Section 627.411, Florida Statutes 2003
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.