Florida Senate - 2025                                     SB 794
       
       
        
       By Senator Bradley
       
       
       
       
       
       6-01155-25                                             2025794__
    1                        A bill to be entitled                      
    2         An act relating to mandatory human reviews of
    3         insurance claim denials; creating s. 627.4263, F.S.;
    4         defining the term “qualified human professional”;
    5         requiring insurers’ decisions to deny claims to be
    6         reviewed, approved, and signed off on by qualified
    7         human professionals; prohibiting artificial
    8         intelligence, machine learning algorithms, and
    9         automated systems from serving as the basis for
   10         denying claims; requiring insurers to maintain certain
   11         records of the human review process for denied claims;
   12         requiring insurers to include certain information in
   13         denial communications to claimants; providing
   14         reporting requirements; authorizing the Office of
   15         Insurance Regulation to audit claim denials; providing
   16         an effective date.
   17          
   18  Be It Enacted by the Legislature of the State of Florida:
   19  
   20         Section 1. Section 627.4263, Florida Statutes, is created
   21  to read:
   22         627.4263 Mandatory human reviews of claim denials.—
   23         (1) As used in this section, the term “qualified human
   24  professional” includes, but is not limited to, a supervisor, a
   25  claims manager, or a licensed claims adjuster having authority
   26  over a claim.
   27         (2)(a) An insurer’s decision to deny a claim must be
   28  reviewed, approved, and signed off on by a qualified human
   29  professional.
   30         (b) Artificial intelligence, a machine learning algorithm,
   31  or an automated system may not serve as the basis for
   32  determining whether to deny a claim.
   33         (3) An insurer shall maintain detailed records of the human
   34  review process described in paragraph (2)(a) for all denied
   35  claims, including:
   36         (a) The name and title of the qualified human professional
   37  who reviewed the denial decision.
   38         (b) The date and time of the review by the qualified human
   39  professional.
   40         (c) Documentation of the basis for the denial, including
   41  any supplemental information provided by automated tools.
   42         (4) In all denial communications to a claimant, an insurer
   43  shall:
   44         (a) Clearly identify the qualified human professional who
   45  reviewed the denial decision.
   46         (b) Include a statement affirming that artificial
   47  intelligence, a machine learning algorithm, or an automated
   48  system did not serve as the basis for determining whether to
   49  deny the claim.
   50         (5) An insurer shall submit periodic compliance reports to
   51  the office detailing the steps taken to comply with this
   52  section.
   53         (6) The office may audit claim denials to verify compliance
   54  with this section.
   55         Section 2. This act shall take effect July 1, 2025.