, and nutrition services only if such services are prescribed by the treating physician or surgeon and such physician or surgeon certifies that such services are medically necessary and consequent to treatment of the cleft lip or cleft palate. The coverage required by this section is subject to terms and conditions applicable to other benefits. This section does not apply to specified-accident, specified-disease, hospital indemnity, limited benefit disability income, or long-term care insurance policies.

History.--s. 1, ch. 98-66.

627.642  Outline of coverage.--

(1)  No individual or family accident and health insurance policy shall be delivered, or issued for delivery, in this state unless:

(a)  It is accompanied by an appropriate outline of coverage; or

(b)  An appropriate outline of coverage is completed and delivered to the applicant at the time application is made, and an acknowledgment of receipt or certificate of delivery of such outline is provided to the insurer with the application.

In the case of a direct response, such as a written application to the insurance company from an applicant, the outline of coverage shall accompany the policy when issued.

(2)  The outline of coverage shall contain:

(a)  A statement identifying the applicable category of coverage afforded by the policy, based on the minimum basic standards set forth in the rules issued to effect compliance with s. 627.643.

(b)  A brief description of the principal benefits and coverage provided in the policy.

(c)  A summary statement of the principal exclusions and limitations or reductions contained in the policy, including, but not limited to, preexisting conditions, probationary periods, elimination periods, deductibles, coinsurance, and any age limitations or reductions.

(d)  A summary statement of the renewal and cancellation provisions, including any reservation of the insurer of a right to change premiums.

(e)  A statement that the outline contains a summary only of the details of the policy as issued or of the policy as applied for and that the issued policy should be referred to for the actual contractual governing provisions.

(f)  When home health care coverage is provided, a statement that such benefits are provided in the policy.

History.--s. 1, ch. 74-69; s. 1, ch. 74-281; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 491, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.6425  Renewability of individual coverage.--

(1)  Except as otherwise provided in this section, an insurer that provides individual health insurance coverage to an individual shall renew or continue in force such coverage at the option of the individual. For the purpose of this section, the term "individual health insurance" means health insurance coverage, as described in s. 627.6561(5)(a)2., offered to an individual in this state, including certificates of coverage offered to individuals in this state as part of a group policy issued to an association outside this state, but the term does not include short-term limited duration insurance or excepted benefits specified in subsection (6) or subsection (7).

(2)  An insurer may nonrenew or discontinue health insurance coverage of an individual in the individual market based only on one or more of the following:

(a)  The individual has failed to pay premiums, contributions, or a required copayment payable to the insurer in accordance with the terms of the health insurance coverage or the insurer has not received timely premium payments. When the copayment is payable to the insurer and exceeds $300, the insurer shall allow the insured up to 90 days after the date of the procedure to pay the required copayment. The insurer shall print in 10-point type on the Declaration of Benefits page notification that the insured could be terminated for failure to make any required copayment to the insurer.

(b)  The individual has performed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the coverage.

(c)  The insurer is ceasing to offer coverage in the individual market in accordance with subsection (3) and applicable state law.

(d)  In the case of a health insurer that offers health insurance coverage in the market through a network plan, the individual no longer resides, lives, or works in the service area, or in an area for which the insurer is authorized to do business, but only if such coverage is terminated under this paragraph uniformly without regard to any health-status-related factor of covered individuals.

(e)  In the case of health insurance coverage that is made available in the individual market only through one or more bona fide associations, as defined in s. 627.6571(5), the membership of the individual in the association, on the basis of which the coverage is provided, ceases, but only if such coverage is terminated under this paragraph uniformly without regard to any health-status-related factor of covered individuals.

(3)(a)  In any case in which an insurer decides to discontinue offering a particular policy form for health insurance coverage offered in the individual market, coverage under such form may be discontinued by the insurer only if:

1.  The insurer provides notice to each covered individual provided coverage under this policy form in the individual market of such discontinuation at least 90 days prior to the date of the nonrenewal of such coverage;

2.  The insurer offers to each individual in the individual market provided coverage under this policy form the option to purchase any other individual health insurance coverage currently being offered by the insurer for individuals in such market in the state; and

3.  In exercising the option to discontinue coverage of this policy form and in offering the option of coverage under subparagraph 2., the insurer acts uniformly without regard to any health-status-related factor of enrolled individuals or individuals who may become eligible for such coverage.

(b)1.  Subject to subparagraph (a)3., in any case in which an insurer elects to discontinue offering all health insurance coverage in the individual market in this state, health insurance coverage may be discontinued by the insurer only if:

a.  The insurer provides notice to the office and to each individual of such discontinuation at least 180 days prior to the date of the nonrenewal of such coverage; and

b.  All health insurance issued or delivered for issuance in the state in the individual market is discontinued and coverage under such health insurance coverage in such market is not renewed.

2.  In the case of a discontinuation under subparagraph 1. in the individual market, the insurer may not provide for the issuance of any individual health insurance coverage in this state during the 5-year period beginning on the date of the discontinuation of the last health insurance coverage not so renewed.

(4)  At the time of coverage renewal, an insurer may modify the health insurance coverage for a policy form offered to individuals in the individual market so long as such modification is consistent with the laws of this state and effective on a uniform basis among all individuals with that policy form.

(5)  In applying this section in the case of health insurance coverage that is made available by an insurer in the individual market to individuals only through one or more associations, a reference to an "individual" includes a reference to such an association of which the individual is a member.

(6)  The requirements of this section do not apply to any health insurance coverage in relation to its provision of excepted benefits described in s. 627.6561(5)(b).

(7)  The requirements of this section do not apply to any health insurance coverage in relation to its provision of excepted benefits described in s. 627.6561(5)(c), (d), or (e), if the benefits are provided under a separate policy, certificate, or contract of insurance.

(8)  This section applies to health insurance coverage offered, sold, issued, or renewed in the individual market on or after July 1, 1997.

History.--s. 2, ch. 96-223; s. 2, ch. 97-179; s. 4, ch. 98-159; s. 33, ch. 2002-400; s. 1151, ch. 2003-261.

627.643  Uniform minimum standards.--

(1)  The commission shall adopt rules which establish minimum standards for the general content of forms of individual and family health insurance policies. The rules must include terms of renewability, initial and subsequent conditions of eligibility, termination of insurance, probationary periods, exclusions, limitations, and reductions. The minimum standards are in addition to, and must comply with, the individual health insurance policy provisions provided in part II and in this part.

(2)  The commission shall adopt rules which establish minimum standards of benefits and identification for each of the following categories of coverage in individual and family accident and health insurance policy forms, other than conversion policy forms:

(a)  Basic hospital expense insurance.

(b)  Basic medical expense insurance.

(c)  Basic surgical expense insurance.

(d)  Hospital confinement indemnity insurance.

(e)  Major medical expense insurance.

(f)  Disability income protection insurance.

(g)  Accident-only insurance.

(h)  Limited benefit insurance.

(i)  Supplemental insurance.

(j)  Home health care coverage.

(k)  Nonconventional coverage.

This subsection does not preclude the issuance of a policy which combines two or more of the categories of coverage enumerated in paragraphs (a)-(e). This subsection does not preclude the issuance of a policy that does not meet the prescribed minimum standards for categories of coverage in paragraphs (a)-(g) if the office determines that the policy is either experimental in nature or is demonstrated to be a type of coverage that fulfills a reasonable need of the person or persons to be insured. Any policy not meeting the minimum standards that is approved by the office must be identified as to category only as prescribed by the office.

(3)  The office may, within the time provided by law for the disapproval of an individual or family form of accident or health insurance, disapprove any form if it finds that the form does not comply with applicable law or it finds that the form is unjust, unfair, or inequitable to the policyholder, any insured, or any beneficiary. In acting upon any submission, the office shall consider whether the benefits afforded under the submitted policy or benefit form fulfill a reasonable need of a policyholder.

History.--s. 1, ch. 74-281; s. 3, ch. 76-168; s. 1, ch. 77-174; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 492, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 60, 114, ch. 92-318; s. 1152, ch. 2003-261.

627.644  Discrimination against handicapped prohibited.--No health insurer shall refuse to provide, or shall charge unfairly discriminatory rates for, health insurance coverage for a person solely because the person is mentally or physically handicapped. Nothing in this section should be construed as requiring an insurer to provide insurance coverage against a handicap which the applicant or policyholder has already sustained.

History.--s. 1, ch. 76-127; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 493, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.645  Denial of health insurance claims restricted.--

(1)  No claim for payment under a health insurance policy or self-insured program of health benefits for treatment, care, or services in a licensed hospital which is accredited by the Joint Commission on the Accreditation of Hospitals, the American Osteopathic Association, or the Commission on the Accreditation of Rehabilitative Facilities shall be denied because such hospital lacks major surgical facilities and is primarily of a rehabilitative nature, if such rehabilitation is specifically for treatment of physical disability.

(2)  No claim for payment under a health insurance policy for medical care or treatment of a child in a licensed hospital which is nonprofit; which primarily provides diagnosis, treatment, or care for patients whose physical functions or movements are impaired by accident, disease, or congenital deformity; and which accepts patients for treatment without regard to race, color, national origin, sex, religion, or affiliation shall be denied because the hospital does not have facilities for major surgery or because the treatment and care are primarily of a charitable nature.

History.--s. 1, ch. 77-32; s. 12, ch. 78-106; ss. 1, 3, ch. 80-33; s. 2, ch. 81-318; ss. 494, 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

Note.--Former s. 391.11.

627.646  Conversion on termination of eligibility.--

(1)  Every health insurance policy providing hospital or medical expense coverage hereafter delivered or issued for delivery in this state or under which benefits are altered, modified, or amended shall contain a provision that, if the insurance on a person covered under the policy ceases because of the termination of such person's eligibility for coverage prior to his or her becoming eligible for Medicare or Medicaid benefits, then such person shall be entitled to have issued to him or her by the insurer, without evidence of insurability, a policy of health insurance, either individual or family, whichever is appropriate, provided application for the policy is made and the first premium is paid to the insurer within 31 days after such termination, and provided further that:

(a)  The coverage under the policy shall be in an amount equal to or, at the option of the insured, less than the amount of health insurance which ceases because of such termination.

(b)  The premium on the policy shall be at the insurer's then customary rate applicable to such policies, to the class of risk to which such person then belongs, and to his or her age attained on the effective date of the policy.

(c)  The policy of health insurance will not result in overinsurance on the basis of the company underwriting standards at the time of issue.

(d)  The policy of health insurance may be reduced by the amount of any benefits paid for the same injury or same sickness under the prior policy.

(e)  The policy of health insurance may exclude any condition excluded by the prior policy.

(2)  An insurer shall offer maternity benefits and dental benefits if those benefits were provided in the policy.

(3)  The provisions of this section shall be effectuated in such a way as to result in continuous coverage during the 31-day period for such insured.

(4)  This section does not apply to disability income, Medicare supplement, accident only, hospital indemnity, specified disease, limited benefit, nonconventional, or excess policies.

History.--s. 1, ch. 78-385; s. 2, ch. 81-318; ss. 495, 497, 809(2nd), ch. 82-243; ss. 60, 79, ch. 82-386; s. 3, ch. 90-249; s. 114, ch. 92-318; s. 345, ch. 97-102.

627.647  Standard health claim form.--

(1)  The commission shall prescribe a standard health claim form to be used by all hospitals and a standard health claim form to be used by all physicians, dentists, and pharmacists. Such forms shall be in a format that allows for the use of generally accepted coding systems by providers in order to facilitate the processing of claims. Such forms shall provide for the disclosure by the claimant of the name, policy number, and address of every insurance policy which may cover the claimant with respect to the submitted claim except those policies specified in s. 627.4235(5). The required information on diagnosis, dental procedures, medical procedures, services, date of service, supplies, and fees may also be met by an attachment to the appropriate physician claim form. However, for the purpose of filing Medicaid claims, such attachments shall be prohibited. Such standard health claim forms shall be accepted by all insurers and all agencies, departments, and divisions of the state.

(2)  This section does not apply to claims submitted by electronic or electromechanical means, except that such claims must include disclosure of every insurance policy which may cover the claimant with respect to the submitted claim.

History.--s. 1, ch. 77-46; s. 1, ch. 79-175; s. 2, ch. 81-318; ss. 496(1st), 497, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 88-30; s. 114, ch. 92-318; s. 1153, ch. 2003-261.

Note.--Former s. 627.6111.

627.6471  Contracts for reduced rates of payment; limitations; coinsurance and deductibles.--

(1)  As used in this section:

(a)  "Insurer" means an insurer as defined in s. 624.03 or a multiple-employer welfare arrangement as defined in s. 624.437.

(b)  "Preferred provider" means any licensed health care provider with which the insurer has directly or indirectly contracted for an alternative or a reduced rate of payment, which shall include any health care provider listed in s. 627.419(3) and (4) and shall provide reasonable access to such health care providers.

(c)  "Preferred provider network" means a group of licensed health care providers with each of which the insurer has directly or indirectly contracted for alternative or reduced rates of payment. If an insurer negotiates with providers practicing as a group, the insurer may contract with the group.

(2)  Any insurer issuing a policy of health insurance in this state, which insurance includes coverage for the services of a preferred provider, must provide each policyholder and certificateholder with a current list of preferred providers and must make the list available for public inspection during regular business hours at the principal office of the insurer within the state.

(3)  A policy may limit payments regardless of the providers chosen by an insured and may offer alternative or reduced rates to an insured who selects preferred providers.

(4)  Any policy that provides schedules of payments for services provided by preferred providers that differ from the schedules of payments for services provided by nonpreferred providers is subject to the following limitations:

(a)  The amount of any annual deductible per covered person or per family for treatment in a facility that is not a preferred provider may not exceed four times the amount of a corresponding annual deductible for treatment in a facility that is a preferred provider.

(b)  If the policy has no deductible for treatment in a preferred provider facility, the deductible for treatment received in a facility that is not a preferred provider facility may not exceed $500 per covered person per visit.

(c)  The amount of any annual deductible per covered person or per family for treatment, other than inpatient treatment, by a provider that is not a preferred provider may not exceed four times the amount of a corresponding annual deductible for treatment, other than inpatient treatment, by a preferred provider.

(d)  If the policy has no deductible for treatment by a preferred provider, the annual deductible for treatment received from a provider which is not a preferred provider shall not exceed $500 per covered person.

(e)  The percentage amount of any coinsurance to be paid by an insured to a provider that is not a preferred provider may not exceed by more than 50 percentage points the percentage amount of any coinsurance payment to be paid to a preferred provider.

(f)  The amount of any deductible and payment of coinsurance paid by the insured must be applied to the reduced charge negotiated between the insurer and the preferred provider.

(g)  Notwithstanding the limitations of deductibles and coinsurance provisions in this section, an insurer may require the insured to pay a reasonable copayment per visit for inpatient or outpatient services.

(h)  If any service or treatment is not within the scope of services provided by the network of preferred providers, but is within the scope of services or treatment covered by the policy, the service or treatment shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to preferred providers. The reimbursement rate must be applied to the usual and customary charges in the area.

(5)  Any policy issued under this section which does not provide direct patient access to a dermatologist must conform to the requirements of s. 627.6472(16). This subsection shall not be construed to affect the amount the insured or patient must pay as a deductible or coinsurance amount authorized under this section.

(6)  If psychotherapeutic services are covered by a policy issued by the insurer, the insurer shall provide eligibility criteria for each group of health care providers licensed under chapter 458, chapter 459, chapter 490, or chapter 491, which include psychotherapy within the scope of their practice as provided by law, or for any person who is certified as an advanced registered nurse practitioner in psychiatric mental health under s. 464.012. When psychotherapeutic services are covered, eligibility criteria shall be established by the insurer to be included in the insurer's criteria for selection of network providers. The insurer may not discriminate against a health care provider by excluding such practitioner from its provider network solely on the basis of the practitioner's license.

History.--ss. 8, 12, ch. 91-296; ss. 126, 149, ch. 92-33; s. 114, ch. 92-318; s. 1, ch. 96-344; s. 3, ch. 99-393.

Note.--Former s. 627.4134.

627.6472  Exclusive provider organizations.--

(1)  As used in this section, the term:

(a)  "Complaint" means any dissatisfaction expressed by a policyholder concerning an insurer or its network providers.

(b)  "Emergency care" means medical services provided after the sudden or unexpected onset of a medical condition manifesting itself by acute symptoms, including injury caused by an accident, which are severe enough that the lack of immediate medical attention could reasonably be expected to result in any of the following:

1.  The patient's life or health would be placed in serious jeopardy.

2.  Vital bodily functions would be seriously impaired.

3.  There would be serious and permanent dysfunction of a bodily organ or part.

(c)  "Exclusive provider" means a provider of health care, or a group of providers of health care, that has entered into a written agreement with the insurer to provide benefits under a health insurance policy issued under this section, which agreement shall include any health care provider listed in s. 627.419(3) and (4) and shall provide reasonable access to such health care providers.

(d)  "Exclusive provider provision" means any provision that conditions the payment of benefits, in whole or in part, on the use of exclusive providers.

(e)  "Agency" means the Agency for Health Care Administration.

(f)  "Grievance" means dissatisfaction with the administration, claims practices, or provisions of services concerning an insurer or its network providers, expressed in writing by a policyholder under a health insurance policy or certificate.

