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.


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    In 2011, the top 5 most expensive medical conditions treated in US hospitals were: Septicemia, Osteoarthritis, Complication of device, implant or graft, Liveborn, and Acute myocardial infarction

    From 2010 to 2013, the number of claims that were individually $1 million or above rose by 1,000%

    In 2017 approximately 18% of the American public will purchase insurance through exchanges, radically transforming the health insurance landscape.

    In 2014, 98% of large firms (= 200 Workers) offer 1+ wellness programs to their employees.

    The most costly 1% of patients account for 20% of national health expenditures – accruing average annual expenses of nearly $90,000 per person.

    6% of firms offering fully-insured plans report they intend to self-insure because of Obamacare.

    In 2014, PPO plans remained the most common plan type, enrolling 58% of covered workers.

    In 2012, 93% of businesses with 5,000+ employees and 80% of companies with 1,000-4,999 employees were self-funded

    Massachusetts has the third-highest prevalence of self-funded insurance in the small-group market (Fewer than 50 employees).

    In 2013, the average deductible was $2,906 for individuals selecting plans from marketplaces. This compares with average deductibles of $1,135 for an individual with employer coverage.

    In 2013, the average annual premiums for employer-sponsored health insurance are $5,884 for single coverage and $16,351 for family coverage, up 5% and 4% respectively from 2012.

    From 2010 – 2013, cancer followed by chronic/end stage renal disease and leukemia accounted for the top 3 costliest illnesses.