Florida Insurance Regulations

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Questions and Answers

The Office of Insurance Regulation (OIR) in Florida does NOT have primary responsibility for:

  • Determining premium rates for insurance policies (correct)
  • Enforcement of insurance statutes
  • Regulation of the business of insurance
  • Compliance with insurance statutes

In Florida, insurance commissioners are primarily elected, ensuring direct accountability to the public.

False (B)

What is the main function of the Bureau of Unclaimed Property overseen by the Chief Financial Officer?

holds unclaimed property accounts

The Financial Services Commission may hold ______ for any purpose within the scope of the insurance code deemed necessary.

<p>hearings</p>
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Which of the following is a requirement for an individual seeking to acquire an insurance license in Florida?

<p>Must be a Florida resident (D)</p>
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An insurance agent in Florida is required to complete 30 hours of continuing education every two years, regardless of how long they have been licensed.

<p>False (B)</p>
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Who has the power to suspend or revoke the license of an insurance agent who violates the Insurance Code in Florida?

<p>Chief Financial Officer</p>
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If an agent changes their residence address, The Department of Financial Services must be notified within ______ days.

<p>30</p>
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What is the term for the authority given to an agent to transact business on behalf of an insurer?

<p>Appointment (A)</p>
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In Florida, an insurance agency can only conduct insurance transactions if there is a licensed insurance agent physically present at the location.

<p>True (A)</p>
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What is the practice of inducing a policyholder to replace one policy with another from the same company for the sole purpose of generating more commission called?

<p>churning</p>
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[Blank] occurs when an agent convinces a policy holder to cancel their current policy so that they can purchase a new life insurance policy with another company.

<p>Twisting</p>
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Which of the following acts constitutes 'sliding' in the context of insurance sales?

<p>Requiring an applicant to purchase an additional product to get the desired product. (C)</p>
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Rebating is always illegal in Florida, regardless of circumstances.

<p>False (B)</p>
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What type of insurance company is owned and controlled by stockholders who share in the profits or losses?

<p>stock</p>
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An insurance company chartered and organized in a country other than the United States is known as a(n) ______ insurance company.

<p>alien</p>
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Which of the following is NOT considered an advertisement?

<p>Internal communication within an insurer's organization (C)</p>
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In Florida, an agent is permitted to give advertising gifts to a prospective customer, provided the gifts do not exceed $50 in value.

<p>False (B)</p>
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What is the name of the association that was established to provide funds to protect an insured in the event of an insurer's insolvency in Florida?

<p>Florida Life and Health Insurance Guaranty Association</p>
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An agent must handle funds of a client or insurance company honestly and fairly and NOT use them for the agent's own purposes due to their ______ responsibility.

<p>fiduciary</p>
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Match the terms with their definitions:

<p>Buyer's Guide = Provides basic information about an insurance policy. Free Look Provision = Allows an insured a period of 14 days to review the policy and return it for a full premium refund if dissatisfied. Grace Period = A period of 31 days after the due date for life insurance policies. Incontestable Clause = policy terms shall be incontestable after it has been in force for a period of 2 years from its date of issue.</p>
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In Florida, what is the maximum fixed policy loan interest rate that an insurer can charge?

<p>10% (D)</p>
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In Florida, if an insured commits suicide more than 2 years after a policy issue, the beneficiary will only receive a refund of premiums paid.

<p>False (B)</p>
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How many days does an insurance company have to reject an application for reinstatement before the policy is considered automatically reinstated?

<p>45</p>
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Under Florida law, '______ business' is permitted when an agent's own company is not able to write the amount of insurance requested by the applicant.

<p>excess</p>
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ERISA supersedes Florida state law relating to employee retirement plans, but the savings clause in ERISA protects state regulation in which of the following areas?

<p>Insurance (C)</p>
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Under the Replacement Rule in Florida, only the replacing insurance company is responsible for providing full disclosure to the purchaser.

<p>False (B)</p>
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What is the term for an agent's attempt to stop the replacement of an existing life insurance policy or annuity?

<p>conservation</p>
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In Florida, group life policies must contain a ______ privilege that allows for conversion to an individual policy for a specified period of time.

<p>conversion</p>
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What is the 'free-look' period required for health insurance policies in Florida?

