WHAT THIS BILL REGULATES · 2 REQUIREMENT TYPES
How Is This Bill Enforced
Verbatim statutory text on the left; plain-language analysis and a per-section checklist on the right. Numbered markers cross-link to the matching checklist row.
(1) As used in this section, the term: (a) "AlgorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a)" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results. (b) "Artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b)" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments. (c) "Machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. § 627.4263(1)(c)" means an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b) that has the ability to learn from provided data without being explicitly programmed. (d) "Qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d)" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.
(2)-(3) 1 An insurer's decision to deny a claim or any portion of a claim must be made by a qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d). (3) A qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d) shall, before determining whether to adjust or deny a claim or a portion of a claim, do all of the following: (a) Analyze the facts of the claim and the terms of the insurance policy independently of any artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b), machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. § 627.4263(1)(c), or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a). (b) Review the accuracy of any output generated by such a system or algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a). (c) Conduct any review of a claim adjustment or claim decision that was made by another qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d).
(4) 4 An insurer shall maintain detailed records of the actions of qualified human professionalsQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d) who are required to perform the actions under subsection (3), including: (a) The name and title of the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d) who made the decision to deny a claim or a portion of a claim and of any qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d) who reviewed a claim adjustment or claim decision. (b) The date and time of the claim decision and of any review of the claim adjustment. (c) Documentation of the basis for the denial of the claim or a portion of the claim, including any information provided by an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. § 627.4263(1)(c).
(5) 2 An algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. § 627.4263(1)(c) may not serve as the sole basis for determining whether to adjust or deny a claim.
(6) 3 In all denial communications to a claimant, an insurer shall: (a) Clearly identify the qualified human professionalQualified human professional"Qualified human professional" means an individual who, under the Florida Insurance Code, has the authority to adjust or deny a claim or a portion of a claim and may exercise such authority over a particular claim.Fla. Stat. § 627.4263(1)(d) who made the decision to deny the claim or a portion of the claim; and (b) Include a statement affirming that an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. § 627.4263(1)(c) did not serve as the sole basis for determining whether to deny the claim or a portion of the claim.
(7) 5 An insurer that uses an algorithmAlgorithm"Algorithm" means a clearly specified mathematical process for computation which uses rules designed to give prescribed results.Fla. Stat. § 627.4263(1)(a), an artificial intelligence systemArtificial intelligence system"Artificial intelligence system" means a machine-based system that may have varying levels of autonomy and that can, for a given set of objectives, generate outputs, such as predictions, recommendations, or content, influencing decisions made in real or virtual environments.Fla. Stat. § 627.4263(1)(b), or a machine learning systemMachine learning system"Machine learning system" means an artificial intelligence system that has the ability to learn from provided data without being explicitly programmed.Fla. Stat. § 627.4263(1)(c) as part of its claims-handling process shall detail in its claims-handling manual the manner in which such systems are to be used and the manner in which the insurer complies with this section.
(8)-(9) The office may conduct market conduct examinations and investigations or use any method it deems necessary to verify compliance with this section. (9) The commission may adopt rules to implement this section.
Section 627.4263 imposes a human-in-the-loop requirement on insurance claim adjudication in Florida. Every decision to deny a claim or any portion of a claim must be made by a qualified human professional — defined as an individual with statutory authority under the Florida Insurance Code to adjust or deny claims. The qualified human professional must independently analyze the claim facts and policy terms, review the accuracy of any AI/algorithmic outputs, and may also serve as the reviewer of another qualified human's prior decision.
The bill prohibits any algorithm, AI system, or machine learning system from serving as the sole basis for adjusting or denying a claim, and requires denial communications to (1) identify the responsible human professional and (2) affirm that AI was not the sole basis for the decision. Insurers must keep detailed records of the human reviewer's actions and, if AI is used in the claims-handling process, must document use and compliance in the claims-handling manual. Enforcement is via the Office of Insurance Regulation through market conduct examinations.