Florida Statutes 627.419 – Construction of policies
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Terms Used In Florida Statutes 627.419
- Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
- Contract: A legal written agreement that becomes binding when signed.
- Policy: means a written contract of insurance or written agreement for or effecting insurance, or the certificate thereof, by whatever name called, and includes all clauses, riders, endorsements, and papers that are a part thereof. See Florida Statutes 627.402
(1) Every insurance contract shall be construed according to the entirety of its terms and conditions as set forth in the policy and as amplified, extended, or modified by any application therefor or any rider or endorsement thereto.
(2) The word “physician” or “medical doctor,” when used in any health insurance policy, health care services plan, or other contract providing for the payment of surgical procedures which are specified in the policy or contract or are performed in an accredited hospital in consultation with a licensed physician and are within the scope of a dentist’s professional license, shall be construed to include a dentist who performs such specified procedures.
(3) Notwithstanding any other provision of law, when any health insurance policy, health care services plan, or other contract provides for the payment for procedures specified in the policy or contract which are within the scope of an optometrist’s or podiatric physician’s professional license, such policy shall be construed to include payment to an optometrist or podiatric physician who performs such procedures. In the case of podiatric services, such payments shall be made in accordance with the coverage now provided for medical and surgical benefits.
(4) Notwithstanding any other provision of law, when any health insurance policy, health care services plan, or other contract provides for the payment for medical expense benefits or procedures, such policy, plan, or contract shall be construed to include payment to a chiropractic physician who provides the medical service benefits or procedures which are within the scope of a chiropractic physician’s license. Any limitation or condition placed upon payment to, or upon services, diagnosis, or treatment by, any licensed physician shall apply equally to all licensed physicians without unfair discrimination to the usual and customary treatment procedures of any class of physicians.
(5) For purposes of coverage under a policy of disability income or credit disability insurance, no determination of disability shall be rejected solely on the basis of the chapter under which the physician is licensed; however, such determination may be rejected on the basis that the determination is outside the scope of the physician’s authorized practice. However, the insurance carrier shall have the option after 30 days of disability to seek a second physician’s opinion prior to paying additional benefits.
(6) Notwithstanding any other provision of law, when any health insurance policy, health care services plan, or other contract provides for payment for surgical first assisting benefits or services, the policy, plan, or contract is to be construed as providing for payment to a registered nurse first assistant or employers of a physician assistant or nurse first assistant who performs such services that are within the scope of a physician assistant’s or a registered nurse first assistant’s professional license. The provisions of this subsection apply only if reimbursement for an assisting physician, licensed under chapter 458 or chapter 459, would be covered and a physician assistant or a registered nurse first assistant who performs such services is used as a substitute.
(7) No health insurance policy, health care services plan, or other contract which provides coverage for any diagnostic or surgical procedure involving bones or joints of the skeleton shall discriminate against coverage for any similar diagnostic or surgical procedure involving bones or joints of the jaw and facial region, if, under accepted medical standards, such procedure or surgery is medically necessary to treat conditions caused by congenital or developmental deformity, disease, or injury. This subsection shall not be construed to affect any other coverage under this part or to restrict the scope of coverage under any policy, plan, or contract. Nothing in this subsection shall be construed to discourage appropriate nonsurgical procedures or to prohibit the continued coverage of nonsurgical procedures in the treatment of a bone or joint of the jaw and facial region. Furthermore, nothing in this subsection requires coverage for care or treatment of the teeth or gums, for intraoral prosthetic devices, or for surgical procedures for cosmetic purposes. This section does not apply to accident only, disability income, specified disease, hospital indemnity, credit, Medicare supplement, or long-term care insurance policies.
(8) If an insurer or licensee advertises an insurance policy in a language other than English, the advertisements shall not be construed to modify or change the insurance policy written in English. The advertisement must disclose that the policy written in English controls in the event of a dispute and that statements contained in the advertisement do not necessarily, as a result of possible linguistic differences, reflect the contents of the policy written in English. Nothing in this subsection shall affect the provisions of s. 626.9541 relating to misrepresentations and false advertising of insurance policies.
(9) With respect to any group or individual insurer covering dental services, each claimant, or dentist acting for a claimant, who has had a claim denied as not medically or dentally necessary or who has had a claim payment based on an alternate dental service in accordance with accepted dental standards for adequate and appropriate care must be provided an opportunity for an appeal to the insurer’s licensed dentist who is responsible for the medical necessity reviews under the plan or is a member of the plan’s peer review group. The appeal may be by telephone, and the insurer’s dentist must respond within a reasonable time, not to exceed 15 business days.