<p>10 days (A)</p>
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Flashcards

Office of Insurance Regulation mission

Promotes public welfare by ensuring the solvency of insurance companies.

Chief Financial Officer (CFO) in Florida

Elected official who oversees the Bureau of Unclaimed Property, holding billions in unclaimed accounts.

Insurance License Eligibility

Must be at least 18, a U.S. citizen/legal alien, and a Florida resident.

CFO Disciplinary Power

The CFO can fine, suspend, or revoke an agent's license.

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Insurance Agent

An individual authorized by an insurer to represent them, solicit applications, and collect premiums.

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Agent Appointment

Authority given to an agent to transact business on behalf of an insurer.

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Agent Address Change

Agent must notify the Department of Financial Services within 30 days.

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Felony Reporting

Agent must notify the Department of Insurance within 30 days.

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Twisting

Convincing a policyholder to switch policies to their detriment.

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Churning

Replacing a policy for the sole purpose of generating commissions.

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Sliding

Agent falsely implies an extra product is required by law.

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Coercion

Using force to make someone buy insurance.

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Misrepresentation

Making false statements to influence the purchase of a policy.

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Defamation

Maliciously injuring someone's reputation in the insurance business.

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Fraud

Intentionally deceiving another to gain financially.

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Illegal Discrimination

Unfairly discriminate against a person on insurance-related matters.

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Controlled Business

Agent writes coverage on their own life, family, or business associates.

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Rebating

Agent shares commission to induce a purchase.

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Domestic Insurer

Company resides and is incorporated under the laws of their home state.

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Foreign Insurer

Company's home office is located in another state.

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Alien Insurer

Company chartered and organized in another country.

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Authorized Insurer

An insurer with a Certificate of Authority to sell insurance in a state.

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Unauthorized Insurer

An insurer without a Certificate of Authority

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Stock Insurance Company

Owned by stockholders who share in profits/losses.

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Mutual Insurance Company

Owned by its policyholders.

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Florida Life & Health Insurance Guaranty Association

Provide funds to protect insureds in the event of an insurer's insolvency.

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Fiduciary Responsibility

Handle funds honestly and fairly; do not use them for personal purposes.

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"Rules of Disclosure"

Disclosure of buyer's guide, policy summary, and free-look period.

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Incontestable Clause

Incontestable after 2 years, unless fraud.

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Free Look Provision

Insured can return policy within 14 days for full refund.

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Study Notes

Florida Insurance Laws, Rules, and Regulations

Office of Insurance Regulation

  • The mission is to promote public welfare by maintaining the solvency of insurance companies.
  • The office has primary responsibility for regulation, compliance, enforcement of statutes, and monitoring of industry markets.
  • Insurance policy forms used in Florida are approved by the Office of Insurance Regulation (OIR).
  • Insurance laws are administered by the Chief Financial Officer, the Financial Services Commission, and the Commissioner of the Office of Insurance Regulation in Florida.
  • The Chief Financial Officer (CFO) is independently elected and heads the Department of Financial Services.
  • Commissioners are mainly appointed by the governor, though some are elected.

Bureau of Unclaimed Property

  • The Chief Financial Officer oversees the Bureau of Unclaimed Property.
  • The Bureau holds unclaimed property accounts valued at over $1 Billion, mostly from dormant accounts in financial institutions, insurance, and utility companies, securities, and trust holdings.

Hearings

  • The Financial Services Commission may hold hearings for any purpose within the scope of the insurance code.
  • Hearings address persons engaging in unfair competition, unfair or deceptive acts or engaging in the business of insurance without a license.

Licensing

  • A licensee may not transact insurance business in Florida until appointed by an insurer.
  • Individuals seeking an insurance license must be at least 18 years old, a US citizen or legal alien, and a Florida resident, must complete a 40-hour pre-licensing education course, pass the state licensing examination and be trustworthy and competent.
  • A licensee must not be an employee of the United States Department of Veterans Affairs, a funeral director, or direct disposer.