(g)  "Service area" means the geographic area approved by the agency within which an insurer is authorized to offer a health insurance policy.

(2)  The agency may authorize a health insurer to offer a health insurance policy or certificate under this section if the agency finds that the insurer has satisfied all of the requirements of this section.

(3)  An insurer may not issue a policy or certificate in this state that is subject to an exclusive provider provision until its plan of operation has been approved by the agency. If the insurer files a plan of operation which states that the insurer will be utilizing a health maintenance organization provider network, subscriber grievance procedure, and internal and external quality assurance program, all of which have been approved by the agency, the insurers plan of operation shall be deemed to have met the requirements of subsections (4), (5), (12), and (14).

(4)  An insurer must file a proposed plan of operation with the agency in a format prescribed by the agency. The plan of operation must contain evidence that all covered services that are subject to exclusive provider provisions are available and accessible through exclusive providers, including a demonstration that:

(a)  Such services can be provided by exclusive providers with reasonable promptness with respect to geographic location, hours of operation, and after-hour care. The hours of operation and availability of after-hour care must reflect usual practice in the local area. Geographic availability must reflect the usual travel times within the community.

(b)  The number of exclusive providers in the service area is sufficient, with respect to current and expected policyholders, either:

1.  To deliver adequately all services that are subject to an exclusive provider provision; or

2.  To make appropriate referrals.

(c)  There are written agreements with exclusive providers describing specific responsibilities.

(d)  Emergency care is available 24 hours a day and 7 days a week.

(e)  In the case of covered services that are subject to an exclusive provider provision, there are written agreements with exclusive providers prohibiting such providers from billing or otherwise seeking reimbursement from or recourse against any policyholders. This paragraph does not apply to supplemental charges or coinsurance amounts stated in the policy or certificate.

(5)  The proposed plan of operation must include:

(a)  A statement or map providing a clear description of the service area.

(b)  A description of the grievance procedure to be used.

(c)  A description of the quality assurance program, including all of the following:

1.  The formal organizational structure.

2.  The written criteria for selection, retention, and removal of exclusive providers.

3.  The procedures for evaluating quality of care provided by exclusive providers, and the process to initiate corrective action when warranted.

(d)  A list and description, by specialty, of the exclusive providers.

(e)  The written information proposed to be used by the insurer to comply with subsection (10).

(f)  Any other information requested by the agency.

(6)  An insurer must file any proposed changes to the plan of operation, except for changes to the list of exclusive providers, with the agency prior to implementing the changes. The changes are considered approved by the agency after 30 days unless specifically disapproved.

(7)  An updated list of exclusive providers must be filed with the agency at least semiannually.

(8)  A health insurance policy or certificate may not restrict payment for covered services provided by nonexclusive providers if:

(a)  The services are for symptoms requiring emergency care or are immediately required for an unforeseen illness, injury, or condition; and

(b)  A network provider is not reasonably accessible.

(9)  If any service or treatment is not within the scope of services provided by the network or exclusive providers, but is within the scope of services or treatment covered by the policy, the service or treatment shall be reimbursed at a rate not less than 10 percentage points lower than the percentage rate paid to network providers. The reimbursement rate must be applied to the usual and customary charges in the area.

(10)  An insurer must make full and fair disclosure in writing of the provisions, restrictions, and limitations of the policy or certificate to each policyholder and certificateholder, including at least the following:

(a)  A description (including address and phone number) of the exclusive providers, including primary care physicians, specialty physicians, hospitals, and other providers.

(b)  A description of the exclusive provider provisions, including coinsurance and deductible levels if providers other than exclusive providers are used.

(c)  A description of coverage for emergency and urgently needed care and other out-of-service area coverage.

(d)  A description of limitations on referrals to restricted exclusive providers and to other providers.

(e)  A description of the insurer's quality assurance program and grievance procedure.

(11)  Prior to or at the time of the sale of a policy or certificate that is subject to an exclusive provider organization, the insurer must obtain from the policyholder or certificateholder a signed and dated form stating that the policyholder or certificateholder has received the information provided pursuant to subsection (10) and that the policyholder or certificateholder understands the restrictions of the policy or certificate.

(12)(a)  An insurer issuing policies or certificates that are subject to an exclusive provider organization must have and use procedures for hearing complaints and resolving written grievances from the policyholders. The procedures must be aimed at mutual agreement for settlement and may include arbitration procedures.

(b)  The grievance procedure must be described in the policy and certificates.

(c)  At the time the policy or certificate is issued, the insurer must provide detailed information to the policyholder describing how a grievance may be registered with the insurer.

(d)  Grievances must be considered in a timely manner and must be transmitted to appropriate decisionmakers who have the authority to fully investigate the issue and take corrective action.

(e)  If a grievance is found to be valid, corrective action must be taken promptly.

(f)  All concerned parties must be notified about the results of a grievance.

(g)  The insurer must report no later than each March 31 to the agency regarding its grievance procedure. The report must be in a format prescribed by the agency and must contain the number of grievances filed in the past year and a summary of the subject, nature, and resolution of such grievances.

(13)  At the time of initial purchase, an insurer issuing policies or certificates that are subject to an exclusive provider organization must offer to each policyholder the opportunity to purchase a policy otherwise offered by the insurer that is not subject to an exclusive provider network.

(14)(a)  There is imposed on every authorized insurer that offers exclusive provider policies under this section an annual assessment payable to the agency. The assessment must be determined and collected pursuant to the procedures specified in s. 641.58, and may not exceed 0.1 percent of the gross premium collected by the insurer in the prior year for exclusive provider policies issued in this state under this section. The assessment does not apply to policies issued pursuant to s. 627.6473.

(b)  The agency must deposit the assessments in the Health Care Trust Fund. Assessments deposited under this subsection must be used to defray the expenses of the agency connected with implementation of this section. Prior to collection of assessments under this subsection, the agency may use moneys in the Health Care Trust Fund, as appropriated by the Legislature, to defray the expenses of the agency connected with implementation of this section.

(c)  The failure of the insurer to pay the assessment within the time specified in s. 641.58 constitutes grounds for suspension or revocation of the insurer's certificate of authority by the office.

(15)  If psychotherapeutic services are covered by a policy issued by the insurer, the insurer shall provide eligibility criteria for all groups of health care providers licensed under chapter 458, chapter 459, chapter 490, or chapter 491, which include psychotherapy within the scope of their practice as provided by law, or for any person who is certified as an advanced registered nurse practitioner in psychiatric mental health under s. 464.012. When psychotherapeutic services are covered, eligibility criteria shall be established by the insurer to be included in the insurer's criteria for selection of network providers. The insurer may not discriminate against a health care provider by excluding such practitioner from its provider network solely on the basis of the practitioner's license.

(16)  Notwithstanding any provision of this section to the contrary, an exclusive provider organization which offers dermatological services shall provide direct patient access, for office visits and minor procedures and testing, to a dermatologist who is under contract with the exclusive provider organization. The term "direct patient access" means the ability of an insured to obtain such services without a referral or other authorization before receiving services. The exclusive provider organization shall, by July 1, 1997, develop criteria for compliance with the provisions of this subsection which do not impede or inhibit access to dermatological services for policyholders of the exclusive provider organization. The criteria may include a maximum of five office visits to a dermatologist without prior authorization for a dermatologic problem within a 12-month period.

(17)  An exclusive provider organization shall not discriminate with respect to participation as to any advanced registered nurse practitioner licensed and certified pursuant to s. 464.012, who is acting within the scope of such license and certification, solely on the basis of such license or certification. This subsection shall not be construed to prohibit a plan from including providers only to the extent necessary to meet the needs of the plan's enrollees or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the plan.

(18)  Each organization shall allow, without prior authorization, a female subscriber to visit a contracted obstetrician/gynecologist for one annual visit and medically necessary followup care detected at that visit. Nothing in this subsection shall prevent an organization from requiring that an obstetrician/gynecologist treating a covered patient coordinate the medical care through the patient's primary care physician, if applicable.

History.--s. 127, ch. 92-33; s. 111, ch. 92-318; s. 2, ch. 96-344; s. 25, ch. 96-418; s. 1, ch. 97-171; s. 1, ch. 98-285; s. 13, ch. 99-356; s. 1154, ch. 2003-261.

¹627.64725  Health maintenance organization or exclusive provider organization; disclosure of terms and conditions of plan.--Each health maintenance organization or exclusive provider organization shall provide prospective enrollees with written information about the terms and conditions of the plan in accordance with s. 641.31(4) so that the prospective enrollees can make informed decisions about accepting a managed-care system of health care delivery; however, information about where, in what manner, and from whom the comprehensive health care services or specific health care services can be obtained need be disclosed only upon request by the prospective enrollee. All marketing materials distributed by the health maintenance organization or exclusive provider organization must contain a notice in boldfaced type which states that the information required under this section is available to the prospective enrollee upon request.

History.--s. 8, ch. 96-223.

¹Note.--Also published at s. 641.31015.

627.6473  Combined preferred provider and exclusive provider policies.--An insurer may issue a policy that provides coverage for certain benefits through a preferred provider network and other benefits through an exclusive provider network. With regard to the coverage provided through a preferred provider network, the requirements of s. 627.6471 apply, and with regard to the coverage provided through an exclusive provider network, the requirements of s. 627.6472 apply.

History.--s. 128, ch. 92-33.

627.6474  Provider contracts.--A health insurer shall not require a contracted health care practitioner as defined in s. 456.001(4) to accept the terms of other health care practitioner contracts with the insurer or any other insurer, or health maintenance organization, under common management and control with the insurer, including Medicare and Medicaid practitioner contracts and those authorized by s. 627.6471, s. 627.6472, or s. 641.315, except for a practitioner in a group practice as defined in s. 456.053 who must accept the terms of a contract negotiated for the practitioner by the group, as a condition of continuation or renewal of the contract. Any contract provision that violates this section is void. A violation of this section is not subject to the criminal penalty specified in s. 624.15.

History.--s. 1, ch. 2001-107.

627.6475  Individual reinsurance pool.--

(1)  PURPOSE.--The purpose of this section is to provide for the establishment of a reinsurance program for coverage of individuals who are eligible for issuance of individual health insurance from a health insurance issuer pursuant to s. 627.6487.

(2)  DEFINITIONS.--As used in this section:

(a)  "Board," "carrier," and "health benefit plan" have the same meaning ascribed in s. 627.6699(3).

(b)  "Health insurance issuer," "issuer," and "individual health insurance" have the same meaning ascribed in s. 627.6487(2).

(c)  "Reinsuring carrier" means a health insurance issuer that elects to comply with the requirements set forth in subsection (7).

(d)  "Risk-assuming carrier" means a health insurance issuer that elects to comply with the requirements set forth in subsection (6).

(e)  "Eligible individual" has the same meaning ascribed in s. 627.6487(3).

(3)  APPLICABILITY AND SCOPE.--This section applies to individual health insurance offered by a health insurance issuer to an eligible individual.

(4)  MAINTENANCE OF RECORDS.--Each health insurance issuer that offers individual health insurance must maintain at its principal place of business a complete and detailed description of its rating practices and renewal practices, as required for small employer carriers pursuant to s. 627.6699(8).

(5)  ISSUER'S ELECTION TO BECOME A RISK-ASSUMING CARRIER.--

(a)  Each health insurance issuer that offers individual health insurance must elect to become a risk-assuming carrier or a reinsuring carrier for purposes of this section. Each such issuer must make an initial election, binding through December 31, 1999. The issuer's initial election must be made no later than October 31, 1997. By October 31, 1997, all issuers must file a final election, which is binding for 2 years, from January 1, 1998, through December 31, 1999, after which an election shall be binding for a period of 5 years. The office may permit an issuer to modify its election at any time for good cause shown, after a hearing.

(b)  The office shall establish an application process for issuers seeking to change their status under this subsection.

(c)  An election to become a risk-assuming carrier is subject to approval under this subsection.

(d)  An issuer that elects to cease participating as a reinsuring carrier and to become a risk-assuming carrier may not reinsure or continue to reinsure any individual health benefits plan under subsection (7) once the issuer becomes a risk-assuming carrier, and the issuer must pay a prorated assessment based upon business issued as a reinsuring carrier for any portion of the year that the business was reinsured. An issuer that elects to cease participating as a risk-assuming carrier and to become a reinsuring carrier may reinsure individual health insurance under the terms set forth in subsection (7) and must pay a prorated assessment based upon business issued as a reinsuring carrier for any portion of the year that the business was reinsured.

(6)  ELECTION PROCESS TO BECOME A RISK-ASSUMING CARRIER.--

(a)1.  A health insurance issuer that offers individual health insurance may become a risk-assuming carrier by filing with the office a designation of election under this subsection in a format and manner prescribed by the commission. The office shall approve the election of a health insurance issuer to become a risk-assuming carrier if the office finds that the issuer is capable of assuming that status pursuant to the criteria set forth in paragraph (b).

2.  The office must approve or disapprove any designation as a risk-assuming carrier within 60 days after a filing.

(b)  In determining whether to approve an application by an issuer to become a risk-assuming carrier, the office shall consider:

1.  The issuer's financial ability to support the assumption of the risk of individuals.

2.  The issuer's history of rating and underwriting individuals.

3.  The issuer's commitment to market fairly to all individuals in the state or its service area, as applicable.

4.  The issuer's ability to assume and manage the risk of enrolling individuals without the protection of the reinsurance program provided in subsection (7).

(c)  The office shall provide public notice of an issuer's designation of election under this subsection to become a risk-assuming carrier and shall provide at least a 21-day period for public comment prior to making a decision on the election. The office shall hold a hearing on the election at the request of the issuer.

(d)  The office may rescind the approval granted to a risk-assuming carrier under this subsection if the office finds that the carrier no longer meets the criteria of paragraph (b).

(7)  INDIVIDUAL HEALTH REINSURANCE PROGRAM.--

(a)  The individual health reinsurance program shall operate subject to the supervision and control of the board of the small employer health reinsurance program established pursuant to s. 627.6699(11). The board shall establish a separate, segregated account for eligible individuals reinsured pursuant to this section, which account may not be commingled with the small employer health reinsurance account.

(b)  A reinsuring carrier may reinsure with the program coverage of an eligible individual, subject to each of the following provisions:

1.  A reinsuring carrier may reinsure an eligible individual within 60 days after commencement of the coverage of the eligible individual.

2.  The program may not reimburse a participating carrier with respect to the claims of a reinsured eligible individual until the carrier has paid incurred claims of at least $5,000 in a calendar year for benefits covered by the program. In addition, the reinsuring carrier is responsible for 10 percent of the next $50,000 and 5 percent of the next $100,000 of incurred claims during a calendar year, and the program shall reinsure the remainder.

3.  The board shall annually adjust the initial level of claims and the maximum limit to be retained by the carrier to reflect increases in costs and utilization within the standard market for health benefit plans within the state. The adjustment may not be less than the annual change in the medical component of the "Commerce Price Index for All Urban Consumers" of the Bureau of Labor Statistics of the United States Department of Labor, unless the board proposes and the office approves a lower adjustment factor.

4.  A reinsuring carrier may terminate reinsurance for all reinsured eligible individuals on any plan anniversary.

5.  The premium rate charged for reinsurance by the program to a health maintenance organization that is approved by the Secretary of Health and Human Services as a federally qualified health maintenance organization pursuant to 42 U.S.C. s. 300e(c)(2)(A) and that, as such, is subject to requirements that limit the amount of risk that may be ceded to the program, which requirements are more restrictive than subparagraph 2., shall be reduced by an amount equal to that portion of the risk, if any, which exceeds the amount set forth in subparagraph 2., which may not be ceded to the program.

6.  The board may consider adjustments to the premium rates charged for reinsurance by the program or carriers that use effective cost-containment measures, including high-cost case management, as defined by the board.

7.  A reinsuring carrier shall apply its case-management and claims-handling techniques, including, but not limited to, utilization review, individual case management, preferred provider provisions, other managed-care provisions, or methods of operation consistently with both reinsured business and nonreinsured business.

(c)1.  The board, as part of the plan of operation, shall establish a methodology for determining premium rates to be charged by the program for reinsuring eligible individuals pursuant to this section. The methodology must include a system for classifying individuals which reflects the types of case characteristics commonly used by carriers in this state. The methodology must provide for the development of basic reinsurance premium rates, which shall be multiplied by the factors set for them in this paragraph to determine the premium rates for the program. The basic reinsurance premium rates shall be established by the board, subject to the approval of the office, and shall be set at levels that reasonably approximate gross premiums charged to eligible individuals for individual health insurance by health insurance issuers. The premium rates set by the board may vary by geographical area, as determined under this section, to reflect differences in cost. An eligible individual may be reinsured for a rate that is five times the rate established by the board.

2.  The board shall periodically review the methodology established, including the system of classification and any rating factors, to ensure that it reasonably reflects the claims experience of the program. The board may propose changes to the rates that are subject to the approval of the office.

(d)  If individual health insurance for an eligible individual is entirely or partially reinsured with the program pursuant to this section, the premium charged to the eligible individual for any rating period for the coverage issued must be the same premium that would have been charged to that individual if the health insurance issuer elected not to reinsure coverage for that individual.

