12.3.3 Unfair Trade Practice Activities by HMOs
Florida defines the following as unfair trade practice activities by HMOs.
- Misrepresentation and false information*
- False advertising
- Defamation
- False statements and entries
- Unfair claim settlement practices**
- Failure to maintain claim handling procedures
- Operating without a subsisting certificate of authority
- Twisting
- Illegal dealing in premiums
- False claims and obtaining money dishonestly
- Prohibited discriminatory practices
- Misrepresentation in availability of providers
- Adverse action against a provider
The penalties in Florida for violating the Unfair Trade Practices Act are probation, suspension, or revocation of licensure or HMO Certificate of Authority and a fine up to $200,000. If the infraction is a criminal violation, penalties can result in imprisonment.
What is meant by "misrepresentation in HMO applications?"
Knowingly making a false or fraudulent representation on or relative to an application for an HMO contract, for the purpose of obtaining a fee, commission, money or other benefit from any HMO, agent or representative, broker or individual.
What is an example of an "unfair claim settlement practice?"
Failing to affirm or deny coverage of claims upon written request of the subscriber within a reasonable time, not to exceed 30 days after a claim or proof-of-loss statements have been completed and documents pertinent to the claim have been requested in a timely manner and received by the HMO.