Continuing Education

  • Agents must abide by guidelines every two years to maintain their license
  • Agents licensed less than 6 years are required to complete 24 hours of continuing education every two years.
  • Agents licensed more than 6 years are required to complete 20 hours of continuing education every two years.
  • Continuing education must include a minimum of 5 hours in ethics.
  • Licensees must pay license fees, appointment, and renewal fee, and continue to be appointed with an insurance company.

Suspension, Termination, Revoking a License

  • The Chief Financial Officer has the power to suspend or revoke the license of insurance agents who violate the Insurance Code.
  • The CFO can issue fines or order probation in lieu of suspension or revocation.

Agents

  • An agent is an individual authorized by an insurer to be its representative, allowed to solicit applications for insurance, collect premiums from policyowners, render services to prospects and clients, and field underwriting if necessary.
  • The authority given to an agent to transact business on behalf of the insurer is called an appointment.
  • If an agent changes their residence address, the Department of Financial Services must be notified within 30 days.
  • If an agent is found guilty of a felony, they must notify the Department of Insurance within 30 days.

Agencies

  • An insurance agency is any business location where insurance transactions occur, performed only by licensed insurance agents.
  • There must be an agent in charge at each licensed agency location where insurance transactions take place.
  • A licensed insurance agent may be the agent in charge of additional branch office locations of the agency as long as insurance activities do not occur at any location when the agent is not physically present.
  • The Department of Financial Services considers several factors when determining whether an agent's home is an insurance agency.
  • Listing the location address on business cards/marketing materials is a determining factor.
  • Having a sign on the house indicating an agent is there, meeting clients there, and conducting insurance transactions at the location are factors.
  • A Professional Employer Organization typically handles only administrative functions.
  • An insurance transaction includes solicitation or inducement to purchase insurance, negotiations toward the sale of insurance, executing a contract of insurance, issuing an insurance contract, and advising on coverages and claims.
  • A licensee may not transact insurance business in Florida until appointed by an insurer.
  • The agent's primary responsibility in the application process is to the insurer.

Twisting

  • Twisting happens when an insurance agent convinces a policyowner to cancel their current policy to purchase a new life insurance policy with another company.
  • This involves the agent using misrepresentations or incomplete comparisons of the advantages and disadvantages of the two policies.
  • Twisting is a form of misrepresentation and is illegal.

Churning

  • Churning occurs when an agent has a policyholder replace one policy for another with the same company to make more commission.
  • This can involve using the cash value and/or dividends of an existing policy to purchase another policy with the same insurer, typically done using misrepresentation or deception and not in the policyholder's best interest.

Sliding

  • Sliding happens when an agent tells an applicant that they are required by law to get an additional product.
  • Sliding can also mean falsely representing to an applicant that specific coverage is included in the policy applied for with no additional charge.

Coercion

  • Coercion is when an agent uses physical or mental force to convince an applicant to buy insurance.

Misrepresentation

  • Misrepresentation is when an agent uses publications, sales materials, or makes statements that are false, misleading, or deceptive to unfairly influence the purchase of a policy.

Defamation

  • Defamation occurs when an oral or written statement is maliciously made to injure a person in the insurance business or be critical and misleading about the financial condition of a person or company.

Fraud

  • Fraud occurs when someone intentionally deceives another with the intention to gain financially.

Discrimination

  • It is an illegal practice to unfairly discriminate against a person in any way on an insurance-related matter, e.g., providing insurance on different terms of coverage for different policyowners in the same risk classification.
  • Fair discrimination is necessary for the issuance of life insurance policies, which is based on mortality.

Controlled Business

  • Controlled business is coverage written by an agent on their own life, health, property, immediate family, or business associates.
  • Most states will not issue a license to a person if their primary purpose is to write controlled business.

Rebating

  • Rebating happens when an agent refunds part of their commission or exchanges anything of value to induce someone to purchase an insurance policy.
  • Rebating is allowed in Florida if the agent rebates insureds in the same actuarial class.
  • Falsely advertising insurance products or publishing misleading information about their insurance coverage is illegal.

Unfair or Deceptive Claim Settlement Practices

  • This includes making false statements about the financial condition, acts, omissions, or practices knowingly committed or performed to indicate a general business practice, and are prohibited:

  • Misrepresenting pertinent facts or policy provisions relating to coverage at issue or failing to acknowledge and act reasonably promptly upon communications related to an insurance claim.