(e)1.  Before March 1 of each calendar year, the board shall determine and report to the office the program net loss in the individual account for the previous year, including administrative expenses for that year and the incurred losses for that year, taking into account investment income and other appropriate gains and losses.

2.  Any net loss in the individual account for the year shall be recouped by assessing the carriers as follows:

a.  The operating losses of the program shall be assessed in the following order subject to the specified limitations. The first tier of assessments shall be made against reinsuring carriers in an amount that may not exceed 5 percent of each reinsuring carrier's premiums for individual health insurance. If such assessments have been collected and additional moneys are needed, the board shall make a second tier of assessments in an amount that may not exceed 0.5 percent of each carrier's health benefit plan premiums.

b.  Except as provided in paragraph (f), risk-assuming carriers are exempt from all assessments authorized pursuant to this section. The amount paid by a reinsuring carrier for the first tier of assessments shall be credited against any additional assessments made.

c.  The board shall equitably assess reinsuring carriers for operating losses of the individual account based on market share. The board shall annually assess each carrier a portion of the operating losses of the individual account. The first tier of assessments shall be determined by multiplying the operating losses by a fraction, the numerator of which equals the reinsuring carrier's earned premium pertaining to direct writings of individual health insurance in the state during the calendar year for which the assessment is levied, and the denominator of which equals the total of all such premiums earned by reinsuring carriers in the state during that calendar year. The second tier of assessments shall be based on the premiums that all carriers, except risk-assuming carriers, earned on all health benefit plans written in this state. The board may levy interim assessments against reinsuring carriers to ensure the financial ability of the plan to cover claims expenses and administrative expenses paid or estimated to be paid in the operation of the plan for the calendar year prior to the association's anticipated receipt of annual assessments for that calendar year. Any interim assessment is due and payable within 30 days after receipt by a carrier of the interim assessment notice. Interim assessment payments shall be credited against the carrier's annual assessment. Health benefit plan premiums and benefits paid by a carrier that are less than an amount determined by the board to justify the cost of collection may not be considered for purposes of determining assessments.

d.  Subject to the approval of the office, the board shall adjust the assessment formula for reinsuring carriers that are approved as federally qualified health maintenance organizations by the Secretary of Health and Human Services pursuant to 42 U.S.C. s. 300e(c)(2)(A) to the extent, if any, that restrictions are placed on them which are not imposed on other carriers.

3.  Before March 1 of each year, the board shall determine and file with the office an estimate of the assessments needed to fund the losses incurred by the program in the individual account for the previous calendar year.

4.  If the board determines that the assessments needed to fund the losses incurred by the program in the individual account for the previous calendar year will exceed the amount specified in subparagraph 2., the board shall evaluate the operation of the program and report its findings and recommendations to the office in the format established in s. 627.6699(11) for the comparable report for the small employer reinsurance program.

(f)  Notwithstanding paragraph (e), the administrative expenses of the program shall be recouped by assessing risk-assuming carriers and reinsuring carriers, and such amounts may not be considered part of the operating losses of the plan for the purposes of this paragraph. Each carrier's portion of such administrative expenses shall be determined by multiplying the total of such administrative expenses by a fraction, the numerator of which equals the carrier's earned premium pertaining to direct writing of individual health benefit plans in the state during the calendar year for which the assessment is levied, and the denominator of which equals the total of such premiums earned by all carriers in the state during such calendar year.

(g)  Except as otherwise provided in this section, the board and the office shall have all powers, duties, and responsibilities with respect to carriers that issue and reinsure individual health insurance, as specified for the board and the office in s. 627.6699(11) with respect to small employer carriers, including, but not limited to, the provisions of s. 627.6699(11) relating to:

1.  Use of assessments that exceed the amount of actual losses and expenses.

2.  The annual determination of each carrier's proportion of the assessment.

3.  Interest for late payment of assessments.

4.  Authority for the office to approve deferment of an assessment against a carrier.

5.  Limited immunity from legal actions or carriers.

6.  Development of standards for compensation to be paid to agents. Such standards shall be limited to those specifically enumerated in s. 627.6699(13)(d).

7.  Monitoring compliance by carriers with this section.

(8)  STANDARDS TO ASSURE FAIR MARKETING.--

(a)  Each health insurance issuer that offers individual health insurance shall actively market coverage to eligible individuals in the state. The provisions of s. 627.6699(13) that apply to small employer carriers that market policies to small employers shall also apply to health insurance issuers that offer individual health insurance with respect to marketing policies to individuals.

(b)  A violation of this section by a health insurance issuer or an agent is an unfair trade practice under s. 626.9541 or ss. 641.3903 and 641.3907.

(9)  RULEMAKING AUTHORITY.--The commission may adopt rules to administer this section, including rules governing compliance by carriers.

History.--s. 3, ch. 97-179; s. 1155, ch. 2003-261.

627.648  Florida Comprehensive Health Association Act.--Sections 627.648-627.6498 may be cited and known as the "Florida Comprehensive Health Association Act."

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 20, ch. 89-167; ss. 1, 13, 14, ch. 90-334; s. 4, ch. 91-429.

¹627.6482  Definitions.--As used in ss. 627.648-627.6498, the term:

(1)  "Agent" means a person who is licensed to sell health insurance in this state.

(2)  "Association" means the Florida Comprehensive Health Association created in s. 627.6488.

(3)  "Case management" means the specific supervision and management of the medical care provided or prescribed for a specific individual, which may include the use of health care providers designated by the plan case manager.

(4)  "Plan case manager" means the person or persons employed by the association to supervise and manage or coordinate with the administrator the supervision and management of the medical care provided or prescribed for a specific individual.

(5)  "Board" means the board of directors of the association.

(6)  "Health insurance" means any hospital and medical expense incurred policy, minimum premium plan, stop-loss coverage, health maintenance organization contract, prepaid health clinic contract, multiple-employer welfare arrangement contract, or fraternal benefit society health benefits contract, whether sold as an individual or group policy or contract. The term does not include any policy covering medical payment coverage or personal injury protection coverage in a motor vehicle policy, coverage issued as a supplement to liability insurance, or workers' compensation.

(7)  "Insurer" means any insurance company authorized to transact health insurance in this state, any insurance company authorized to transact health insurance or casualty insurance in this state that is offering a minimum premium plan or stop-loss coverage for any person or entity providing health care benefits, health maintenance organization authorized to transact business in this state pursuant to part I of chapter 641, prepaid health clinic authorized to transact business in this state pursuant to part II of chapter 641, multiple-employer welfare arrangement authorized to transact business in this state pursuant to ss. 624.436-624.45, or fraternal benefit society providing health benefits to its members as authorized pursuant to chapter 632.

(8)  "Medicare" means coverage under both parts A and B of Title XVIII of the Social Security Act, 42 U.S.C. ss. 1395 et seq., as amended.

(9)  "Minimum premium plan" means an arrangement whereby the expected amount of health care claims is self-funded, but the insurance company assumes the risk that claims will exceed that amount.

(10)  "Physician" means a physician licensed under chapter 458; an osteopathic physician licensed under chapter 459; a chiropractic physician licensed under chapter 460; a podiatric physician licensed under chapter 461; or, for purposes of oral surgery only, a dental surgeon licensed under chapter 466.

(11)  "Plan" means the comprehensive health insurance plan adopted by the association or by rule of the commission.

(12)  "Premium" means the entire cost of an insurance plan, including the administrative fee, the risk assumption charge, and, in the instance of a minimum premium plan or stop-loss coverage, the incurred claims whether or not such claims are paid directly by the insurer. "Premium" shall not include a health maintenance organization's annual earned premium revenue for Medicare and Medicaid contracts for any assessment due for calendar years 1990 and 1991. For assessments due for calendar year 1992 and subsequent years, a health maintenance organization's annual earned premium revenue for Medicare and Medicaid contracts is subject to assessments unless the office determines that the health maintenance organization has made a reasonable effort to amend its Medicare or Medicaid government contract for 1992 and subsequent years to provide reimbursement for any assessment on Medicare or Medicaid premiums paid by the health maintenance organization and the contract does not provide for such reimbursement.

(13)  "Resident" means a person who is legally domiciled in this state.

(14)  "Stop-loss coverage" means an arrangement whereby an insurer insures against the risk that any one claim will exceed a specific dollar amount or that an entire self-insurance plan's loss will exceed a specific amount.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 1, ch. 83-28; s. 103, ch. 83-216; s. 20, ch. 89-167; ss. 2, 13, 14, ch. 90-334; s. 1, ch. 91-304; s. 4, ch. 91-429; s. 24, ch. 95-211; s. 59, ch. 97-264; ss. 224, 292, ch. 98-166; s. 1156, ch. 2003-261.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 1, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

¹627.6484  Termination of enrollment; availability of other coverage.--

(1)  The association shall accept applications for insurance only until June 30, 1991, after which date no further applications may be accepted. Upon receipt of an application for insurance, the association shall issue coverage for an eligible applicant. When appropriate, the administrator shall forward a copy of the application to a market assistance plan created by the office, which shall conduct a diligent search of the private marketplace for a carrier willing to accept the application.

(2)  The office shall, after consultation with the health insurers licensed in this state, adopt a market assistance plan to assist in the placement of risks of Florida Comprehensive Health Association applicants. All health insurers and health maintenance organizations licensed in this state shall participate in the plan.

(3)  Guidelines for the use of such program shall be a part of the association's plan of operation. The guidelines shall describe which types of applications are to be exempt from submission to the market assistance plan. An exemption shall be based upon a determination that due to a specific health condition an applicant is ineligible for coverage in the standard market. The guidelines shall also describe how the market assistance plan is to be conducted, and how the periodic reviews to depopulate the association are to be conducted.

(4)  If a carrier is found through the market assistance plan, the individual shall apply to that company. If the individual's application is accepted, association coverage shall terminate upon the effective date of the coverage with the private carrier. For the purpose of applying a preexisting condition limitation or exclusion, any carrier accepting a risk pursuant to this section shall provide coverage as if it began on the date coverage was effectuated on behalf of the association, and shall be indemnified by the association for claims costs incurred as a result of utilizing such effective date.

(5)  The association shall establish a policyholder assistance program by July 1, 1991, to assist in placing eligible policyholders in other coverage programs, including Medicare and Medicaid.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 2, ch. 83-28; s. 20, ch. 89-167; ss. 3, 13, 14, ch. 90-334; s. 2, ch. 91-304; s. 4, ch. 91-429; s. 1157, ch. 2003-261.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 2, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

¹627.6486  Eligibility.--

(1)  Except as provided in subsection (2), any resident of this state shall be eligible for coverage under the plan, including:

(a)  The insured's spouse.

(b)  Any dependent unmarried child of the insured, from the moment of birth. Subject to the provisions of s. 627.6041, such coverage shall terminate at the end of the premium period in which the child marries, ceases to be a dependent of the insured, or attains the age of 19, whichever occurs first. However, if the child is a full-time student at an accredited institution of higher learning, the coverage may continue while the child remains unmarried and a full-time student, but not beyond the premium period in which the child reaches age 23.

(c)  The former spouse of the insured whose coverage would otherwise terminate because of annulment or dissolution of marriage, if the former spouse is dependent upon the insured for financial support. The former spouse shall have continued coverage and shall not be subject to waiting periods because of the change in policyholder status.

(2)(a)  The board or administrator shall require verification of residency and shall require any additional information or documentation, or statements under oath, when necessary to determine residency upon initial application and for the entire term of the policy.

(b)  No person who is currently eligible for health care benefits under Florida's Medicaid program is eligible for coverage under the plan unless:

1.  He or she has an illness or disease which requires supplies or medication which are covered by the association but are not included in the benefits provided under Florida's Medicaid program in any form or manner; and

2.  He or she is not receiving health care benefits or coverage under Florida's Medicaid program.

(c)  No person who is covered under the plan and terminates the coverage is again eligible for coverage.

(d)  No person on whose behalf the plan has paid out $500,000 in covered benefits is eligible for coverage under the plan.

(e)  The coverage of any person who ceases to meet the eligibility requirements of this section may be terminated immediately. If such person again becomes eligible for subsequent coverage under the plan, any previous claims payments shall be applied towards the $500,000 lifetime maximum benefit and any limitation relating to preexisting conditions in effect at the time such person again becomes eligible shall apply to such person. However, no such person may again become eligible for coverage after June 30, 1991.

(f)  No person is eligible for coverage under the plan unless such person has been rejected by two insurers for coverage substantially similar to the plan coverage and no insurer has been found through the market assistance plan pursuant to s. 627.6484 that is willing to accept the application. As used in this paragraph, "rejection" includes an offer of coverage with a material underwriting restriction or an offer of coverage at a rate greater than the association plan rate.

(g)  No person is eligible for coverage under the plan if such person has, on the date of issue of coverage under the plan, substantially similar coverage under another contract or policy, unless such coverage is provided pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985, Pub. L. No. 99-272, 100 Stat. 82 (1986) (COBRA), as amended, and scheduled to end at a time certain and the person meets all other requirements of eligibility. Coverage provided by the association shall be secondary to any coverage provided by an insurer pursuant to COBRA.

(h)  All eligible persons who are classified as high-risk individuals pursuant to s. 627.6498(4)(a)4. shall, upon application or renewal, agree to be placed in a case management system when it is determined by the board and the plan case manager that such system will be cost-effective and provide quality care to the individual.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 3, ch. 83-28; s. 104, ch. 83-216; s. 20, ch. 89-167; ss. 4, 13, 14, ch. 90-334; s. 3, ch. 91-304; s. 4, ch. 91-429; s. 25, ch. 95-211; s. 346, ch. 97-102.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 3, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

627.6487  Guaranteed availability of individual health insurance coverage to eligible individuals.--

(1)  Subject to the requirements of this section, each health insurance issuer that offers individual health insurance coverage in this state may not, with respect to an eligible individual who desires to enroll in individual health insurance coverage:

(a)  Decline to offer such coverage to, or deny enrollment of, such individual; or

(b)  Impose any preexisting condition exclusion with respect to such coverage. For purposes of this section, the term "preexisting condition" means, with respect to coverage, a limitation of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.

(2)  For the purposes of this section:

(a)  "Health insurance issuer" and "issuer" mean an authorized insurer or a health maintenance organization.

(b)  "Individual health insurance" means health insurance, as defined in s. 627.6561(5)(a)2., which is offered to an individual, including certificates of coverage offered to individuals in this state as part of a group policy issued to an association outside this state, but the term does not include short-term limited duration insurance or excepted benefits specified in s. 627.6561(5)(b) or, if the benefits are provided under a separate policy, certificate, or contract, the term does not include excepted benefits specified in s. 627.6561(5)(c), (d), or (e).

(3)  For the purposes of this section, the term "eligible individual" means an individual:

(a)1.  For whom, as of the date on which the individual seeks coverage under this section, the aggregate of the periods of creditable coverage, as defined in s. 627.6561(5) and (6), is 18 or more months; and

2.a.  Whose most recent prior creditable coverage was under a group health plan, governmental plan, or church plan, or health insurance coverage offered in connection with any such plan; or

b.  Whose most recent prior creditable coverage was under an individual plan issued in this state by a health insurer or health maintenance organization, which coverage is terminated due to the insurer or health maintenance organization becoming insolvent or discontinuing the offering of all individual coverage in the State of Florida, or due to the insured no longer living in the service area in the State of Florida of the insurer or health maintenance organization that provides coverage through a network plan in the State of Florida;

(b)  Who is not eligible for coverage under:

1.  A group health plan, as defined in s. 2791 of the Public Health Service Act;

2.  A conversion policy or contract issued by an authorized insurer or health maintenance organization under s. 627.6675 or s. 641.3921, respectively, offered to an individual who is no longer eligible for coverage under either an insured or self-insured employer plan;

3.  Part A or part B of Title XVIII of the Social Security Act; or

4.  A state plan under Title XIX of such act, or any successor program, and does not have other health insurance coverage;

(c)  With respect to whom the most recent coverage within the coverage period described in paragraph (a) was not terminated based on a factor described in s. 627.6571(2)(a) or (b), relating to nonpayment of premiums or fraud, unless such nonpayment of premiums or fraud was due to acts of an employer or person other than the individual;

(d)  Who, having been offered the option of continuation coverage under a COBRA continuation provision or under s. 627.6692, elected such coverage; and

(e)  Who, if the individual elected such continuation provision, has exhausted such continuation coverage under such provision or program.

(4)(a)  The health insurance issuer may elect to limit the coverage offered under subsection (1) if the issuer offers at least two different policy forms of health insurance coverage, both of which:

1.  Are designed for, made generally available to, actively marketed to, and enroll both eligible and other individuals by the issuer; and

2.  Meet the requirement of paragraph (b).

For purposes of this subsection, policy forms that have different cost-sharing arrangements or different riders are considered to be different policy forms.

(b)  The requirement of this subsection is met for health insurance coverage policy forms offered by an issuer in the individual market if the issuer offers the policy forms for individual health insurance coverage with the largest, and next to largest, premium volume of all such policy forms offered by the issuer in this state or applicable marketing or service area, as prescribed in rules adopted by the commission, in the individual market in the period involved. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.

