SB45,1396,6 (c) Cancel coverage under the policy after a claim is submitted due to alleged misstatements on the policy application.

SB45,1396,8 (d) Deny a claim based on hidden or ambiguous exclusions in a disability insurance policy.

SB45,1396,9 (e) Stall review of a claim to avoid timely payment.

SB45,1396,11 (f) Reject a claim without reviewing all relevant medical records or consulting qualified experts.

SB45,1396,13 (g) Fail to properly review or respond to an insured’s appeal in a timely manner.

SB45,1396,15 (h) Allow non-physician personnel to determine whether care is medically necessary.

SB45,1396,17 (i) Apply different medical necessity criteria based on financial interests rather than patient needs.

SB45,1396,19 (j) Disregard a treating health care provider’s medical assessment without a valid clinical reason.

SB45,1396,21 (k) Mandate prior approval for routine or urgent procedures in a manner that causes harmful delays.

SB45,1396,24 (L) For a disability insurance policy that provides coverage of emergency medical services, refuse to cover emergency medical services provided by out-of- network providers.

SB45,1397,2 (m) List a health care provider as in-network on a provider directory and then deny a claim by stating the health care provider is out-of-network.

SB45,1397,4 (n) Deny coverage based on age, gender, disability, or a chronic condition rather than medical necessity.

SB45,1397,6 (o) Apply stricter standards in reviewing claims related to mental health conditions than claims related to physical health conditions.

SB45,1397,8 (p) Perform a blanket denial of claims for high-cost conditions without an individualized review of each claim.

SB45,1397,9 (r) Reclassify a claim to a lower-cost treatment to reduce insurer payout.

SB45,1397,11 (s) Require an insured to fail a cheaper treatment before approving coverage for necessary care.

SB45,1397,12 (t) Manipulate cost-sharing rules to shift higher costs to insureds.

SB45,1397,17 (5) Transparency and reporting. (a) Beginning on January 1, 2027, an insurer shall annually publish a report detailing the insurer’s claim denial rates, reasons for claim denials, and the outcome of any appeal of a claim denial for the previous year for all disability insurance policies under which the insurer provides coverage.

SB45,1397,19 (b) The commissioner shall maintain a public database of insurers’ claim denial rates and the outcomes of independent reviews under s. 632.835.

SB45,1397,23 (c) Beginning on January 1, 2027, an insurer that uses artificial intelligence or algorithmic decision-making in claims processing shall annually publish a report detailing all of the following for the previous year for all disability insurance policies under which the insurer provides coverage:

SB45,1398,2 1. The percentage of claims submitted to the insurer that were reviewed by artificial intelligence or algorithmic decision-making.

SB45,1398,5 2. The claim denial rate of claims reviewed by artificial intelligence or algorithmic decision-making compared to the claim denial rate of claims reviewed by humans.

SB45,1398,7 3. The steps the insurer takes to ensure fairness and accuracy in decisions made by artificial intelligence or algorithmic decision-making.

SB45,1398,11 (6) Claim denial rate audits. (a) The commissioner may conduct an audit of an insurer if the insurer’s claim denials are of such frequency as to indicate a general business practice. This paragraph is supplemental to and does not limit any other powers or duties of the commissioner.

SB45,1398,13 (b) The commissioner may collect any relevant information from an insurer that is necessary to conduct an audit under par. (a).

SB45,1398,15 (c) The commissioner may contract with a 3rd party to conduct an audit under par. (a).

SB45,1398,20 (d) The commissioner may, based on the findings of an audit under par. (a), order the insurer who is the subject of the audit to comply with a corrective action plan approved by the commissioner. The commissioner shall specify in any corrective action plan under this paragraph the deadline by which an insurer must be in compliance with the corrective action plan.

SB45,1398,22 (e) An insurer who is the subject of an audit under par. (a) shall provide a written response to any adverse findings of the audit.

SB45,1399,2 (f) If an insurer fails to comply with a corrective action plan under par. (d) by the deadline specified by the commissioner, the commissioner may order the insurer to pay a forfeiture pursuant to s. 601.64 (3).