DEPARTMENT OF FINANCIAL SERVICES
Division of Insurance FraudRULE NO: RULE TITLE
69D-2.001: Purpose and Scope
69D-2.002: Definitions
69D-2.003: Insurer SIUs
69D-2.004: Insurer Anti-Fraud Plans
69D-2.005: Compliance and EnforcementNOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed Rules 69D-2.001, 69D-2.002, 69D-2.003, 69D-2.004, and 69D-2.005, F.A.C., in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 32, No. 16, April 21, 2006, of the Florida Administrative Weekly. These changes are being made to address concerns expressed by the Florida Insurance Council and the Joint Administrative Procedures Committee.
WHEN AMENDED THE PROPOSED RULE WILL READ AS FOLLOWS:
69D-2.001 Purpose and Scope.
The purpose of this rule chapter is to implement the provisions of Section 626.9891, F.S., establishing guidelines and reporting requirements for insurer anti-fraud investigative units and anti-fraud plans.
Specific Authority 624.308, 626.9891, 626.9891(8) FS. Law Implemented 624.307, 626.9891(8) FS. History–New________.
69D-2.002 Definitions.
For the purposes of this rule:
(1) “Division” refers to the Department of Financial Services, Division of Insurance Fraud.
(2) “NAIC” refers to the National Association of Insurance Commissioners.
(3) Office” refers to the Office of Insurance Regulation.
(4) “SIU” refers to an insurer’s internal or contracted anti-fraud investigative unit.
Specific Authority 624.308, 626.9891, 626.9891(8) FS. Law Implemented 624.307, 626.9891(8) FS. History–New_______.
69D-2.003 Insurer SIUs.
(1) An insurer subject to Section 626.9891(1), F.S., shall file with the Division a detailed deion of their SIU, and shall submit the following information in the SIU deion to satisfy this filing requirement:
(a) The names of all personnel assigned to the SIU, and a deion of each person’s work responsibilities relating to the SIU’s anti-fraud efforts;
(b) An acknowledgment that the SIU has established criteria that will be used to detect suspicious or fraudulent activity during investigations relating to the different types of insurance offered by that insurer;
(c) An acknowledgment that the SIU has established criteria that will be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer.
(d) An acknowledgment that the insurer or SIU shall report all suspected fraudulent insurance acts directly to the Division electronically via Form DFS-L1-1691 (Eff._____) “Suspected Fraud Referral Form,” or an electronic reporting interface that is linked to such form, as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1691 (Eff.______) Suspected Fraud Referral Form is hereby adopted and incorporated by reference.
(e) An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines and supports the allegation of suspicious activity.
(f) An acknowledgement that the insurer or SIU shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud are sent directly to the Division;
(g) An acknowledgement that the insurer or SIU shall provide training relating to the detection and investigation of fraudulent insurance acts for all personnel involved in anti-fraud related efforts.
(h) An acknowledgement that the insurer or SIU shall provide on-going training during the reporting period;
(i) The contact information including names, email addresses, and telephone numbers, for personnel designated by the insurer or SIU to be responsible for achieving and maintaining compliance with Section 626.9891(1), FS., and this rule chapter;
(j) The insurer’s NAIC individual and group code numbers;
(2) An insurer or SIU subject to Section 626.9891(1), F.S., and this rule chapter, shall submit this SIU deion electronically via the Division’s website at www.fldfs.com/fraud/. The SIU deion shall be submitted electronically on Form DFS-L1-1689 (Eff.____) “SIU Deion Form” as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1689 (Eff.____) SIU Deion Form is hereby adopted and incorporated by reference. The insurer’s filing of the information required in subsection (1) above shall constitute an adequately detailed deion of its SIU as required by Section 626.9891(1), F.S.
(3) Nothing in this rule shall require that an SIU utilize all established criteria in every circumstance.
(4) The filing of the information required herein is not intended to constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its SIU, its SIU deion, or its SIU policies and procedures.