(5)(a)  In the case of a health insurance issuer that offers individual health insurance coverage through a network plan, the issuer may:

1.  Limit the individuals who may be enrolled under such coverage to those who live, reside, or work within the service area for such network plan; and

2.  Within the service area of such plan, deny such coverage to such individuals if the issuer has demonstrated to the office that:

a.  It will not have the capacity to deliver services adequately to additional individual enrollees because of its obligations to existing group contract holders and enrollees and individual enrollees; and

b.  It is applying this paragraph uniformly to individuals without regard to any health-status-related factor of such individuals and without regard to whether the individuals are eligible individuals.

(b)  An issuer, upon denying individual health insurance coverage in any service area in accordance with subparagraph (a)2., may not offer coverage in the individual market within such service area for a period of 180 days after such coverage is denied.

(6)(a)  A health insurance issuer may deny individual health insurance coverage to an eligible individual if the issuer has demonstrated to the office that:

1.  It does not have the financial reserves necessary to underwrite additional coverage; and

2.  It is applying this paragraph uniformly to all individuals in the individual market in this state consistent with the laws of this state and without regard to any health-status-related factor of such individuals and without regard to whether the individuals are eligible individuals.

(b)  An issuer, upon denying individual health insurance coverage in any service area in accordance with paragraph (a), may not offer such coverage in the individual market within such service area for a period of 180 days after the date such coverage is denied or until the issuer has demonstrated to the office that the issuer has sufficient financial reserves to underwrite additional coverage, whichever occurs later.

(7)(a)  Subsection (1) does not require that a health insurance issuer that offers health insurance coverage only in connection with group health plans or through one or more bona fide associations, as defined in s. 627.6571(5), or both, offer such health insurance coverage in the individual market.

(b)  A health insurance issuer that offers health insurance coverage in connection with group health plans is not deemed to be a health insurance issuer offering individual health insurance coverage solely because such issuer offers a conversion policy.

(8)  This section does not:

(a)  Restrict the amount of the premium rates that an issuer may charge an individual for individual health insurance coverage; or

(b)  Prevent a health insurance issuer that offers individual health insurance coverage from establishing premium discounts or rebates or modifying otherwise applicable copayments or deductibles in return for adherence to programs of health promotion and disease prevention.

(9)  Each health insurance issuer that offers individual health insurance coverage to an eligible individual shall elect to become a risk-assuming carrier or a reinsuring carrier, as provided by s. 627.6475.

(10)  This section applies to individual health insurance coverage offered on or after January 1, 1998. An individual who would have been eligible for coverage on July 1, 1997, shall be eligible for coverage on January 1, 1998, and shall remain eligible for the same period of time after January 1, 1998, that the individual would have remained eligible for coverage after July 1, 1997.

History.--s. 4, ch. 97-179; s. 5, ch. 98-159; s. 4, ch. 2000-365; s. 59, ch. 2001-63; s. 1158, ch. 2003-261.

627.64871  Certification of coverage.--

(1)  Section 627.6561(8) applies to health insurance coverage offered by an insurer in the individual market in the same manner as it applies to health insurance coverage offered by an insurer in connection with a group health plan in the small-group market or large-group market.

(2)  This section does not apply to any health insurance coverage in relation to its provision of excepted benefits described in s. 627.6561(5)(b).

(3)  This section does not apply to any health insurance coverage in relation to its provision of excepted benefits described in s. 627.6561(5)(c), (d), or (e), if the benefits are provided under a separate policy, certificate, or contract of insurance.

(4)  This section applies to health insurance coverage offered, sold, issued, renewed, or in effect on or after July 1, 1997.

History.--s. 5, ch. 97-179.

627.64872  Florida Health Insurance Plan.--

(1)  LEGISLATIVE INTENT.--

(a)  The Legislature recognizes that to secure a more stable and orderly health insurance market, the establishment of a plan to assume risks deemed uninsurable by the private marketplace is required.

(b)  The Florida Health Insurance Plan is to make coverage available to individuals who have no other option for similar coverage, at a premium that is commensurate with the risk and benefits provided, and with benefit designs that are reasonable in relation to the general market. While plan operations may include supplementary funding, the plan shall fundamentally operate on sound actuarial principles, using basic insurance management techniques to ensure that the plan is run in an economical, cost-efficient, and sound manner, conserving plan resources to serve the maximum number of people possible in a sustainable fashion.

(2)  DEFINITIONS.--As used in this section:

(a)  "Board" means the board of directors of the plan.

(b)  "Dependent" means a resident spouse or resident unmarried child under the age of 19 years, a child who is a student under the age of 25 years and who is financially dependent upon the parent, or a child of any age who is disabled and dependent upon the parent.

(c)  "Director" means the Director of the Office of Insurance Regulation.

(d)  "Health insurance" means any hospital or medical expense incurred policy or health maintenance organization subscriber contract pursuant to chapter 641. The term does not include short-term, accident, dental-only, vision-only, fixed-indemnity, limited-benefit, or credit insurance; disability income insurance; coverage for onsite medical clinics; insurance coverage specified in federal regulations issued pursuant to Pub. L. No. 104-191, under which benefits for medical care are secondary or incidental to other insurance benefits; benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof, or other similar, limited benefits specified in federal regulations issued pursuant to Pub. L. No. 104-191; benefits provided under a separate policy, certificate, or contract of insurance, under which there is no coordination between the provision of the benefits and any exclusion of benefits under any group health plan maintained by the same plan sponsor and the benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health plan maintained by the same plan sponsor, such as for coverage only for a specified disease or illness; hospital indemnity or other fixed indemnity insurance; coverage offered as a separate policy, certificate, or contract of insurance, such as Medicare supplemental health insurance as defined under s. 1882(g)(1) of the Social Security Act; coverage supplemental to the coverage provided under chapter 55 of Title 10, U.S.C., the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS); similar supplemental coverage provided to coverage under a group health plan; coverage issued as a supplement to liability insurance; insurance arising out of a workers' compensation or similar law; automobile medical payment insurance; or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self-insurance.

(e)  "Implementation" means the effective date after the first meeting of the board when legal authority and administrative ability exists for the board to subsume the transfer of all statutory powers, duties, functions, assets, records, personnel, and property of the Florida Comprehensive Health Association as specified in s. 627.6488.

(f)  "Insurer" means any entity that provides health insurance in this state. For purposes of this section, insurer includes an insurance company with a valid certificate in accordance with chapter 624, a health maintenance organization with a valid certificate of authority in accordance with part I or part III of chapter 641, a prepaid health clinic authorized to transact business in this state pursuant to part II of chapter 641, multiple employer welfare arrangements authorized to transact business in this state pursuant to ss. 624.436-624.45, or a fraternal benefit society providing health benefits to its members as authorized pursuant to chapter 632.

(g)  "Medicare" means coverage under both Parts A and B of Title XVIII of the Social Security Act, 42 U.S.C. ss. 1395 et seq., as amended.

(h)  "Medicaid" means coverage under Title XIX of the Social Security Act.

(i)  "Office" means the Office of Insurance Regulation of the Financial Services Commission.

(j)  "Participating insurer" means any insurer providing health insurance to citizens of this state.

(k)  "Provider" means any physician, hospital, or other institution, organization, or person that furnishes health care services and is licensed or otherwise authorized to practice in the state.

(l)  "Plan" means the Florida Health Insurance Plan created in subsection (1).

(m)  "Plan of operation" means the articles, bylaws, and operating rules and procedures adopted by the board pursuant to this section.

(n)  "Resident" means an individual who has been legally domiciled in this state for a period of at least 6 months.

(3)  BOARD OF DIRECTORS.--

(a)  The plan shall operate subject to the supervision and control of the board. The board shall consist of the director or his or her designated representative, who shall serve as a member of the board and shall be its chair, and an additional eight members, five of whom shall be appointed by the Governor, at least two of whom shall be individuals not representative of insurers or health care providers, one of whom shall be appointed by the President of the Senate, one of whom shall be appointed by the Speaker of the House of Representatives, and one of whom shall be appointed by the Chief Financial Officer.

(b)  The term to be served on the board by the Director of the Office of Insurance Regulation shall be determined by continued employment in such position. The remaining initial board members shall serve for a period of time as follows: two members appointed by the Governor and the members appointed by the President of the Senate and the Speaker of the House of Representatives shall serve a term of 2 years; and three members appointed by the Governor and the Chief Financial Officer shall serve a term of 4 years. Subsequent board members shall serve for a term of 3 years. A board member's term shall continue until his or her successor is appointed.

(c)  Vacancies on the board shall be filled by the appointing authority, such authority being the Governor, the President of the Senate, the Speaker of the House of Representatives, or the Chief Financial Officer. The appointing authority may remove board members for cause.

(d)  The director, or his or her recognized representative, shall be responsible for any organizational requirements necessary for the initial meeting of the board which shall take place no later than September 1, 2004.

(e)  Members shall not be compensated in their capacity as board members but shall be reimbursed for reasonable expenses incurred in the necessary performance of their duties in accordance with s. 112.061.

(f)  The board shall submit to the Financial Services Commission a plan of operation for the plan and any amendments thereto necessary or suitable to ensure the fair, reasonable, and equitable administration of the plan. The plan of operation shall ensure that the plan qualifies to apply for any available funding from the Federal Government that adds to the financial viability of the plan. The plan of operation shall become effective upon approval in writing by the Financial Services Commission consistent with the date on which the coverage under this section must be made available. If the board fails to submit a suitable plan of operation within 1 year after the appointment of the board of directors, or at any time thereafter fails to submit suitable amendments to the plan of operation, the Financial Services Commission shall adopt such rules as are necessary or advisable to effectuate the provisions of this section. Such rules shall continue in force until modified by the office or superseded by a plan of operation submitted by the board and approved by the Financial Services Commission.

(4)  PLAN OF OPERATION.--The plan of operation shall:

(a)  Establish procedures for operation of the plan.

(b)  Establish procedures for selecting an administrator in accordance with subsection (11).

(c)  Establish procedures to create a fund, under management of the board, for administrative expenses.

(d)  Establish procedures for the handling, accounting, and auditing of assets, moneys, and claims of the plan and the plan administrator.

(e)  Develop and implement a program to publicize the existence of the plan, plan eligibility requirements, and procedures for enrollment and maintain public awareness of the plan.

(f)  Establish procedures under which applicants and participants may have grievances reviewed by a grievance committee appointed by the board. The grievances shall be reported to the board after completion of the review, with the committee's recommendation for grievance resolution. The board shall retain all written grievances regarding the plan for at least 3 years.

(g)  Provide for other matters as may be necessary and proper for the execution of the board's powers, duties, and obligations under this section.

(5)  POWERS OF THE PLAN.--The plan shall have the general powers and authority granted under the laws of this state to health insurers and, in addition thereto, the specific authority to:

(a)  Enter into such contracts as are necessary or proper to carry out the provisions and purposes of this section, including the authority, with the approval of the Chief Financial Officer, to enter into contracts with similar plans of other states for the joint performance of common administrative functions, or with persons or other organizations for the performance of administrative functions.

(b)  Take any legal actions necessary or proper to recover or collect assessments due the plan.

(c)  Take such legal action as is necessary to:

1.  Avoid payment of improper claims against the plan or the coverage provided by or through the plan;

2.  Recover any amounts erroneously or improperly paid by the plan;

3.  Recover any amounts paid by the plan as a result of mistake of fact or law; or

4.  Recover other amounts due the plan.

(d)  Establish, and modify as appropriate, rates, rate schedules, rate adjustments, expense allowances, agents' commissions, claims reserve formulas, and any other actuarial functions appropriate to the operation of the plan. Rates and rate schedules may be adjusted for appropriate factors such as age, sex, and geographic variation in claim cost and shall take into consideration appropriate factors in accordance with established actuarial and underwriting practices. For purposes of this paragraph, usual and customary agent's commissions shall be paid for the initial placement of coverage with the plan and for one renewal only.

(e)  Issue policies of insurance in accordance with the requirements of this section.

(f)  Appoint appropriate legal, actuarial, investment, and other committees as necessary to provide technical assistance in the operation of the plan and develop and educate its policyholders regarding health savings accounts, policy and contract design, and any other function within the authority of the plan.

(g)  Borrow money to effectuate the purposes of the plan. Any notes or other evidence of indebtedness of the plan not in default shall be legal investments for insurers and may be carried as admitted assets.

(h)  Employ and fix the compensation of employees.

(i)  Prepare and distribute certificate of eligibility forms and enrollment instruction forms to insurance producers and to the general public.

(j)  Provide for reinsurance of risks incurred by the plan.

(k)  Provide for and employ cost-containment measures and requirements, including, but not limited to, preadmission screening, second surgical opinion, concurrent utilization review, and individual case management for the purpose of making the plan more cost-effective.

(l)  Design, use, contract, or otherwise arrange for the delivery of cost-effective health care services, including, but not limited to, establishing or contracting with preferred provider organizations, health maintenance organizations, and other limited network provider arrangements.

(m)  Adopt such bylaws, policies, and procedures as may be necessary or convenient for the implementation of this section and the operation of the plan.

(n)  Subsume the transfer of statutory powers, duties, functions, assets, records, personnel, and property of the Florida Comprehensive Health Association as specified in ss. 627.6488, 627.6489, 627.649, 627.6492, 627.6496, 627.6498, and 627.6499, unless otherwise specified by law.

(6)  INTERIM REPORT; ANNUAL REPORT.--

(a)  By no later than December 1, 2004, the board shall report to the Governor, the President of the Senate, and the Speaker of the House of Representatives the results of an actuarial study conducted by the board to determine, including, but not limited to:

1.  The impact the creation of the plan will have on the small group insurance market and the individual market on premiums paid by insureds. This shall include an estimate of the total anticipated aggregate savings for all small employers in the state.

2.  The number of individuals the pool could reasonably cover at various funding levels, specifically, the number of people the pool may cover at each of those funding levels.

3.  A recommendation as to the best source of funding for the anticipated deficits of the pool.

4.  The effect on the individual and small group market by including in the Florida Health Insurance Plan persons eligible for coverage under s. 627.6487, as well as the cost of including these individuals.

The board shall take no action to implement the Florida Health Insurance Plan, other than the completion of the actuarial study authorized in this paragraph, until funds are appropriated for startup cost and any projected deficits.

(b)  No later than December 1, 2005, and annually thereafter, the board shall submit to the Governor, the President of the Senate, the Speaker of the House of Representatives, and the substantive legislative committees of the Legislature a report which includes an independent actuarial study to determine, including, but not be limited to:

1.  The impact the creation of the plan has on the small group and individual insurance market, specifically on the premiums paid by insureds. This shall include an estimate of the total anticipated aggregate savings for all small employers in the state.

2.  The actual number of individuals covered at the current funding and benefit level, the projected number of individuals that may seek coverage in the forthcoming fiscal year, and the projected funding needed to cover anticipated increase or decrease in plan participation.

3.  A recommendation as to the best source of funding for the anticipated deficits of the pool.

4.  A summarization of the activities of the plan in the preceding calendar year, including the net written and earned premiums, plan enrollment, the expense of administration, and the paid and incurred losses.

5.  A review of the operation of the plan as to whether the plan has met the intent of this section.

(7)  LIABILITY OF THE PLAN.--Neither the board nor its employees shall be liable for any obligations of the plan. No member or employee of the board shall be liable, and no cause of action of any nature may arise against a member or employee of the board, for any act or omission related to the performance of any powers and duties under this section, unless such act or omission constitutes willful or wanton misconduct. The board may provide in its bylaws or rules for indemnification of, and legal representation for, its members and employees.

(8)  AUDITED FINANCIAL STATEMENT.--No later than June 1 following the close of each calendar year, the plan shall submit to the Financial Services Commission an audited financial statement prepared in accordance with statutory accounting principles as adopted by the National Association of Insurance Commissioners.

(9)  ELIGIBILITY.--

(a)  Any individual person who is and continues to be a resident of this state shall be eligible for coverage under the plan if:

1.  Evidence is provided that the person received notices of rejection or refusal to issue substantially similar coverage for health reasons from at least two health insurers or health maintenance organizations. A rejection or refusal by an insurer offering only stop-loss, excess of loss, or reinsurance coverage with respect to the applicant shall not be sufficient evidence under this paragraph.

2.  The person is enrolled in the Florida Comprehensive Health Association as of the date the plan is implemented.

(b)  Each resident dependent of a person who is eligible for coverage under the plan shall also be eligible for such coverage.

(c)  A person shall not be eligible for coverage under the plan if:

1.  The person has or obtains health insurance coverage substantially similar to or more comprehensive than a plan policy, or would be eligible to obtain such coverage, unless a person may maintain other coverage for the period of time the person is satisfying any preexisting condition waiting period under a plan policy or may maintain plan coverage for the period of time the person is satisfying a preexisting condition waiting period under another health insurance policy intended to replace the plan policy.

2.  The person is determined to be eligible for health care benefits under Medicaid, Medicare, the state's children's health insurance program, or any other federal, state, or local government program that provides health benefits;

3.  The person voluntarily terminated plan coverage unless 12 months have elapsed since such termination;

4.  The person is an inmate or resident of a public institution; or

5.  The person's premiums are paid for or reimbursed under any government-sponsored program or by any government agency or health care provider.

