Number of High-Cost Medical Claims Continues to Rise

Number of High-Cost Medical Claims Continues to Rise

Report says catastrophic medical claims up nearly 70 percent over four years.

The number of catastrophic medical claims rose 68 percent from 2013 to 2016 with cancer continuing to be the most prevalent medical condition driving the jump in big-ticket claims.
That’s according to an analysis of stop-loss catastrophic medical claims data recently released by Sun Life Financial, the Wellesley, Massachusetts-based stop-loss insurance company.
The analysis is based on $4.5 billion in catastrophic medical claims paid by Sun Life to 53,000 claimants from 2009 through 2016. The claims data are from employers that have Sun Life stop-loss health insurance policies. Employers ranged in size from 50 to more than 100,000 employees per company. The insurer’s report covers the four-year period from 2013 through 2016.
The total number of claims paid for $1 million or more in medical care climbed to 192 in 2016 from 114 in 2013, the report said. The total amount paid out for the same claims rose 48 percent to $192.5 million last year from $129.8 million in 2013. The average amount per claim dipped to about $1 million in 2016 from a little over $1.1 million in 2013.
“An unintended result of removing caps under employer plans has been a steady rise in the frequency of multi-million-dollar claims fueled by life-saving treatments and drugs,” the report said.
The Patient Protection and Affordable Care Act prohibits most health plans from placing lifetime limits on medical payments.
The top 10 medical conditions leading to the catastrophic medical claims from 2013 to 2016 were:
  • Malignant neoplasm (cancer)
  • Leukemia/lymphoma/multiple myeloma (cancer)
  • Chronic/end-stage renal disease
  • Congenital anomalies
  • Transplant
  • Disorders relating to short gestation and low birth weight
  • Septicemia (infection)
  • Complications from surgical and medical care
  • Cerebrovascular disease
  • Pulmonary collapse/respiratory failure
The total of amount paid out in claims for the 10 medical conditions was $1.4 billion, representing 51.7 percent of the catastrophic medical claims Sun Life paid out from 2013 through 2016. Some 70 percent of the employers had a least one claim for one of the 10 conditions over that period with two-thirds having at least one claim for an employee with cancer.