  • Failing to adopt and implement reasonable standards for prompt investigation and processing of insured's claims.

  • Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements are completed and submitted by insured.

  • Not attempting in good faith to effect prompt, fair, and equitable settlements of claims on which liability has become reasonably clear.

  • Refusing or delaying a settlement solely because there is other insurance available to partially or entirely satisfy the claim loss

  • The claimant who can recover from more than one insurer has the right to choose the coverage from which to recover and the order in which payment is to be made.

  • Compelling insured to initiate suits to recover amounts due under an insurance policy by offering substantially less than the amount ultimately recovered in those suits.

Insurance Company Classifications

  • Insurance companies are classified according to the location of their corporation.
  • Regardless of where they are incorporated, they must get a Certificate of Authority before transacting insurance within a state.
  • A domestic insurance company resides and is incorporated under the laws of the state in which its home office is located.
  • A foreign insurance company has its home office in another state, considered a foreign company in all states except for its home state.
  • An alien insurance company is chartered and organized in any country other than the United States, considered an alien insurance company in all states.
  • An authorized insurer has qualified and received a Certificate of Authority from the Department of Insurance (or Department of Financial Services) to sell insurance in that state, also called an admitted insurance company.
  • An unauthorized insurer has been denied or not yet applied for a Certificate of Authority and cannot sell insurance in that state, also called a non-admitted insurance company.
  • Stock Insurance Companies are owned and controlled by stockholders (shareholders).
  • The stockholders provide the capital and share in profits or losses.
  • Mutual Life Insurance Companies are owned and controlled by its policyowners.
  • Policyholders elect a board of trustees or directors to manage the firm.
  • The profits of a mutual insurance company are returned to the policyowners in the form of dividends or retained as surplus to meet future obligations.
  • Advertisement may include any method of communication, such as in a newspaper, magazine, other publication or in the form of a notice, circular, pamphlet, letter, or poster.

Advertisements

  • Advertisements do not include material used solely for training and education of an insurer's employees, agents, or brokers, internal communication within an insurer's own organization or correspondence between a prospective group or blanket policyholder and an insurer during negotiations.
  • Testimonials and endorsements used in advertisements must be genuine and represent the current opinion of the author.
  • Advertisements must not directly or indirectly make unfair or incomplete comparisons of policies, contracts, or benefits.
  • The name of the actual insurer must be stated in all of the insurer's advertisements.
  • The form number or numbers of the policy advertised must in any invitation to contract, and may not use a trade name, the name of the parent company of the insurer, or any other device that would be misleading to the true identity of the actual insurer.
  • Advertisements mustn't contain statements that are untrue or misleading with respect to the assets, corporate structure, financial standing, age, or relative position of the insurer.
  • Each insurer must maintain a complete file of its advertising materials at its home office, available for inspection, for 4 years.
  • An agent can provide advertising gifts to a prospective customer, provided they do not exceed $25.
  • The Florida Life and Health Insurance Guaranty Association was established to provide funds to protect an insured if an insurer becomes insolvent.
  • The life insurance industry has been declared a public trust, so the service of all agents of all companies has a common obligation to work together in serving the best interest of the insuring public.
  • Agents have a fiduciary responsibility and must handle funds of a client or insurance company honestly and fairly, and not use them for their own purposes.

Licensed Agents

  • Agents may not submit applications to an insurer unless the insurer's name is legibly typed or printed on the first page of the application when coverage is bound or the premium quoted.
  • The application must disclose the name and license identification number of the agent shown on the agent's license, legible, typed, printed, stamped, or written, and a copy of the completed application must be provided to the prospective insured.
  • The National Association of Insurance and Financial Advisors, NAIFA, is a professional organization with a code of ethics incorporated into Florida law, responsible for establishing the activities of agents.

Florida Laws, Rules, and Regulations Pertinent to Life Insurance

  • The "rules of disclosure” review what needs to be provided to each prospective purchaser
  • This includes a buyer's guide, policy summary, and 14-day free-look period.
  • The minimum age at which an individual can sign a life insurance application is 15 years.
  • Policy terms are incontestable after the policy has been in force for two years from its date of issue, unless coverage was taken out for the purpose of fraud.