(d)  Coverage shall cease:

1.  On the date a person is no longer a resident of this state;

2.  On the date a person requests coverage to end;

3.  Upon the death of the covered person;

4.  On the date state law requires cancellation or nonrenewal of the policy; or

5.  At the option of the plan, 30 days after the plan makes any inquiry concerning the person's eligibility or place of residence to which the person does not reply.

6.  Upon failure of the insured to pay for continued coverage.

(e)  Except under the circumstances described in this subsection, coverage of a person who ceases to meet the eligibility requirements of this subsection shall be terminated at the end of the policy period for which the necessary premiums have been paid.

(10)  UNFAIR REFERRAL TO PLAN.--It is an unfair trade practice for the purposes of part IX of chapter 626 or s. 641.3901 for an insurer, health maintenance organization insurance agent, insurance broker, or third-party administrator to refer an individual employee to the plan, or arrange for an individual employee to apply to the plan, for the purpose of separating that employee from group health insurance coverage provided in connection with the employee's employment.

(11)  PLAN ADMINISTRATOR.--The board shall select through a competitive bidding process a plan administrator to administer the plan. The board shall evaluate bids submitted based on criteria established by the board, which shall include:

(a)  The plan administrator's proven ability to handle health insurance coverage to individuals.

(b)  The efficiency and timeliness of the plan administrator's claim processing procedures.

(c)  An estimate of total charges for administering the plan.

(d)  The plan administrator's ability to apply effective cost-containment programs and procedures and to administer the plan in a cost-efficient manner.

(e)  The financial condition and stability of the plan administrator.

The administrator shall be an insurer, a health maintenance organization, or a third-party administrator, or another organization duly authorized to provide insurance pursuant to the Florida Insurance Code.

(12)  ADMINISTRATOR TERM LIMITS.--The plan administrator shall serve for a period specified in the contract between the plan and the plan administrator subject to removal for cause and subject to any terms, conditions, and limitations of the contract between the plan and the plan administrator. At least 1 year prior to the expiration of each period of service by a plan administrator, the board shall invite eligible entities, including the current plan administrator, to submit bids to serve as the plan administrator. Selection of the plan administrator for each succeeding period shall be made at least 6 months prior to the end of the current period.

(13)  DUTIES OF THE PLAN ADMINISTRATOR.--

(a)  The plan administrator shall perform such functions relating to the plan as may be assigned to it, including, but not limited to:

1.  Determination of eligibility.

2.  Payment of claims.

3.  Establishment of a premium billing procedure for collection of premiums from persons covered under the plan.

4.  Other necessary functions to ensure timely payment of benefits to covered persons under the plan.

(b)  The plan administrator shall submit regular reports to the board regarding the operation of the plan. The frequency, content, and form of the reports shall be specified in the contract between the board and the plan administrator.

(c)  On March 1 following the close of each calendar year, the plan administrator shall determine net written and earned premiums, the expense of administration, and the paid and incurred losses for the year and report this information to the board and the Governor on a form prescribed by the Governor.

(14)  PAYMENT OF THE PLAN ADMINISTRATOR.--The plan administrator shall be paid as provided in the contract between the plan and the plan administrator.

(15)  FUNDING OF THE PLAN.--

(a)  Premiums.--

1.  The plan shall establish premium rates for plan coverage as provided in this section. Separate schedules of premium rates based on age, sex, and geographical location may apply for individual risks. Premium rates and schedules shall be submitted to the office for approval prior to use.

2.  Initial rates for plan coverage shall be limited to no more than 300 percent of rates established for individual standard risks as specified in s. 627.6675(3)(c). Subject to the limits provided in this paragraph, subsequent rates shall be established to provide fully for the expected costs of claims, including recovery of prior losses, expenses of operation, investment income of claim reserves, and any other cost factors subject to the limitations described herein, but in no event shall premiums exceed the 300-percent rate limitation provided in this section. Notwithstanding the 300-percent rate limitation, sliding scale premium surcharges based upon the insured's income may apply to all enrollees.

(b)  Sources of additional revenue.--Any deficit incurred by the plan shall be primarily funded through amounts appropriated by the Legislature from general revenue sources, including, but not limited to, a portion of the annual growth in existing net insurance premium taxes. The board shall operate the plan in such a manner that the estimated cost of providing health insurance during any fiscal year will not exceed total income the plan expects to receive from policy premiums and funds appropriated by the Legislature, including any interest on investments. After determining the amount of funds appropriated to the board for a fiscal year, the board shall estimate the number of new policies it believes the plan has the financial capacity to insure during that year so that costs do not exceed income. The board shall take steps necessary to ensure that plan enrollment does not exceed the number of residents it has estimated it has the financial capacity to insure.

(16)  BENEFITS.--

(a)  The benefits provided shall be the same as the standard and basic plans for small employers as outlined in s. 627.6699. The board shall also establish an option of alternative coverage such as catastrophic coverage that includes a minimum level of primary care coverage and a high deductible plan that meets the federal requirements of a health savings account.

(b)  In establishing the plan coverage, the board shall take into consideration the levels of health insurance provided in the state and such medical economic factors as may be deemed appropriate and adopt benefit levels, deductibles, copayments, coinsurance factors, exclusions, and limitations determined to be generally reflective of and commensurate with health insurance provided through a representative number of large employers in the state.

(c)  The board may adjust any deductibles and coinsurance factors annually according to the medical component of the Consumer Price Index.

(d)1.  Plan coverage shall exclude charges or expenses incurred during the first 6 months following the effective date of coverage for any condition for which medical advice, care, or treatment was recommended or received for such condition during the 6-month period immediately preceding the effective date of coverage.

2.  Such preexisting condition exclusions shall be waived to the extent that similar exclusions, if any, have been satisfied under any prior health insurance coverage which was involuntarily terminated, provided application for pool coverage is made not later than 63 days following such involuntary termination. In such case, coverage under the plan shall be effective from the date on which such prior coverage was terminated and the applicant is not eligible for continuation or conversion rights that would provide coverage substantially similar to plan coverage.

(17)  NONDUPLICATION OF BENEFITS.--

(a)  The plan shall be payor of last resort of benefits whenever any other benefit or source of third-party payment is available. Benefits otherwise payable under plan coverage shall be reduced by all amounts paid or payable through any other health insurance, by all hospital and medical expense benefits paid or payable under any workers' compensation coverage, automobile medical payment, or liability insurance, whether provided on the basis of fault or nonfault, and by any hospital or medical benefits paid or payable under or provided pursuant to any state or federal law or program.

(b)  The plan shall have a cause of action against an eligible person for the recovery of the amount of benefits paid that are not for covered expenses. Benefits due from the plan may be reduced or refused as a setoff against any amount recoverable under this paragraph.

(18)  ANNUAL AND MAXIMUM BENEFITS.--Maximum benefits under the plan shall be determined by the board.

(19)  TAXATION.--The plan is exempt from any tax imposed by this state. The plan shall apply for federal tax exemption status.

(20)  COMBINING MEMBERSHIP OF THE FLORIDA COMPREHENSIVE HEALTH ASSOCIATION; ASSESSMENT.--

(a)1.  Upon implementation of the Florida Health Insurance Plan, the Florida Comprehensive Health Association, as specified in s. 627.6488, is abolished as a separate nonprofit entity and shall be subsumed under the board of directors of the Florida Health Insurance Plan. All individuals actively enrolled in the Florida Comprehensive Health Association shall be enrolled in the plan subject to its rules and requirements, except as otherwise specified in this section. Maximum lifetime benefits paid to an individual in the plan shall not exceed the amount established under subsection (16), and benefits previously paid for any individual by the Florida Comprehensive Health Association shall be used in the determination of total lifetime benefits paid under the plan.

2.  All persons enrolled in the Florida Comprehensive Health Association upon implementation of the Florida Health Insurance Plan are only eligible for the benefits authorized under subsection (16). Persons identified by this section shall convert to the benefits authorized under subsection (16) no later than January 1, 2005.

3.  Except as otherwise provided in this section, the administration of the coverage of persons actively enrolled in the Florida Comprehensive Health Association shall operate under the existing plan of operation without modification until the adoption of the new plan of operation for the Florida Health Insurance Plan.

(b)1.  As a condition of doing business in this state, an insurer shall pay an assessment to the board in the amount prescribed by this section. For operating losses incurred on or after July 1, 2004, by persons enrolled in the Florida Comprehensive Health Association, each insurer shall annually be assessed by the board in the following calendar year a portion of such incurred operating losses of the plan. Such portion shall be determined by multiplying such operating losses by a fraction, the numerator of which equals the insurer's earned premium pertaining to direct writings of health insurance in the state during the calendar year preceding that for which the assessment is levied, and the denominator of which equals the total of all such premiums earned by insurers in the state during such calendar year.

2.  The total of all assessments under this paragraph upon an insurer shall not exceed 1 percent of such insurer's health insurance premium earned in this state during the calendar year preceding the year for which the assessments were levied.

3.  All rights, title, and interest in the assessment funds collected under this paragraph shall vest in this state. However, all of such funds and interest earned shall be used by the plan to pay claims and administrative expenses.

(c)  If assessments and other receipts by the plan, board, or plan administrator exceed the actual losses and administrative expenses of the plan, the excess shall be held in interest and used by the board to offset future losses. As used in this subsection, the term "future losses" includes reserves for claims incurred but not reported.

(d)  Each insurer's assessment shall be determined annually by the board or plan administrator based on annual statements and other reports deemed necessary by the board or plan administrator and filed with the board or plan administrator by the insurer. Any deficit incurred under the plan by persons previously enrolled in the Florida Comprehensive Health Association shall be recouped by the assessments against insurers by the board or plan administrator in the manner provided in paragraph (b), and the insurers may recover the assessment in the normal course of their respective businesses without time limitation.

(e)  If a person actively enrolled in the Florida Comprehensive Health Association after implementation of the plan loses eligibility for participation in the Florida Comprehensive Health Association, such person shall not be included in the calculation of the assessment if the person later regains eligibility for participation in the plan.

(f)  When all persons actively enrolled in the Florida Comprehensive Health Association as of the date of implementation of the plan are no longer eligible for participation in the Florida Comprehensive Health Association, the board of directors and plan administrator shall no longer be allowed to assess insurers in this state for incurred losses in the Florida Comprehensive Health Association.

History.--s. 21, ch. 2004-297.

¹627.6488  Florida Comprehensive Health Association.--

(1)  There is created a nonprofit legal entity to be known as the "Florida Comprehensive Health Association." All insurers, as a condition of doing business, shall be members of the association.

(2)(a)  The association shall operate subject to the supervision and approval of a three-member board of directors. The board of directors shall be appointed by the Chief Financial Officer as follows:

1.  The chair of the board shall be the Chief Financial Officer or his or her designee.

2.  One representative of policyholders who is not associated with the medical profession, a hospital, or an insurer.

3.  One representative of insurers.

The administrator or his or her affiliate shall not be a member of the board. Any board member appointed by the Chief Financial Officer may be removed and replaced by him or her at any time without cause.

(b)  All board members, including the chair, shall be appointed to serve for staggered 3-year terms beginning on a date as established in the plan of operation.

(c)  The board of directors shall have the power to employ or retain such persons as are necessary to perform the administrative and financial transactions and responsibilities of the association and to perform other necessary and proper functions not prohibited by law.

(d)  Board members may be reimbursed from moneys of the association for actual and necessary expenses incurred by them as members, but may not otherwise be compensated for their services.

(e)  There shall be no liability on the part of, and no cause of action of any nature shall arise against, any member insurer, or its agents or employees, agents or employees of the association, members of the board of directors of the association, or the Chief Financial Officer's representatives for any act or omission taken by them in the performance of their powers and duties under this act, unless such act or omission by such person is in intentional disregard of the rights of the claimant.

(f)  Meetings of the board are subject to s. 286.011.

(3)  The association shall adopt a plan pursuant to this act and submit its articles, bylaws, and operating rules to the office for approval. If the association fails to adopt such plan and suitable articles, bylaws, and operating rules within 180 days after the appointment of the board, the commission shall adopt rules to effectuate the provisions of this act; and such rules shall remain in effect until superseded by a plan and articles, bylaws, and operating rules submitted by the association and approved by the office.

(4)  The association shall:

(a)  Establish administrative and accounting procedures for the operation of the association.

(b)  Establish procedures under which applicants and participants in the plan may have grievances reviewed by an impartial body and reported to the board.

(c)  Select an administrator in accordance with s. 627.649.

(d)  Collect assessments from all insurers to provide for operating losses incurred or estimated to be incurred during the period for which the assessment is made. The level of payments shall be established by the board, as formulated in s. 627.6492(1). Annual assessment of the insurers for each calendar year shall occur as soon thereafter as the operating results of the plan for the calendar year and the earned premiums of insurers being assessed for that year are known. Annual assessments are due and payable within 30 days of receipt of the assessment notice by the insurer.

(e)  Require that all policy forms issued by the association conform to standard forms developed by the association. The forms shall be approved by the office.

(f)  Develop and implement a program to publicize the existence of the plan, the eligibility requirements for the plan, and the procedures for enrollment in the plan and to maintain public awareness of the plan.

(g)  Design and employ cost containment measures and requirements which may include preadmission certification, home health care, hospice care, negotiated purchase of medical and pharmaceutical supplies, and individual case management.

(h)  Contract with preferred provider organizations and health maintenance organizations giving due consideration to the preferred provider organizations and health maintenance organizations which have contracted with the state group health insurance program pursuant to s. 110.123. If cost-effective and available in the county where the policyholder resides, the board, upon application or renewal of a policy, shall place a high-risk individual, as established under s. 627.6498(4)(a)4., with the plan case manager who shall determine the most cost-effective quality care system or health care provider and shall place the individual in such system or with such health care provider. If cost-effective and available in the county where the policyholder resides, the board, with the consent of the policyholder, may place a low-risk or medium-risk individual, as established under s. 627.6498(4)(a)4., with the plan case manager who may determine the most cost-effective quality care system or health care provider and shall place the individual in such system or with such health care provider. Prior to and during the implementation of case management, the plan case manager shall obtain input from the policyholder, parent, or guardian.

(i)  Make a report to the Governor, the President of the Senate, the Speaker of the House of Representatives, and the Minority Leaders of the Senate and the House of Representatives not later than October 1 of each year. The report shall summarize the activities of the plan for the 12-month period ending July 1 of that year, including then-current data and estimates as to net written and earned premiums, the expense of administration, and the paid and incurred losses for the year. The report shall also include analysis and recommendations for legislative changes regarding utilization review, quality assurance, an evaluation of the administrator of the plan, access to cost-effective health care, and cost containment/case management policy and recommendations concerning the opening of enrollment to new entrants as of July 1, 1992.

(j)  Make a report to the Governor, the office, the President of the Senate, the Speaker of the House of Representatives, and the Minority Leaders of the Senate and House of Representatives, not later than 45 days after the close of each calendar quarter, which includes, for the prior quarter, current data and estimates of net written and earned premiums, the expenses of administration, and the paid and incurred losses. The report shall identify any statutorily mandated program that has not been fully implemented by the board.

(k)  To facilitate preparation of assessments and for other purposes, the board shall direct preparation of annual audited financial statements for each calendar year as soon as feasible following the conclusion of that calendar year, and shall, within 30 days after rendition of such statements, file with the office the annual report containing such information as required by the office to be filed on March 1 of each year.

(l)  Employ a plan case manager or managers to supervise and manage the medical care or coordinate the supervision and management of the medical care, with the administrator, of specified individuals. The plan case manager, with the approval of the board, shall have final approval over the case management for any specific individual.

(5)  The association may:

(a)  Exercise powers granted to insurers under the laws of this state.

(b)  Sue or be sued.

(c)  In addition to imposing annual assessments under paragraph (4)(d), levy interim assessments against insurers to ensure the financial ability of the plan to cover claims expenses and administrative expenses paid or estimated to be paid in the operation of the plan for a calendar year prior to the association's anticipated receipt of annual assessments for that calendar year. Any interim assessment shall be due and payable within 30 days of receipt by an insurer of an interim assessment notice. Interim assessment payments shall be credited against the insurer's annual assessment.

(d)  Prepare or contract for a performance audit of the administrator of the association.

(6)  The office shall examine and investigate the association in the manner provided in part II of chapter 624.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 4, ch. 83-28; s. 105, ch. 83-216; s. 1, ch. 89-131; s. 20, ch. 89-167; ss. 5, 13, 14, ch. 90-334; s. 4, ch. 91-304; s. 4, ch. 91-429; s. 347, ch. 97-102; s. 1159, ch. 2003-261; s. 22, ch. 2004-297.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 4, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

C.  Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.6489  Disease Management Program.--

(1)  The association may contract with insurers to provide disease management services for insurers that elect to participate in the association disease management program.

(2)  An insurer that elects to contract for such services shall provide the association with all medical records and claims information necessary for the association to effectively manage the services.

(3)  Moneys collected by the association for providing disease management services shall be used by the association to pay administrative expenses associated with the disease management program and to reduce any deficits incurred by the association. No funds received at any time by the association as a result of assessments against insurers may be used in connection with the disease management program. No costs related to the disease management program provided to an insurer shall be assessed against any other insurer.

History.--s. 6, ch. 97-179; s. 22, ch. 2004-297.