Specific Authority 624.308, 626.9891, 626.9891(8) FS. Law Implemented 624.307, 626.989, 626.9891(1) FS. History– New________.
69D-2.004 Insurer Anti-Fraud Plans.
(1) An insurer subject to Section 626.9891(2), F.S., shall file with the Division of Insurance Fraud such anti-fraud plan, and such anti-fraud plan shall include:
(a) A written deion or chart outlining the organizational arrangement of the insurer's anti-fraud personnel who are responsible for the investigation and reporting of possible fraudulent insurance acts.
(b) A deion of the insurer’s procedures for detecting and investigating possible fraudulent insurance acts. Nothing in this rule shall require that an insurer utilize all established criteria in every circumstance. This deion shall include:
1. An acknowledgment that the insurer has established criteria that will be used to detect suspicious or fraudulent activity during investigations relating to the different types of insurance offered by that insurer;
2. An acknowledgment that the insurer has established criteria that will be used for the investigation of acts of suspected insurance fraud relating to the different types of insurance offered by that insurer.
(c) A deion of the insurer’s procedures for the mandatory reporting of possible fraudulent insurance acts to the Division pursuant to Section 626.989(6), F.S. This deion shall include:
1. An explanation of the insurer’s method for reporting all suspected fraudulent insurance acts directly to the Division electronically on Form DFS-L1-1691 as incorporated and provided for in paragraph 69D-2.003(1)(d), F.A.C.
2. An acknowledgment that all such reports of suspected insurance fraud shall contain information that clearly defines and supports the allegation of suspicious activity.
3. An acknowledgement that the insurer shall record the date that suspected fraudulent activity is detected, and shall record the date that reports of such suspected insurance fraud are sent directly to the Division.
(d) A deion of the insurer’s plan for anti-fraud education and training of its claims adjusters and any other personnel involved in anti-fraud related efforts. This deion shall include:
1. A plan that involves training relating to the detection and investigation of fraudulent insurance acts for all employees involved in anti-fraud related efforts.
2. A plan that involves on-going training during the reporting period;
(e) The contact information, including names, e-mail addresses, and telephone numbers, for personnel designated by the insurer to be responsible for achieving and maintaining compliance with Section 626.9891(2), F.S., and this rule chapter;
(f) The insurer’s NAIC individual and group code numbers;
(2) An insurer subject to Section 626.9891(2), F.S., and this rule chapter, shall submit this anti-fraud plan electronically via the Division’s website at www.fldfs.com/fraud/. The anti-fraud plan shall be submitted electronically on Form DFS-L1-1690 (Eff.____) “Anti-Fraud Plan Form as provided on the Division’s website at www.fldfs.com/fraud/. Form DFS-L1-1690 (Eff._______) Anti-Fraud Plan Form is hereby adopted and incorporated by reference. The insurer’s filing of the information required in subsection (1) above shall constitute an acceptable anti-fraud plan as required by Section 626.9891(2), F.S.
(3) The filing of the information required herein is not intended to constitute a waiver of an insurer’s privilege, trade secret, confidentiality or any proprietary interest in its anti-fraud plan or its anti-fraud related policies and procedures.
Specific Authority 624.308, 626.9891 FS. 626.9891(8), FS. Law Implemented 624.307, 626.9891(2),(3) FS. History–New________.
69D-2.005 Compliance and Enforcement.
(1) The Division shall review the filings of SIU deions and insurer anti-fraud plans and the Office shall conduct audits pursuant to Section 624.3161, F.S., to determine compliance with Section 626.9891, F.S., and this rule chapter.
(2) If an insurer fails to timely file an anti-fraud plan or SIU deion, fails to implement or follow the provisions of their anti-fraud plan or SIU deion, or in any other way fails to comply with the requirements of Section 626.9891, F.S., and this rule chapter, the Office shall take appropriate administrative action as provided in Section 626.9891(7), F.S., and Section 624.4211, F.S.
Specific Authority 624.308, 626.9891, 626.9891(8) FS. Law Implemented 624.307, 626.9891(7) FS. History–New_______.