Free Look Provision

  • Free Look allows an insured 14 days from the delivery date of the policy to review and return for a full premium refund if dissatisfied.
  • The 14-day period begins when the applicant receives the policy in the mail or is delivered by an agent.
  • A Buyer's Guide provides basic information about an insurance policy and amount and type of insurance needed as well as comparison to save money.
  • Life insurance policies must provide a grace period of 31 days after the due date, and if the insured dies during the grace period, the insurance company may deduct any premium due from the death benefit.
  • The maximum fixed policy loan interest rate in Florida is 10%, and adjustable rates for policy loans are based on Moody's corporate bond index.
  • In Florida, if a policy is made payable to a named beneficiary, a creditor has no claim on the proceeds.
  • In Florida, anyone over 64 will receive an additional 21 days beyond the normal policy grace period.
  • In Florida, if an insured commits suicide within 2 years of policy issue, the beneficiary will only receive a refund of premiums paid; after two years, the face amount will be paid.
  • An insured with industrial life insurance policies with a single insurance company totaling $3,000 or more in face value can convert all policies into one ordinary life insurance policy at the standard premium without evidence of insurability.
  • Insurance companies that require an application for reinstatement have 45 days to reject the application before reinstatement is automatic; otherwise, the policy is considered reinstated automatically.
  • Under Florida law, "excess business" is permitted when an agent's own company cannot write the insurance amount requested by the applicant.
  • Excess business is the portion of risk above the agent's own insurer's limits, can place excess or rejected risks with any other authorized insurer without being required to secure an appointment as to such other insurer.
  • Excess charges occur when an agent knowingly collects money for a premium or an additional charge for insurance not provided for in the policy.
  • ERISA supersedes Florida state law relating to employee retirement plans.
  • The savings clause in ERISA protects Insurance and Banking areas of state regulation.
  • The Solicitation Law details information and procedures necessary from an agent when proposing life insurance.
  • The Replacement Rule sets forth the requirements and procedures for insurance companies and agents when a life insurance buyer is replacing contracts with proposed new insurance.
  • The code of ethics establishes a broad outline defining appropriate and inappropriate business behavior for life insurance agents.
  • Replacement is strictly regulated, requiring full disclosure by the agent and the replacing insurance company, and exists to assure purchasers receive specified information and reduce the opportunity for misrepresentation.

Duties of the Replacing Agent include

  • Presenting a Notice Regarding Replacement, signed by both the applicant and the agent, must be left with the applicant.
  • Obtain a list of all existing life insurance and/or annuity policies to be replaced, including policy numbers and the names of all companies being replaced.
  • Leave the applicant with the original or a copy of written or printed communications used for presentation to the applicant.
  • Submit a copy of the Replacement Notice with the application to the replacing insurance company.
  • Disclose the possible tax consequences of replacing or exchanging an existing annuity or life insurance policy.
  • The Replacing Insurance Company must require from the agent a list of the applicant's life insurance or annuity contracts to be replaced and a copy of the replacement notice provided to the applicant.
  • Each existing insurance company will be sent written communication about the proposed replacement within a specified period of time from the date the application is received in the replacing insurance company's home or regional office.
  • A policy summary or ledger statement containing policy data on the proposed life insurance or annuity must be included.
  • Replacing existing life insurance policies with new contracts requires a written Comparison and Summary Statement at the policyowner's request.
  • An agent's attempt to stop the replacement of an existing life insurance policy or annuity is known as conservation.
  • Certificates of insurance, not policies, are issued under group plans as evidence of coverage and each person insured under a Group Life insurance policy is a certificate holder.
  • In Florida, group life policies must contain a conversion privilege that allows for conversion to an individual policy for a specified period of time
  • Converted individual policies do not require evidence of insurability.
  • Participants are given an eligibility period to join the group plan, while other plans use an open enrollment period, so all new employees must wait until the next enrollment period.
  • There is no minimum number of insureds in Florida required for a group life insurance policy.
  • Employees eligible for group insurance must be all of the employees.
  • If terminated from a group life plan or the covered employee is terminated, coverage can convert to an individual policy within 31 days without proving insurability; if right is exercised, the employee is responsible for the payment of premium.
  • There are no restrictions regarding the assignment of coverage under a group life insurance policy.
  • An insurer must notify each certificate holder (employee) when the master policy has expired or is being cancelled
  • The insurer may take action through the policyholder (employer).
  • Fraternal life insurance organizations are nonprofit providers of life insurance covered by a special section of the Florida insurance code.
  • Personal producing general agencies, independent agency systems and career agency systems are authorized for selling life insurance in Florida.
  • In a noncontributory group, the policy must cover 100% of eligible persons.