¹Note.--Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.649  Administrator.--

(1)  The board shall select an administrator, through a competitive bidding process, to administer the plan. The board shall evaluate bids submitted under this subsection based on criteria established by the board, which criteria shall include:

(a)  The administrator's proven ability to handle large group accident and health insurance, and due consideration shall be given to any administrator who has acted as a third-party administrator for the state group health insurance program pursuant to s. 110.123.

(b)  The extent to which the administrator has developed a network of health care providers for providing managed health care on a statewide basis.

(c)  The efficiency of the administrator's claims-paying procedures.

(d)  An estimate of total charges for administering the plan.

(2)  The administrator shall serve for a period of 3 years. At least 1 year prior to the expiration of each 3-year period of service by an administrator, the board shall invite all insurers, including the current administering insurer, to submit bids to serve as the administrator for the succeeding 3-year period. The selection of the administrator for the succeeding period shall be made at least 6 months prior to the end of the current 3-year period.

(3)  The administrator shall:

(a)  Perform all eligibility and administrative claims-payment functions relating to the plan.

(b)  Pay an agent's referral fee as established by the board to each insurance agent who refers an applicant to the plan, if the applicant's application is accepted. The selling or marketing of plans shall not be limited to the administrator or its agents. The referral fees shall be paid by the administrator from moneys received as premiums for the plan.

(c)  Establish a premium-billing procedure for collection of premiums from insured persons. Billings shall be made periodically as determined by the board.

(d)  Perform all necessary functions to assure timely payment of benefits under the plan, including:

1.  Making available information relating to the proper manner of submitting a claim for benefits under the plan and distributing forms upon which submissions shall be made.

2.  Evaluating the eligibility of each claim for payment under the plan.

3.  Notifying each claimant within the time limits prescribed by law as to insurers after receiving a properly completed and executed proof of loss whether the claim is accepted, rejected, or compromised.

(e)  Submit regular reports to the board regarding the operation of the plan. The frequency, content, and form of the reports shall be as determined by the board.

(f)  Following the close of each calendar year, determine net premiums, reinsurance premiums less administrative expense allowance, the expense of administration pertaining to the reinsurance operations of the association, and the incurred losses of the year and report this information to the association and the office.

(g)  Pay claims expenses from the premium payments received from or on behalf of covered persons under the plan. If the payments by the administrator for claims expenses exceed the portion of premiums allocated by the board for payment of claims expenses, the board shall provide the administrator with additional funds for payment of claims expenses to the extent that such funds are available.

(4)(a)  The administrator shall be paid, as provided in the contract of the association, for its direct and indirect expenses incurred in the performance of its services.

(b)  As used in this subsection, the term "direct and indirect expenses" includes that portion of the audited administrative costs, printing expenses, claims administration expenses, management expenses, building overhead expenses, and other actual operating and administrative expenses of the administering insurer which are approved by the board as allocable to the administration of the plan and included in the bid specifications.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 5, ch. 83-28; s. 106, ch. 83-216; s. 20, ch. 89-167; ss. 6, 13, 14, ch. 90-334; s. 4, ch. 91-429; s. 1160, ch. 2003-261; s. 22, ch. 2004-297.

¹Note.--Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.6492  Participation of insurers.--

(1)(a)  As a condition of doing business in this state an insurer shall pay an assessment to the board, in the amount prescribed by this section. For operating losses incurred on July 1, 1991, and thereafter, each insurer shall annually be assessed by the board in the following calendar year a portion of such incurred operating losses of the plan; such portion shall be determined by multiplying such operating losses by a fraction, the numerator of which equals the insurer's earned premium pertaining to direct writings of health insurance in the state during the calendar year preceding that for which the assessment is levied, and the denominator of which equals the total of all such premiums earned by participating insurers in the state during such calendar year.

(b)  For operating losses incurred from July 1, 1991, through December 31, 1991, the total of all assessments upon a participating insurer shall not exceed .375 percent of such insurer's health insurance premiums earned in this state during 1990. For operating losses incurred in 1992 and thereafter, the total of all assessments upon a participating insurer shall not exceed 1 percent of such insurer's health insurance premium earned in this state during the calendar year preceding the year for which the assessments were levied.

(c)  For operating losses incurred from October 1, 1990, through June 30, 1991, the board shall assess each insurer in the amount and manner prescribed by chapter 90-334, Laws of Florida. The maximum assessment against an insurer, as provided in such act, shall apply separately to the claims incurred in 1990 (October 1 through December 31) and the claims incurred in 1991 (January 1 through June 30). For operating losses incurred on January 1, 1991, through June 30, 1991, the maximum assessment against an insurer shall be one-half of the amount of the maximum assessment specified for such insurer in former s. 627.6492(1)(b), 1990 Supplement, as amended by chapter 90-334, Laws of Florida.

(d)  All rights, title, and interest in the assessment funds collected shall vest in this state. However, all of such funds and interest earned shall be used by the association to pay claims and administrative expenses.

(2)  If assessments and other receipts by the association, board, or administrator exceed the actual losses and administrative expenses of the plan, the excess shall be held at interest and used by the board to offset future losses. As used in this subsection, the term "future losses" includes reserves for claims incurred but not reported.

(3)  Each insurer's assessment shall be determined annually by the association based on annual statements and other reports deemed necessary by the association and filed with it by the insurer. Any deficit incurred under the plan shall be recouped by assessments against participating insurers by the board in the manner provided in subsection (1); and the insurers may recover the assessment in the normal course of their respective businesses without time limitation.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 6, ch. 83-28; s. 107, ch. 83-216; s. 2, ch. 89-131; ss. 9, 20, ch. 89-167; ss. 7, 13, 14, ch. 90-334; s. 5, ch. 91-304; s. 4, ch. 91-429; s. 22, ch. 2004-297.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 5, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

C.  Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.6494  Assessments; deferment, limitation.--

(1)  Notwithstanding the provisions of s. 624.509, premiums for coverage issued or reinsured through the association shall, as to the association and participating insurers, be exempt from premium taxation.

(2)  The association, upon approval of the office, may abate or defer, in whole or in part, the assessment of a participating insurer if, in the opinion of the board, payment of the assessment would endanger the ability of the participating insurer to fulfill its contractual obligations. In the event that an assessment against a participating insurer is abated or deferred, in whole or in part, the amount by which such assessment is abated or deferred may be assessed against the other participating insurers in a manner consistent with the basis for assessments set forth in s. 627.6492; and the insurer receiving such abatement or deferment shall remain liable to the association for the deficiency for 4 years.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 20, ch. 89-167; ss. 8, 13, 14, ch. 90-334; s. 6, ch. 91-304; s. 4, ch. 91-429; s. 1161, ch. 2003-261; s. 22, ch. 2004-297.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 6, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

C.  Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.6496  Issuing of policies.--The coverage provided by this plan shall be directly insured by the association, and the policies shall be issued through the administrator pursuant to s. 627.6498(1)(a).

History.--ss. 496(2nd), 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 20, ch. 89-167; ss. 9, 13, 14, ch. 90-334; s. 7, ch. 91-304; s. 4, ch. 91-429; s. 22, ch. 2004-297.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 7, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

C.  Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.6498  Minimum benefits coverage; exclusions; premiums; deductibles.--

(1)  COVERAGE OFFERED.--

(a)  The plan shall offer in a semiannually renewable policy the coverage specified in this section for each eligible person. For applications accepted on or after June 7, 1991, but before July 1, 1991, coverage shall be effective on July 1, 1991, and shall be renewable on January 1, 1992, and every 6 months thereafter. Policies in existence on June 7, 1991, shall, upon renewal, be for a term of less than 6 months that terminates and becomes subject to subsequent renewal on the next succeeding January 1 or July 1, whichever is sooner.

(b)  If an eligible person is also eligible for Medicare coverage, the plan shall not pay or reimburse any person for expenses paid by Medicare.

(c)  Any person whose health insurance coverage is involuntarily terminated for any reason other than nonpayment of premium may apply for coverage under the plan. If such coverage is applied for within 60 days after the involuntary termination and if premiums are paid for the entire period of coverage, the effective date of the coverage shall be the date of termination of the previous coverage.

(d)  The plan shall provide that, upon the death or divorce of the individual in whose name the contract was issued, every other person then covered in the contract may elect within 60 days to continue under the same or a different contract.

(e)  No coverage provided to a person who is eligible for Medicare benefits shall be issued as a Medicare supplement policy as defined in s. 627.672.

(2)  BENEFITS.--

(a)  The plan shall offer major medical expense coverage similar to that provided by the state group health insurance program as defined in s. 110.123 except as specified in subsection (3) to every eligible person who is not eligible for Medicare. Major medical expense coverage offered under the plan shall pay an eligible person's covered expenses, subject to limits on the deductible and coinsurance payments authorized under subsection (4), up to a lifetime limit of $500,000 per covered individual. The maximum limit under this paragraph shall not be altered by the board, and no actuarially equivalent benefit may be substituted by the board.

(b)  The plan shall provide that any policy issued to a person eligible for Medicare shall be separately rated to reflect differences in experience reasonably expected to occur as a result of Medicare payments.

(3)  COVERED EXPENSES.--The coverage to be issued by the association shall be patterned after the state group health insurance program as defined in s. 110.123, including its benefits, exclusions, and other limitations, except as otherwise provided in this act. The plan may cover the cost of experimental drugs which have been approved for use by the Food and Drug Administration on an experimental basis if the cost is less than the usual and customary treatment. Such coverage shall only apply to those insureds who are in the case management system upon the approval of the insured, the case manager, and the board.

(4)  PREMIUMS, DEDUCTIBLES, AND COINSURANCE.--

(a)  The plan shall provide for annual deductibles for major medical expense coverage in the amount of $1,000 or any higher amounts proposed by the board and approved by the office, plus the benefits payable under any other type of insurance coverage or workers' compensation. The schedule of premiums and deductibles shall be established by the association. With regard to any preferred provider arrangement utilized by the association, the deductibles provided in this paragraph shall be the minimum deductibles applicable to the preferred providers and higher deductibles, as approved by the office, may be applied to providers who are not preferred providers.

1.  Separate schedules of premium rates based on age may apply for individual risks.

2.  Rates are subject to approval by the office.

3.  Standard risk rates for coverages issued by the association shall be established by the office, pursuant to s. 627.6675(3).

4.  The board shall establish separate premium schedules for low-risk individuals, medium-risk individuals, and high-risk individuals and shall revise premium schedules annually beginning January 1999. No rate shall exceed 200 percent of the standard risk rate for low-risk individuals, 225 percent of the standard risk rate for medium-risk individuals, or 250 percent of the standard risk rate for high-risk individuals. For the purpose of determining what constitutes a low-risk individual, medium-risk individual, or high-risk individual, the board shall consider the anticipated claims payment for individuals based upon an individual's health condition.

(b)  If the covered costs incurred by the eligible person exceed the deductible for major medical expense coverage selected by the person in a policy year, the plan shall pay in the following manner:

1.  For individuals placed under case management, the plan shall pay 90 percent of the additional covered costs incurred by the person during the policy year for the first $10,000, after which the plan shall pay 100 percent of the covered costs incurred by the person during the policy year.

2.  For individuals utilizing the preferred provider network, the plan shall pay 80 percent of the additional covered costs incurred by the person during the policy year for the first $10,000, after which the plan shall pay 90 percent of covered costs incurred by the person during the policy year.

3.  If the person does not utilize either the case management system or the preferred provider network, the plan shall pay 60 percent of the additional covered costs incurred by the person for the first $10,000, after which the plan shall pay 70 percent of the additional covered costs incurred by the person during the policy year.

(5)  PREEXISTING CONDITIONS.--An association policy may contain provisions under which coverage is excluded during a period of 12 months following the effective date of coverage with respect to a given covered individual for any preexisting condition, as long as:

(a)  The condition manifested itself within a period of 6 months before the effective date of coverage; or

(b)  Medical advice or treatment was recommended or received within a period of 6 months before the effective date of coverage.

(6)  OTHER SOURCES PRIMARY.--

(a)  No amounts paid or payable by Medicare or any other governmental program or any other insurance, or self-insurance maintained in lieu of otherwise statutorily required insurance, may be made or recognized as claims under such policy or be recognized as or towards satisfaction of applicable deductibles or out-of-pocket maximums or to reduce the limits of benefits available.

(b)  The association has a cause of action against a participant for any benefits paid to the participant which should not have been claimed or recognized as claims because of the provisions of this subsection or because otherwise not covered.

History.--ss. 496(2nd), 809(2nd), ch. 82-243; ss. 61, 79, ch. 82-386; s. 8, ch. 83-28; s. 109, ch. 83-216; s. 2, ch. 87-345; s. 20, ch. 89-167; ss. 10, 13, 14, ch. 90-334; s. 8, ch. 91-304; s. 4, ch. 91-429; s. 6, ch. 98-159; s. 1162, ch. 2003-261; s. 22, ch. 2004-297.

¹Note.--

A.  Section 12, ch. 90-334, provides that "[i]f an [assessment] against any insurer or insurers under the Florida Comprehensive Health Association Act is determined by a court of competent jurisdiction to be unlawful or prohibited, it is the intent of the Legislature that all provisions in ss. 627.648-627.6498 relating to assessments for funding the deficit of the association that were in effect on January 1, 1990 be reenacted and reinstated."

B.  As amended by s. 8, ch. 91-304. Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

C.  Section 22, ch. 2004-297, provides that "[u]pon implementation, as defined in s. 627.64872(2), Florida Statutes, and as provided in s. 627.64872(20), Florida Statutes, of the Florida Health Insurance Plan created under s. 627.64872, Florida Statutes, sections 627.6488, 627.6489, 627.649, 627.6492, 627.6494, 627.6496, and 627.6498, Florida Statutes, are repealed."

¹627.6499  Reporting by insurers and third-party administrators.--

(1)  The office may require any insurer, third-party administrator, or service company to report any information reasonably required to assist the board in assessing insurers as required by this act.

(2)  Each health insurance issuer shall make available on its Internet website a link to the performance outcome and financial data that is published by the Agency for Health Care Administration pursuant to s. 408.05(3)(l) and shall include in every policy delivered or issued for delivery to any person in the state or any materials provided as required by s. 627.64725 notice that such information is available electronically and the address of its Internet website.

History.--s. 9, ch. 91-304; s. 1163, ch. 2003-261; s. 40, ch. 2004-297.

¹Note.--Section 10(2) and (3), ch. 91-304, provides that:

"(2)  In the event that the application of the assessment to minimum premium plans, stop-loss plans or any other specific type of insurer or health insurance is determined by a court of competent jurisdiction to be unlawful, then the assessment method specified in this act shall continue to apply to all other insurers.

"(3)  The provisions of section 12 of chapter 90-335 [The reference is apparently in error. Section 12, ch. 90-335, concerns public printing; ch. 90-334 is relevant], Laws of Florida, shall continue in full force and effect, but the provisions of this section shall control to the extent of any conflict."

PART VII

GROUP, BLANKET, AND FRANCHISE
HEALTH INSURANCE POLICIES

627.651  Group contracts and plans of self-insurance must meet group requirements.

627.6512  Exemption of certain group health insurance policies.

627.6515  Out-of-state groups.

627.6516  Trustee groups.

627.652  Group health insurance; definitions.

627.653  Employee groups.

627.654  Labor union, association, and small employer health alliance groups.

627.655  Debtor groups.

627.6551  Teacher and student groups.

627.656  Additional groups.

627.6561  Preexisting conditions.

627.65615  Special enrollment periods.

627.6562  Dependent coverage.

627.65625  Prohibiting discrimination against individual participants and beneficiaries based on health status.

627.65626  Insurance rebates for healthy lifestyles.

627.6563  Full-time employment defined.

627.657  Provisions of group health insurance policies.

627.6571  Guaranteed renewability of coverage.

627.65735  Nondiscrimination of coverage for surgical procedures.

627.6574  Maternity care.

627.65745  Diabetes treatment services.

627.6575  Coverage for newborn children.

627.65755  Dental procedures; anesthesia and hospitalization coverage.

627.6577  Dental care.

627.6578  Coverage for natural-born, adopted, and foster children; children in insured's custodial care.

627.6579  Coverage for child health supervision services.

627.658  Use of dividends, refunds, rate reductions, commissions, service fees; premium rates.

627.659  Blanket health insurance; eligible groups.

627.660  Conditions and provisions of blanket health insurance policies.

627.661  School accident insurance claims; policy service.

627.6612  Coverage for surgical procedures and devices incident to mastectomy.

627.66121  Coverage for length of stay and outpatient postsurgical care.

627.66122  Requirements with respect to breast cancer and routine followup care.

627.6613  Coverage for mammograms.

627.6615  Handicapped children; continuation of coverage under group policy.

627.6616  Coverage for ambulatory surgical center service.

627.6617  Coverage for home health care services.

627.6618  Payment of acupuncture benefits to certified acupuncturists.

627.6619  Massage.

627.662  Other provisions applicable.

627.663  Franchise health insurance.

627.664  Assignment of incidents of ownership in group, blanket, or franchise health policies.

627.6645  Notification of cancellation, expiration, nonrenewal, or change in rates.

627.6646  Cancellation or nonrenewal prohibited.

627.6647  Release of claims experience.

627.6651  Replacement or termination of group, blanket, or franchise health policy or contract; liability of prior insurer.

