In The Top Ten Catastrophic Claims Conditions report, insight about factors impacting medical costs is explored, such as the most expensive medical conditions covered by stop-loss insurance and emerging trends, as reported in Sun Life Financial U.S.

The report examines medical conditions covered by Sun Life’s stop-loss insurance, a type of insurance that protects insurers against “large claims”, and found that charges billed by medical care providers amounted to $9 billion, and self-insured employers paid $5.3 billion of the $9 billion. Additionally, they received $2.3 billion in reimbursements from stop-loss protection.

From 2012 to 2015, the time period the report was analyzing, the average that an employer paid on a claim above $1 million was $1.45 million, which decreased to $491,000 after applying the average stop-loss claim reimbursement ($962,000).
According to the report, cancer is number one and two, with $618 million in stop-loss reimbursements, and also accounts for $26.6 percent of all stop-loss claims. Breast cancer is responsible for $13.6 percent of cancer claims, and intravenous (IV) medications are the “key driver” in rising cancer costs.

Number three on the list is chronic/end-stage kidney disease, which accounts for over $369 million first-dollar claims — covering copays and deductibles — and stop-loss claims reimbursements. The report mentions how to improve cost management and increase the use of transplants to reduce the costs associated with kidney disease.

The complete list of stop-loss claims is as follows:

• Malignant neoplasm (cancer): $429.5 million


• Leukemia/lymphoma/ multiple myeloma (cancers): $188.6 million


• Chronic/end-stage renal disease (kidneys): $156.5 million


• Congenital anomalies (conditions present at birth): $96.3 million


• Disorders relating to short gestation/low birth weight (premature birth): $75.2 million


• Transplant: $62.2 million


• Congestive heart failure: $57.8 million


• Cerebrovascular disease (brain blood vessels): $57.4 million


• Pulmonary collapse/respiratory failure (lungs): $55 million


• Septicemia (infection): $54.7 million


• All other conditions: $1.09 billion

Transplants increased 65 percent from 2012 to 2015, and an increase in organ donations and improved procedures may be reasons for an increase in transplants, the report said. Over $62.2 million in stop-loss claims is due to transplants, and there is a 79 percent increase in the cost of bone marrow/stem cell transplant.

“By highlighting the conditions that create catastrophic claims and providing insights into trends influencing high costs, we can help employers anticipate what they’ll see when self-funding and raise awareness about the importance of cost-containment resources and stop-loss insurance,” said Brand Nieland, vice president of stop-loss at Sun Life Financial U.S. in a statement.

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