Viatical Settlements

  • Viatical Settlements allow someone with a terminal illness to sell their existing life insurance policy to a third party for a percentage of the face value.
  • To receive a percentage of the policy face value, an owner of a life policy may sell the policy to a viatical settlement provider, who continues to make the premium payments and eventually collects the entire death benefit.
  • Viatical settlement brokers must be licensed before conducting any viatical transactions.
  • Proceeds of the viatical settlement contract may be subject to creditors' claims.
  • An agent wanting to sell Variable annuities must be licensed by the state and take examinations in Life and Variable contracts.
  • Regulations ensure proper information and recommendations for those looking to purchase, exchange, or replace an annuity and addresses insurance needs and financial objectives.

Florida Laws, Rules, Regulations Pertinent to Health Insurance

  • An entire contract provision requiring the policy, application, and all attachments constitute the entire contract between the parties.
  • A Time limit on certain defenses (Incontestable Period) requires a health or disability policy to be incontestable after it has been in force for 2 years
  • Only fraudulent misstatements in the application may be used to void the policy or deny any claim at this point.
  • Grace Period for health and accident insurance must be no less than 7 days for weekly premium policies, 10 days for monthly premium policies, 31 days for all other policies; if premium is paid within the grace period, coverage shall remain in effect.
  • If a health policy is reinstated after lapsing for nonpayment, there is a 10-day waiting period before sickness claims will be covered; injuries from an accident will be covered immediately.
  • If the insurer takes no action within 45 days after receiving the reinstatement application, the policy is automatically reinstated.
  • Written notice of claim must be given within 20 days after a covered loss starts or as soon as reasonably possible.
  • An insurance company will send claim forms within 15 days of receiving notice of a claim.
  • Written proof of loss must be provided to the insurance company within 90 days.
  • The time payment of claims provision allows insurers 45 days after receiving notice and proof of loss to pay or deny the claim
  • Claims MUST be paid monthly under an Individual Disability policy.
  • Health insurance policies must provide a 10-day minimum free-look period, allowing the policyowner to decide whether or not to keep it.
  • A full refund will be given if the policyowner rejects the policy within 10 days.
  • No legal action can be initiated within 60 days after proof of loss or after 5 years from the time written proof of loss was provided.
  • All advertisements for health insurance must clearly identify the insurer.
  • Insurance companies are responsible for the accuracy of testimonials.

The insurer

  • The insurer has the right to examine the insured during the claim process and where death is involved, order an autopsy unless illegal to do so.

  • The insurer is not liable for any loss to which a contributing cause was the insured being engaged in a felony or illegal occupation.

  • The change of beneficiary provision grants the policyowner to change the policy beneficiary or surrender/assign the policy without obtaining the beneficiary's permission, so long as the beneficiary designation is revocable.

  • Florida prohibits individual health insurance policies (other than disability income insurance) from excluding coverage for preexisting conditions for longer than 24 months after the effective date of coverage if it manifested during the previous 24-month period.

  • Pre-existing conditions are conditions for which medical advice, diagnosis, care, or treatment was recommended or received in the 6 months before the effective date of enrollment, which may be excluded for up to 12 months from enrollment (18 months for late enrollees) in group health insurance. Coverage is creditable unless individual has a 63-day coverage gap.

  • All employees or members must be eligible to participate in a master group health policy in Florida, regardless of health history.

  • When a person transfers their health insurance plan, any credit toward fulfilling a preexisting-condition requirement on the prior plan must be transferred to the new plan.

  • All Health plans that provide coverage to family members of the insured, must provide coverage for the insured's newborn child from birth for 18 months.

  • Coverage for a child who is dependent on parents in Florida due to a physical handicap is continued beyond the contractual limiting age when the child is incapable of self-sustaining employment.