627.666  Liability of succeeding insurer on replacement of group, blanket, or franchise health insurance policy.

627.667  Extension of benefits.

627.6675  Conversion on termination of eligibility.

627.668  Optional coverage for mental and nervous disorders required; exception.

627.6685  Mental health coverage.

627.669  Optional coverage required for substance abuse impaired persons; exception.

627.6691  Coverage for osteoporosis screening, diagnosis, treatment, and management.

627.66911  Required coverage for cleft lip and cleft palate.

627.6692  Florida Health Insurance Coverage Continuation Act.

627.6698  Attorney's fees.

627.6699  Employee Health Care Access Act.

627.651  Group contracts and plans of self-insurance must meet group requirements.--

(1)  Except as otherwise provided by law, a group health insurance policy or certificate insuring more than one individual delivered or issued for delivery in this state must be delivered or issued for delivery to one of the groups provided for in ss. 627.653-627.656. A plan of self-insurance providing health coverage benefits to residents of this state must comply with s. 627.419 and the applicable provisions of this part relating to the rights of individuals to specified benefits and coverages.

(2)  Subsection (1) does not apply to health insurance policies or plans of self-insurance:

(a)  Insuring or providing benefits only to individuals related by blood, marriage, or legal adoption.

(b)  Insuring or providing benefits only to individuals who have a common interest through ownership of a business enterprise, or a substantial legal interest or equity in the business enterprise, and who are actively engaged in the management of the business enterprise.

(c)  Insuring or providing benefits only to individuals otherwise having an insurable interest in each other's lives.

(d)  Issued as blanket insurance pursuant to s. 627.659.

(3)  A nongovernmental self-insurance plan for health benefits may not be contributory by participants.

(4)  This section does not apply to any plan which is established or maintained by an individual employer in accordance with the Employee Retirement Income Security Act of 1974, Pub. L. No. 93-406, or to a multiple-employer welfare arrangement as defined in s. 624.437(1), except that a multiple-employer welfare arrangement shall comply with ss. 627.419, 627.657, 627.6575, 627.6578, 627.6579, 627.6612, 627.66121, 627.66122, 627.6615, 627.6616, and 627.662(7). This subsection does not allow an authorized insurer to issue a group health insurance policy or certificate which does not comply with this part.

History.--s. 584, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 4, 10, ch. 80-341; ss. 2, 3, ch. 81-318; ss. 498, 500, 523, 809(2nd), ch. 82-243; ss. 62, 79, ch. 82-386; s. 6, ch. 83-203; s. 1, ch. 83-213; s. 17, ch. 83-288; s. 1, ch. 84-50; s. 4, ch. 86-122; s. 1, ch. 90-255; ss. 61, 114, ch. 92-318; s. 26, ch. 95-211; s. 5, ch. 97-48; s. 82, ch. 2000-154; s. 6, ch. 2002-389.

627.6512  Exemption of certain group health insurance policies.--Sections 627.6561, 627.65615, 627.65625, and 627.6571 do not apply to:

(1)  Any group insurance policy in relation to its provision of excepted benefits described in s. 627.6561(5)(b).

(2)  Any group health insurance policy in relation to its provision of excepted benefits described in s. 627.6561(5)(c), if the benefits:

(a)  Are provided under a separate policy, certificate, or contract of insurance; or

(b)  Are otherwise not an integral part of the policy.

(3)  Any group health insurance policy in relation to its provision of excepted benefits described in s. 627.6561(5)(d), if all of the following conditions are met:

(a)  The benefits are provided under a separate policy, certificate, or contract of insurance;

(b)  There is no coordination between the provision of such benefits and any exclusion of benefits under any group policy maintained by the same policyholder; and

(c)  Such benefits are paid with respect to an event without regard to whether benefits are provided with respect to such an event under any group health policy maintained by the same policyholder.

(4)  Any group health policy in relation to its provision of excepted benefits described in s. 627.6561(5)(e), if the benefits are provided under a separate policy, certificate, or contract of insurance.

History.--s. 7, ch. 97-179.

627.6515  Out-of-state groups.--

(1)  Any group health insurance policy issued or delivered outside this state under which a resident of this state is provided coverage shall comply with the provisions of this part in the same manner as group health policies issued in this state.

(2)  Except as otherwise provided in this part, this part does not apply to a group health insurance policy issued or delivered outside this state under which a resident of this state is provided coverage if:

(a)  The policy is issued to an employee group the composition of which is substantially as described in s. 627.653; a labor union group or association group the composition of which is substantially as described in s. 627.654; an additional group the composition of which is substantially as described in s. 627.656; a group insured under a blanket health policy when the composition of the group is substantially in compliance with s. 627.659; a group insured under a franchise health policy when the composition of the group is substantially in compliance with s. 627.663; an association group to cover persons associated in any other common group, which common group is formed primarily for purposes other than providing insurance; a group that is established primarily for the purpose of providing group insurance, provided the benefits are reasonable in relation to the premiums charged thereunder and the issuance of the group policy has resulted, or will result, in economies of administration; or a group of insurance agents of an insurer, which insurer is the policyholder;

(b)  Certificates evidencing coverage under the policy are issued to residents of this state and contain in contrasting color and not less than 10-point type the following statement: "The benefits of the policy providing your coverage are governed primarily by the law of a state other than Florida"; and

(c)  The policy provides the benefits specified in ss. 627.419, 627.6574, 627.6575, 627.6579, 627.6612, 627.66121, 627.66122, 627.6613, 627.667, 627.6675, 627.6691, and 627.66911.

(d)  Applications for certificates of coverage offered to residents of this state must contain, in contrasting color and not less than 12-point type, the following statement on the same page as the applicant's signature:

"This policy is primarily governed by the laws of  insert state where the master policy if filed . As a result, all of the rating laws applicable to policies filed in this state do not apply to this coverage, which may result in increases in your premium at renewal that would not be permissible under a Florida-approved policy. Any purchase of individual health insurance should be considered carefully, as future medical conditions may make it impossible to qualify for another individual health policy. For information concerning individual health coverage under a Florida-approved policy, consult your agent or the Florida Department of Financial Services."

This paragraph applies only to group certificates providing health insurance coverage which require individualized underwriting to determine coverage eligibility for an individual or premium rates to be charged to an individual except for the following:

1.  Policies issued to provide coverage to groups of persons all of whom are in the same or functionally related licensed professions, and providing coverage only to such licensed professionals, their employees, or their dependents;

2.  Policies providing coverage to small employers as defined by s. 627.6699. Such policies shall be subject to, and governed by, the provisions of s. 627.6699;

3.  Policies issued to a bona fide association, as defined by s. 627.6571(5), provided that there is a person or board acting as a fiduciary for the benefit of the members, and such association is not owned, controlled by, or otherwise associated with the insurance company; or

4.  Any accidental death, accidental death and dismemberment, accident-only, vision-only, dental-only, hospital indemnity-only, hospital accident-only, cancer, specified disease, Medicare supplement, products that supplement Medicare, long-term care, or disability income insurance, or similar supplemental plans provided under a separate policy, certificate, or contract of insurance, which cannot duplicate coverage under an underlying health plan, coinsurance, or deductibles or coverage issued as a supplement to workers' compensation or similar insurance, or automobile medical-payment insurance.

(3)  Section 624.428 is not applicable when residents of this state are enrolled for coverage under a policy or certificate issued in accordance with subsection (2).

(4)  Prior to solicitation in this state, a copy of the master policy and a copy of the form of the certificate evidencing coverage that will be issued to residents of this state shall be filed with the office for informational purposes.

(5)  Prior to solicitation in this state, an officer of the insurer shall truthfully certify to the office that the policy and certificates evidencing coverage have been reviewed and approved by the state in which the group policy is issued.

(6)  Any insurer who provides coverage under certificates of insurance issued to residents of this state shall designate one Florida-licensed resident agent as agent of record for the service of such certificates, unless the policy is issued to a group substantially as described in s. 627.653, s. 627.654, s. 627.656, s. 627.659, or s. 627.663.

(7)  No group, franchise, or blanket health insurance policy issued or delivered outside this state, under which policy a resident of this state is provided coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton, shall discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. This subsection shall not be construed to affect any other coverage under this part or to restrict the scope of coverage under any policy, plan, or contract. Nothing in this subsection shall be construed to discourage appropriate nonsurgical procedures or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the jaw and facial region. Furthermore, nothing in this subsection requires coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes.

(8)  For purposes of this subsection, dental treatment or surgery shall be considered necessary when the dental condition is likely to result in a medical condition if left untreated. Any group, franchise, or blanket health insurance policy issued or delivered outside this state, under which policy a resident of this state is provided coverage for general anesthesia and hospitalization services to a covered person, shall not preclude such coverage in assuring the safe delivery of necessary dental care provided to a covered person who:

(a)  Is under 8 years of age and is determined by a licensed dentist, and the child's physician licensed under chapter 458 or chapter 459, to require necessary dental treatment in a hospital or ambulatory surgical center due to a significantly complex dental condition or a developmental disability in which patient management in the dental office has proved to be ineffective; or

(b)  Has one or more medical conditions that would create significant or undue medical risk for the individual in the course of delivery of any necessary dental treatment or surgery if not rendered in a hospital or ambulatory surgical center.

As provided herein, all terms and conditions of the covered person's health insurance policy shall apply to such services, and this section does not require coverage for the diagnosis or treatment of dental disease. An insurer may require prior authorization for general anesthesia and hospital services required under this section in the same manner the insurer requires prior authorization for hospitalization for other covered services. This subsection shall not apply to Medicare supplement, long-term care, disability, limited benefit, accident only, or specified disease policies.

(9)  Any insured shall be able to terminate membership or affiliation with the group to whom the master policy is issued. An insured that elects to terminate his or her membership or affiliation with the group shall provide written notice to the insurer. Upon providing the written notice, the member shall be entitled to the rights and options provided by s. 627.6675.

(10)  Any pricing structure that results, or is reasonably expected to result, in rate escalations resulting in a death spiral, which is a rate escalation caused by segmenting healthy and unhealthy lives resulting in an ultimate pool of primarily less healthy insureds, is considered a predatory pricing structure and constitutes unfair discrimination as provided in s. 626.9541(1)(g). The Financial Services Commission may adopt rules to define other unfairly discriminatory or predatory health insurance rating practices.

History.--ss. 499, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 110, ch. 83-216; s. 3, ch. 84-202; s. 5, ch. 86-122; s. 2, ch. 89-190; s. 7, ch. 90-249; s. 2, ch. 90-255; ss. 129, 149, ch. 92-33; s. 114, ch. 92-318; s. 5, ch. 96-282; s. 3, ch. 96-361; s. 6, ch. 97-48; s. 2, ch. 98-66; s. 2, ch. 98-312; s. 3, ch. 2003-139; s. 1164, ch. 2003-261; s. 1, ch. 2004-7.

627.6516  Trustee groups.--A group of employees of employers or members of labor unions may be insured for the benefit of persons other than the employers or unions under a policy issued to the trustees of a fund established by two or more employers in the same industry or by two or more labor unions, or to the trustees of a fund established by one or more employers in the same industry and one or more labor unions or by one or more employers and one or more labor unions whose members are in the same or related occupations or trades, which trustees are deemed to be the policyholder, subject to the following requirements:

(1)  A policy may not be issued:

(a)  To insure employees of any employer whose eligibility to participate in the fund as an employer arises out of considerations directly related to the employer being a commercial correspondent or business client or patron of another employer, regardless of whether the other employer is or is not participating in the fund; or

(b)  To insure employees of any employer not located in this state, unless the majority of the employers whose employees are to be insured are located in this state, or unless the employer has assumed obligations through a collective bargaining agreement and is participating in the fund either pursuant to those obligations with regard to one or more classes of its employees that are encompassed in the collective bargaining agreement or as a method of providing insurance benefits for other classes of its employees, or unless the policy is issued to the trustees of a fund established by two or more labor unions.

(2)(a)  The persons eligible for insurance must be all of the employees of the employers or all of the members of the unions, or all of the members of any class or classes of employees or members determined by conditions pertaining to their employment or to membership in the unions, or both. The policy may provide that the term "employees" includes corporate directors, former employees, or retired employees and the individual proprietor or partners if an employer is an individual proprietor or a partnership.

(b)  Except as provided in paragraph (a) as to retired employees, an individual proprietor or partner is not eligible for insurance under the policy as an employee unless he or she is actively engaged in and devotes a substantial part of his or her time to the conduct of the business of the proprietor or partnership. The policy may provide that the term "employees" includes the trustees or their employees, or both, if their duties are principally connected with such trusteeship.

(c)  A policy may insure the spouse or dependent children with or without the employee of the employer or member of the union being insured.

(3)  The premium for the policy must be paid by the policyholder either wholly from the policyholder's funds or from funds contributed by the employer or employers of the insured persons or by the union or unions, or by both, or partly from such funds and partly from funds contributed by the insured persons.

(4)(a)  The policy must cover at date of issue not less than five persons, other than individual proprietors or partners, from each employer unit unless any of the following apply:

1.  The policy is issued to the trustees of a fund established by employers who have assumed obligations through a collective bargaining agreement and are participating in the fund either pursuant to those obligations with regard to one or more classes of their employees encompassed in the collective bargaining agreement or as a method of providing insurance benefits for other classes of their employees.

2.  The employer unit is a subsidiary corporation of an employer in the group or is an affiliated corporation, proprietorship, or partnership of an employer in the group whose business is under common control with the business of the employer.

3.  The policy is issued to the trustees of a fund established by two or more labor unions.

(b)  If the fund is established by the members of a group of employers:

1.  The policy may be issued only if the participating employers constitute at date of issue at least 60 percent of those employer members whose employees are not already covered for group health insurance or if the total number of persons covered at date of issue exceeds 600.

2.  The policy may not require that, if a participating employer discontinues membership in such group of employers, the insurance of its employees will cease solely by reason of such discontinuance.

(5)  The amounts of insurance under the policy must be based upon some plan precluding individual selection either by the insured persons or by the policyholder, employer, or unions.

History.--s. 62, ch. 92-318; s. 27, ch. 95-211; s. 348, ch. 97-102.

627.652  Group health insurance; definitions.--As used in this part:

(1)  Group health insurance is that form of health insurance covering groups of persons under a master group health insurance policy issued to any one of the groups listed in ss. 627.653-627.656.

(2)(a)  The terms "policy," "insurance policy," "health insurance policy," "group health policy," and "group health insurance policy" include plans of self-insurance providing health insurance benefits.

(b)  The terms "amount of insurance" and "insurance" include the benefits provided under a plan of self-insurance.

(c)  The term "insurer" includes any person or governmental unit providing a plan of self-insurance.

History.--s. 585, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 500, 523, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

627.653  Employee groups.--

(1)(a)  A group of individual employees of an employer, or employees and their dependents, may be insured, for the benefit of persons other than the employer, under a policy issued to the employer or to the trustees of a fund established by an employer, which employer or board of trustees is deemed to be the policyholder, insuring employees of the employer for the benefit of persons other than the employer.

(b)  Employees insured under a policy issued pursuant to this section may include any of the following:

1.  Directors of a corporate employer, former employees, or retired employees.

2.  The individual proprietor or partners if the employer is a proprietor or partnership.

3.  Elected or appointed officials if the policy is issued to insure employees of a public body.

(c)  A policy issued pursuant to this section may insure the employees of one or more subsidiary or affiliated corporations, proprietors, and partnerships if the business of the employer and the subsidiary or affiliated corporations, proprietors, or partnerships are under common control.

(2)  A policy may not be issued pursuant to this section unless all employees of the employer are declared eligible and acceptable to the insurer at the time of issuance of the policy, or unless all members of any class or classes of the employees, determined by conditions pertaining to their employment, but not determined so as to exclude those in the more hazardous employment solely because of their hazardous employment, are declared eligible and acceptable to the insurer at the time of issuance of the policy.

(3)  A policy issued pursuant to this section may insure the spouse or dependent children with or without the employee being insured.

(4)  This section does not affect the provisions of ss. 112.08-112.14.

History.--s. 586, ch. 59-205; s. 1, ch. 63-218; s. 1, ch. 72-17; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 501, 523, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 63, 114, ch. 92-318.

Note.--Former s. 627.0602.

627.654  Labor union, association, and small employer health alliance groups.--

(1)(a)  A group of individuals may be insured under a policy issued to an association, including a labor union, which association has a constitution and bylaws and not less than 25 individual members and which has been organized and has been maintained in good faith for a period of 1 year for purposes other than that of obtaining insurance, or to the trustees of a fund established by such an association, which association or trustees shall be deemed the policyholder, insuring at least 15 individual members of the association for the benefit of persons other than the officers of the association, the association, or trustees.

(b)  A small employer, as defined in s. 627.6699 and including the employer's eligible employees and the spouses and dependents of such employees, may be insured under a policy issued to a small employer health alliance by a carrier as defined in s. 627.6699. A small employer health alliance must be organized as a not-for-profit corporation under chapter 617. Notwithstanding any other law, if a small employer member of an alliance loses eligibility to purchase health care through the alliance solely because the business of the small employer member expands to more than 50 and fewer than 75 eligible employees, the small employer member may, at its next renewal date, purchase coverage through the alliance for not more than 1 additional year. A small employer health alliance shall establish conditions of participation in the alliance by a small employer, including, but not limited to:

1.  Assurance that the small employer is not formed for the purpose of securing health benefit coverage.

2.  Assurance that the employees of a small employer have not been added for the purpose of securing health benefit coverage.

