The Top 10 Catastrophic Claims in Self-Funded Plans in 2016

In July of this year, Sun Life Financial released its fourth annual Top Ten Catastrophic Claims Conditions report. We reported on their results last year in this blog, so we’ll take a look at this year’s report and compare it to previous reports.

As specialized medical care becomes more widely available, it is also responsible for an increase in spending. And it’s not just better procedures, it’s more effective diagnoses, more types of drugs to combat disease, and more clinical trials. Employers, consumers and insurance companies bear the costs of these advances in medical care.

This year’s report shows that claims in excess of $1 million continue their upward trend, with an increase of 25% over 2015. And, as is been true for years, less than 2% of the million-dollar claimants accounted for 18.5% of the overall stop-loss claim reimbursements.

Although claims that exceed $1 million are not very common, they account for the majority of dollars in catastrophic stop loss claims. For employers with self-funded plans, stop loss insurance is a critical resource for cost-containment.

Cancer again occupied the top two spots on the Top Ten Catastrophic Claims Conditions list, accounting for 26.6% of total claims and $618.1 million in stop loss claim reimbursements from 2012-2015. Chronic/end-stage renal disease held firm in the number three position on the list, accounting for 6.7% of claims. Congenital abnormalities, in the number four spot, decreased by 0.1% compared to 2011-2014, but still account for 4.1% of total stop-loss claims from 2012-2015. Transplants (#6) and septicemia (#10) trended upward this year by 0.7% and 0.2%, respectively.

The full list is as follows:

  • Malignant neoplasm (cancer)
  • Leukemia/lymphoma/multiple myeloma
  • Chronic/end-stage renal disease (kidney)
  • Congenital abnormalities (conditions present at birth)
  • Premature birth and low birth weight
  • Transplant
  • Congestive heart failure
  • Cerebrovascular disease (stroke)
  • Pulmonary collapse/respiratory failure
  • Septicemia (septic shock from infection)

The only different ailment on this year’s list was the #10 condition: “complications of surgical and medical care” was displaced by septicemia.

The top three conditions (cancer and renal disease) accounted for 33% of Sun Life’s total stop loss claim payments, and the top ten conditions accounted for 53% of payments, or $1.233 billion. “All other conditions” accounted for 47% of payments, totaling $1.09 billion.

In many of the above cases, the ailments are long-term, taking years of treatment, or they may be chronic, lasting throughout the person’s life. If you have a self-funded plan, ensuring catastrophic care is in place will ensure that if someone in your employee pool experiences one of these ailments, both your organization as well as your employee is taken care of.

At Stop Loss Insurance Brokers Inc,, we’re staying on top of trends and insights involving insurance and claims as they relate to stop loss insurance. To learn more on how you can save money while increasing coverage, contact us today.