  • Coverage is provided to the insured's adopted children on the same basis as other dependents.

  • All health plans must provide benefits when confined for treatment of alcoholism or drug abuse and must provide mental health benefits when confined for in-patient care, in a licensed medical care facility.

  • A separate converted policy may be issued to cover a dependent, at the option of the insurer.

  • The use of genetic information or test results by health insurers or HMO's is prohibited.

  • Small employers, those that employ not more than 50 employees, must be offered the standard health benefit plan.

  • A Small employer carriers in the small employer group market must renew or continue coverage.

  • An Exclusive Provider Organization has an agreement with a health insurance company to provide health care services for covered individuals, offering services through its own facilities or through a network of health care professionals.

  • Dread disease policies only cover a single disease or illness.

  • Discount Medical Plans provide access for members to medical services at a discount, in in exchange for fees or other consideration.

  • There is no law in Florida that specifies a minimum percentage participation for employees covered by employee group health insurance in a contributory group plan.

  • The Coordination of benefits (COB) provision in group health plans avoids duplication of benefit payments.

  • Association Plans must be fully insured by an authorized insurer and insurer is is subject to state regulation. A Prepaid Limited Health Service Organization (PLHSO) undertakes to provide or arrange for access to limited health services to enrollees through an exclusive panel of providers for services such as ambulance, dental, vision care, mental and substance abuse, chiropractic and podiatric care and pharmaceutical services, in return for prepayment.

  • The Consolidated Omnibus Budget Reconciliation Act (COBRA) is federal law requiring employers with 20 or more employees to include a continuation of benefits provision for former employees and dependents.

  • COBRA guarantees a group rate if participation in a group plan terminates via death of the employee, termination of employment (except for gross misconduct) or a reduction in work hours resulting in the participant no longer qualifying for group coverage.

  • COBRA benefits only apply to group health insurance, not group life insurance.

  • Employees covered under a group health plan for 3 months before termination are eligible to continue their coverage under COBRA, must request continuation within 31 days following termination.

  • Florida's Health Insurance Coverage Continuation Act (Mini COBRA) applies to employers who employ less than 20 employees.

  • The purpose of the Florida Employee Health Care Access Act is to make group health insurance available to employers with 50 or fewer employees.

  • Florida Healthy Kids offers health insurance for children ages 5-18, designed to provide families not eligible for Medicaid with quality affordable health insurance,

  • Long-term care insurance is for diagnostic, preventive, therapeutic, rehabilitative, maintenance, and personal care services in settings other than acute care units of a hospital.

  • A "notice to buyer” must be on the first for long-term care policies, explaining costs may not be covered.

  • An Outline of Coverage is required and provides a brief summary:

  • A summary of a policy's principal exclusions and limitations

  • A statement of the policy's renewal and cancellation provisions.

  • Includes description of the policy's principal benefits and coverage.

  • Individual long-term care insurance policies shall specify information on renewability provision on the first page which needs to specify if the policy is guaranteed renewable or noncancellable.

  • Pre-existing conditions are conditions for which medical advice/treatment was received within six months before the effective date of an individual long-term care policy.

  • Required on Long-Term Care policies is a 30 day free look period.

  • All insurers issuing long-term care policies must offer an optional inflation protection benefit for automatic future increases in the level of benefits without evidence of insurability.

  • Must provide reasonable protection from future increases in the costs of care for which benefits are provided.

  • An insurer mailing long term care lapse is required at least 30 days prior to the cancellation date to both the policyholder and a specified secondary addressee.

  • Long-term care policies are required to pay for "at-home" care at the same daily amount as paid for a nursing home if qualifications for nursing home care are met.

  • Exclusion or limitation of benefits for Alzheimer's Disease is not permitted.