(2)  No such policy of insurance as defined in subsection (1) may be issued to any such association or alliance, unless all individual members of such association, or all small employer members of an alliance, or all of any class or classes thereof, are declared eligible and acceptable to the insurer at the time of issuance of the policy.

(3)  Any such policy issued under paragraph (1)(a) may insure the spouse or dependent children with or without the member being insured.

(4)  A single master policy issued to an association, labor union, or small employer health alliance may include more than one health plan from the same insurer or affiliated insurer group as alternatives for an employer, employee, or member to select.

History.--s. 587, ch. 59-205; s. 1, ch. 61-368; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 502, 523, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318; s. 35, ch. 2000-256; s. 2, ch. 2000-296.

627.655  Debtor groups.--A group of individual debtors of a creditor may be insured under a policy issued to a creditor under which the debtors are indemnified in connection with a specific loan or credit transaction against loss of time resulting from bodily injury or sickness. The creditor is deemed the policyholder of a policy issued pursuant to this section. Two types of insurance may be used to insure against the occurrence of disability of the lives of a group of individual debtors pursuant to this section as follows:

(1)  Credit disability insurance as defined in s. 627.677. The debtors eligible for insurance under this section are all of the debtors of the creditor, or all members of any class or classes of debtors of the creditor, determined by conditions pertaining to the indebtedness or to the credit transaction giving rise to the indebtedness. A policy issued pursuant to this section may insure the debtors of one or more subsidiary or affiliated corporations, proprietors, or partnerships, if the business of the creditor and of such subsidiary or affiliated corporations, proprietors, or partnerships is under common control. A policy may be issued pursuant to this section only if the group of eligible debtors is then receiving new entrants at the rate of at least 100 persons yearly, or may reasonably be expected to receive at least 100 new entrants during the first policy year, and only if the policy reserves to the insurer the right to require evidence of individual insurability if less than 75 percent of the new entrants become insured.

(2)  Mortgage insurance as defined in s. 627.982. The debtors eligible for insurance under the policy are all of the debtors of the creditor, or all of any class or classes of debtors of the creditor. The term "debtors" includes borrowers of money in connection with an indebtedness of more than 10 years' duration, which indebtedness is secured by a first real estate mortgage and which indebtedness is not subject to part IX.

History.--s. 588, ch. 59-205; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 523, 809(2nd), ch. 82-243; s. 79, ch. 82-386; ss. 64, 114, ch. 92-318.

627.6551  Teacher and student groups.--A group of teachers or students of an institution of learning may be insured under a policy issued by an insurer authorized under chapter 624 or a health maintenance organization authorized under chapter 641 to a school, district school systems, college, university, or other institution of learning. Any policy or contract issued may insure the spouse, dependent children, parents, or siblings of the insured student or teacher.

History.--ss. 6, 7, ch. 89-190; s. 114, ch. 92-318.

627.656  Additional groups.--

(1)  A group of individuals, other than the groups defined in s. 627.556, may be insured under a policy issued to any person or organization to which a policy of group life insurance may be issued or delivered in this state to insure any class or classes of individuals for health insurance that could be insured under such group life policy. Any such policy may insure the spouse and dependent children with or without the employee being insured.

(2)  A credit union group, as defined in s. 627.556, may purchase health insurance for its members under a policy issued to the credit union. The benefits shall be limited to a maximum of $10,000.

History.--s. 1, ch. 61-377; s. 3, ch. 76-168; s. 1, ch. 77-457; ss. 2, 3, ch. 81-318; ss. 503, 523, 809(2nd), ch. 82-243; s. 79, ch. 82-386; s. 114, ch. 92-318.

¹627.6561  Preexisting conditions.--

(1)  As used in this section, the term:

(a)  "Enrollment date" means, with respect to an individual covered under a group health policy, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period of such enrollment.

(b)  "Late enrollee" means, with respect to coverage under a group health policy, a participant or beneficiary who enrolls under the policy other than during:

1.  The first period in which the individual is eligible to enroll under the policy.

2.  A special enrollment period, as provided under s. 627.65615.

(c)  "Waiting period" means, with respect to a group health policy and an individual who is a potential participant or beneficiary of the policy, the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the policy.

(2)  Subject to the exceptions specified in subsection (4), an insurer that offers group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if:

(a)  Such exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on the enrollment date;

(b)  Such exclusion extends for a period of not more than 12 months, or 18 months in the case of a late enrollee, after the enrollment date; and

(c)  The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage, as defined in subsection (5), applicable to the participant or beneficiary as of the enrollment date.

(3)  Genetic information may not be treated as a condition described in paragraph (2)(a) in the absence of a diagnosis of the condition related to such information.

(4)(a)  Subject to paragraph (b), an insurer that offers group health insurance coverage may not impose any preexisting condition exclusion in the case of:

1.  An individual who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage.

2.  A child who is adopted or placed for adoption before attaining 18 years of age and who, as of the last day of the 30-day period beginning on the date of the adoption or placement for adoption, is covered under creditable coverage. This provision does not apply to coverage before the date of such adoption or placement for adoption.

3.  Pregnancy.

(b)  ²Subparagraphs 1. and 2. do not apply to an individual after the end of the first 63-day period during all of which the individual was not covered under any creditable coverage.

(5)(a)  The term, "creditable coverage," means, with respect to an individual, coverage of the individual under any of the following:

1.  A group health plan, as defined in s. 2791 of the Public Health Service Act.

2.  Health insurance coverage consisting of medical care, provided directly, through insurance or reimbursement, or otherwise and including terms and services paid for as medical care, under any hospital or medical service policy or certificate, hospital or medical service plan contract, or health maintenance contract offered by a health insurance issuer.

3.  Part A or part B of Title XVIII of the Social Security Act.

4.  Title XIX of the Social Security Act, other than coverage consisting solely of benefits under s. 1928.

5.  Chapter 55 of Title 10, United States Code.

6.  A medical care program of the Indian Health Service or of a tribal organization.

7.  The Florida Comprehensive Health Association or another state health benefit risk pool.

8.  A health plan offered under chapter 89 of Title 5, United States Code.

9.  A public health plan as defined by rules adopted by the commission. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.

10.  A health benefit plan under s. 5(e) of the Peace Corps Act (22 U.S.C. s. 2504(e)).

(b)  Creditable coverage does not include coverage that consists solely of one or more or any combination thereof of the following excepted benefits:

1.  Coverage only for accident, or disability income insurance, or any combination thereof.

2.  Coverage issued as a supplement to liability insurance.

3.  Liability insurance, including general liability insurance and automobile liability insurance.

4.  Workers' compensation or similar insurance.

5.  Automobile medical payment insurance.

6.  Credit-only insurance.

7.  Coverage for on-site medical clinics, including prepaid health clinics under part II of chapter 641.

8.  Other similar insurance coverage, specified in rules adopted by the commission, under which benefits for medical care are secondary or incidental to other insurance benefits. To the extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.

(c)  The following benefits are not subject to the creditable coverage requirements, if offered separately:

1.  Limited scope dental or vision benefits.

2.  Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof.

3.  Such other similar, limited benefits as are specified in rules adopted by the commission.

(d)  The following benefits are not subject to creditable coverage requirements if offered as independent, noncoordinated benefits:

1.  Coverage only for a specified disease or illness.

2.  Hospital indemnity or other fixed indemnity insurance.

(e)  Benefits provided through a Medicare supplemental health insurance, as defined under s. 1882(g)(1) of the Social Security Act, coverage supplemental to the coverage provided under chapter 55 of Title 10, United States Code, and similar supplemental coverage provided to coverage under a group health plan are not considered creditable coverage if offered as a separate insurance policy.

(6)(a)  A period of creditable coverage may not be counted, with respect to enrollment of an individual under a group health plan, if, after such period and before the enrollment date, there was a 63-day period during all of which the individual was not covered under any creditable coverage.

(b)  Any period during which an individual is in a waiting period for any coverage under a group health plan or for group health insurance coverage may not be taken into account in determining the 63-day period under paragraph (a) or paragraph (4)(b).

(7)(a)  Except as otherwise provided under paragraph (b), an insurer shall count a period of creditable coverage without regard to the specific benefits covered under the period.

(b)  An insurer may elect to count, as creditable coverage, coverage of benefits within each of several classes or categories of benefits specified in rules adopted by the commission rather than as provided under paragraph (a). To the extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services. Such election shall be made on a uniform basis for all participants and beneficiaries. Under such election, an insurer shall count a period of creditable coverage with respect to any class or category of benefits if any level of benefits is covered within such class or category.

(c)  In the case of an election with respect to an insurer under paragraph (b), the insurer shall:

1.  Prominently state in 10-point type or larger in any disclosure statements concerning the policy, and state to each certificateholder at the time of enrollment under the policy, that the insurer has made such election; and

2.  Include in such statements a description of the effect of this election.

(8)(a)  Periods of creditable coverage with respect to an individual shall be established through presentation of certifications described in this subsection or in such other manner as is specified in rules adopted by the commission. To the extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.

(b)  An insurer that offers group health insurance coverage shall provide the certification described in paragraph (a):

1.  At the time an individual ceases to be covered under the plan or otherwise becomes covered under a COBRA continuation provision or continuation pursuant to s. 627.6692.

2.  In the case of an individual becoming covered under a COBRA continuation provision or pursuant to s. 627.6692, at the time the individual ceases to be covered under such a provision.

3.  Upon the request on behalf of an individual made not later than 24 months after the date of cessation of the coverage described in this paragraph.

The certification under subparagraph 1. may be provided, to the extent practicable, at a time consistent with notices required under any applicable COBRA continuation provision or continuation pursuant to s. 627.6692.

(c)  The certification described in this section is a written certification that must include:

1.  The period of creditable coverage of the individual under the policy and the coverage, if any, under such COBRA continuation provision or continuation pursuant to s. 627.6692; and

2.  The waiting period, if any, imposed with respect to the individual for any coverage under such policy.

(d)  In the case of an election described in subsection (7) by an insurer, if the insurer enrolls an individual for coverage under the plan and the individual provides a certification of coverage of the individual, as provided in this subsection:

1.  Upon request of such insurer, the insurer that issued the certification provided by the individual shall promptly disclose to such requesting plan or insurer information on coverage of classes and categories of health benefits available under such insurer's plan or coverage.

2.  Such insurer may charge the requesting insurer for the reasonable cost of disclosing such information.

(e)  The commission shall adopt rules to prevent an insurer's failure to provide information under this subsection with respect to previous coverage of an individual from adversely affecting any subsequent coverage of the individual under another group health plan or health insurance coverage. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.

(9)(a)  Except as provided in paragraph (b), no period before July 1, 1996, shall be taken into account in determining creditable coverage.

(b)  The commission shall adopt rules that provide a process whereby individuals who need to establish creditable coverage for periods before July 1, 1996, and who would have such coverage credited but for paragraph (a), may be given credit for creditable coverage for such periods through the presentation of documents or other means. To the greatest extent possible, such rules must be consistent with regulations adopted by the United States Department of Health and Human Services.

(10)  Except as otherwise provided in this subsection, paragraph (8)(b) applies to events that occur on or after July 1, 1996.

(a)  In no case is a certification required to be provided under paragraph (8)(b) prior to June 1, 1997.

(b)  In the case of an event that occurred on or after July 1, 1996, and before October 1, 1996, a certification is not required to be provided under paragraph (8)(b), unless an individual, with respect to whom the certification is required to be made, requests such certification in writing.

(11)  In the case of an individual who seeks to establish creditable coverage for any period for which certification is not required because it relates to an event that occurred before July 1, 1996:

(a)  The individual may present other creditable coverage in order to establish the period of creditable coverage.

(b)  An insurer is not subject to any penalty or enforcement action with respect to the insurer's crediting, or not crediting, such coverage if the insurer has sought to comply in good faith with applicable provisions of this section.

(12)  For purposes of subsection (9), any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement of this section may not be treated as a termination of such collective bargaining agreement.

(13)  This section does not apply to any health insurance coverage in relation to its provision of excepted benefits described in paragraph (5)(b).

(14)  This section does not apply to any health insurance coverage in relation to its provision of excepted benefits described in paragraphs (5)(c), (d), or (e), if the benefits are provided under a separate policy, certificate, or contract of insurance.

(15)  This section applies to health insurance coverage offered, sold, issued, renewed, or in effect on or after July 1, 1997.

History.--s. 130, ch. 92-33; s. 2, ch. 95-364; s. 8, ch. 97-179; s. 1165, ch. 2003-261.

¹Note.--Section 34(2), ch. 97-179, provides that:

"(2)  Except as provided in section 627.6561(9), (10), and (11), and section 641.31071(10), (11), and (12), Florida Statutes, in the case of a group health plan or group health insurance contract maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers which is ratified before this act becomes a law, sections 627.6561, 627.65615, 627.65625, 627.6571, 627.6699, 641.31071, 641.31072, 641.31073, and 641.31074, Florida Statutes, except for section 627.6561(8)(b), Florida Statutes, as amended or created by this act, apply to policies or contracts with plan years that begin on or after the later of:

"(a)  The date on which the last of any collective bargaining agreement that relates to the plan terminates, determined without regard to any extension thereof, which is agreed to after the date this act becomes a law; or

"(b)  July 1, 1997."

²Note.--Paragraph (b) is not divided into subparagraphs. The reference may be to subparagraphs (a)1. and (a)2.

¹627.65615  Special enrollment periods.--

(1)  An insurer that issues a group health insurance policy shall permit an employee who is eligible, but not enrolled, for coverage under the terms of the policy, or a dependent of such an employee if the dependent is eligible but not enrolled for coverage under such terms, to enroll for coverage under the terms of the policy if each of the following conditions is met:

(a)  The employee or dependent was covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent. For the purpose of this section, the terms "group health plan" and "health insurance coverage" have the same meaning ascribed in s. 2791 of the Public Health Service Act.

(b)  The employee stated in writing at such time that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the plan sponsor or insurer, if applicable, required such a statement at such time and provided the employee with notice of such requirement and the consequences of such requirement at such time.

(c)  The employee's or dependent's coverage described in paragraph (a):

1.  Was under a COBRA continuation provision or continuation pursuant to s. 627.6692, and the coverage under such provision was exhausted; or

2.  Was not under such a provision and the coverage was terminated as a result of loss of eligibility for the coverage, including legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment, or the coverage was terminated as a result of the termination of employer contributions toward such coverage.

(d)  Under the terms of the plan, the employee requests such enrollment not later than 30 days after the date of exhaustion of coverage described in subparagraph (c)1., or termination or employer contribution described in subparagraph (c)2.

(2)  For dependent beneficiaries, if:

(a)  A group health insurance policy makes coverage available with respect to a dependent of an individual;

(b)  The individual is a participant under the policy, or has met any waiting period applicable to becoming a participant under the policy, and is eligible to be enrolled under the policy but for a failure to enroll during a previous enrollment period; and

(c)  A person becomes such a dependent of the individual through marriage, birth, or adoption or placement for adoption,

the insurer shall provide for a dependent special enrollment period described in subsection (3) during which the person, or, if not otherwise enrolled, the individual, may be enrolled under the policy as a dependent of the individual, and in the case of the birth or adoption of a child, the spouse of the individual may be enrolled as a dependent of the individual if such spouse is otherwise eligible for coverage.

(3)  A dependent special enrollment period under subsection (2) shall be a period of not less than 30 days and shall begin on the later of:

(a)  The date that dependent coverage is made available; or

(b)  The date of the marriage, birth, or adoption or placement for adoption described in paragraph (2)(c).

(4)  If an individual seeks to enroll a dependent during the first 30 days of such a dependent special enrollment period, the coverage of the dependent shall become effective:

(a)  In the case of marriage, not later than the first day of the first month beginning after the date the completed request for enrollment is received.

(b)  In the case of a dependent's birth, as of the date of such birth.

(c)  In the case of dependent's adoption or placement for adoption, the date of such adoption or placement for adoption.

History.--s. 9, ch. 97-179.

¹Note.--Section 34(2), ch. 97-179, provides that:

"(2)  Except as provided in section 627.6561(9), (10), and (11), and section 641.31071(10), (11), and (12), Florida Statutes, in the case of a group health plan or group health insurance contract maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers which is ratified before this act becomes a law, sections 627.6561, 627.65615, 627.65625, 627.6571, 627.6699, 641.31071, 641.31072, 641.31073, and 641.31074, Florida Statutes, except for section 627.6561(8)(b), Florida Statutes, as amended or created by this act, apply to policies or contracts with plan years that begin on or after the later of:

"(a)  The date on which the last of any collective bargaining agreement that relates to the plan terminates, determined without regard to any extension thereof, which is agreed to after the date this act becomes a law; or

"(b)  July 1, 1997."

627.6562  Dependent coverage.--

(1)  If an insurer offers coverage that insures dependent children of the policyholder or certificateholder, the policy must insure a dependent child of the policyholder or certificateholder at least until the en