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