Limits and exclusions may be placed on:

  • Preexisting conditions or diseases
  • Alcoholism and drug addiction War or acts of war
  • Participation in a felony, riot or insurrection Suicide or self-inflicted injury
  • Aviation (except for fare-paying passengers)
  • Insurers must file a copy of any Medicare supplement advertisement with the Commissioner before it is used in Florida.
  • Marketing Medicare Supplements is regulated to prevent excessive sales of insurance, inaccurate policy comparisons and failure to display notice of limitations to the buyer.
  • The agent soliciting the application is responsible for determining the appropriateness of a Medicare supplement policy.
  • Every agent soliciting Medicare Supplements must provide a suitability form.
  • Medicare supplement sales must inquire about replacement in the application form, as insurance law requires there is a question.
  • The agent deliver the Outline of Coverage to the applicant no later than at the time the Medicare Supplement policy is sold.
  • When purchasing a Medicare supplement policy during the open enrollment period, the policy must be issued, regardless of health.
  • Free-look period for Medicare Supplements is 30 days, and begins 3 months before your 65th birthday and lasts for 7 months.
  • An insurer may exclude coverage for a preexisting condition on a Medicare Supplement Policy for up to 6 months.

Prohibited sales practices are

  • Twisting induces terminating or borrowing a current policy to take out insurance policy with another insurer with misrepresentations, or comparisons.

  • High pressure tactics are used to induce the purchase of insurance through force, fright, threat, or undue pressure

  • Failing to disclose the purpose of the marketing effort is cold lead advertising.

  • Misrepresenting a material fact is Misrepresentation

  • A Member is a person who contracts their health care services with a health maintenance organization.

  • A Provider is any person, including a physician/hospital, who is licensed or in this state to provide health care services.

  • Subscriber is a person who a contract with a health maintenance agency under which they are entitled to the health care that agreement.

  • In Restorative dentistry, the function and integrity of a tooth is restored with dental procedure.

  • Restotative Dentsitry restorations include bridges

  • Oral and maxillofacial restoration involves the surgery of a tooth

  • Examples of Endodontic treatments, dealing with Diseases of dentalpulp, include root canals

  • Periodontics is a dental specialty that involves the prevention, diagnosis and treatment of disease of the health function and esthetics

  • Prosthodontics is a branch of dentistry that has is devoted to replacing missing elements using biocompatible sustutites such as dentures

  • Orthodontics treatment includes teeth and jaw alignment

  • Dental insurance is health coverage, some are an integrated part of a single dental insurance

  • Integrated deductibles offer coverage and claims are covered along side medical expesesn

  • Dental policies also can provide a proboation periods

  • Some dental policies are scheduled, meaning benefits are limited to specified maximums

  • Comrehensive polices are the same as Comprehensive Medical Coverage, in conjunction with deductible, coinsurance

  • The PATIENT PROTECTION AND AFFORDABLE CARE ACT is an act formed to health reform to help individuals and small business purchase health care coverage

The affordable Heath Care Act (ACA) purposes includes

  • Reduce the number of Uninsured in the United health
  • Assist Employers that are qualified
  • Assist Employers in accessing Public Programs

Role in regards to certifications

  • Certify heath plans based on pre determine criteria
  • Utilization and unique formatting for the persentation
  • Utilizized and reviewed any incosistent information

-Beginning January 1, 2014 minimum statndard were set as a bench market

  • All plans have this services Ambuatory pt service with a minimum benefit plan

  • Mentat treatment

  • Prevention services

  • There 4 levels of quailing Health plans you emplyer can purchase -"Bronze” plans with affordable “Silver plans" .

  • The Bronze plams and have coverage, The ACA will prohibited denied in benefits

  • This appies to group and individual poles

  • This act puts limits in the dollasr benefits that are received by Insurance'

  • Grandfathered planes must be followed with regulations, and these regulations were put in place with the "Date" March 23'rd

  • However that the the grandfathered plane are is required to follow and imposed a limit on health care coverage.

  • However "Heath plans" may loose coverage but is covered by charge, deducatables or payment expenses.

  • This Act defines that the Flexiable Savings Account will have funds up to 2'500

  • Parents" can insure their "Dependent act" under the affordable heath care act; even if they are living with their parents

  • All income and individuals who live below the "FED" will receive Subsides upon a sludng scheme

  • It's "Mandatory" that" "The insurer" follows the appeal to and review the appeal.

  • The employer is required to provides healthcare' and is mandate for the amount of 2k and this will reduce the amount of 30 employees

Employment requiment

  • Employment size should be lower than 25
  • Wages must be less than 5 Ok and the employee can be 50K due yo "Tax credits“

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