Multimillion-dollar medical claims continue to rise – Sun Life US

Sun Life US has published its latest “High-Cost Claims and Injectable Drug Trends Analysis” report, which examined 60,000 stop-loss claims from 2020 to 2023. The report revealed that 87% of self-funded employers encountered at least one high-cost claim during the period.

A significant finding is that cardiovascular disease (CVD) has risen to the second-highest paid claims position, overtaking blood cancers for the first time in the report’s 12-year history. Since 2020, the average cost of CVD claims has surged by 33%, surpassing the overall increase in medical claims costs.

Malignant neoplasms (solid tumors) continue to lead, with twice the medical expenditure of CVD.

Meanwhile, according to the key trends in the report, the top 10 high-cost medical conditions accounted for 72% of all stop-loss reimbursements, while the top 20 conditions accounted for 92%.

Claims related to newborn and infant care saw a significant rise, with an average cost increase of $100,000 from 2022 to 2023, reaching an annual average cost of $470,800.

Orthopedics and musculoskeletal conditions ranked fourth in 2023 reimbursements and had the highest number of individual high-cost claims, excluding solid cancers, although with a lower average cost of just over $100,000.

Based on the Sun Life US report, multimillion-dollar claims remain on the rise. The insurer noted that all top 20 claim categories experienced claims exceeding $1 million, with the highest claim being over $11 million for newborn and infant care.

In 2023, there was a notable increase in the $3 million-plus category, with 32 such claims, nearly double the number from 2022. Half of these $3 million-plus claims were related to congenital anomalies, which can affect an individual’s health throughout their life.

Jen Collier (pictured), president of health and risk solutions at Sun Life US, highlighted: “Our extensive claims database allows us to provide guidance to our self-funded clients so they can understand how to best manage their health plans and costs, while ensuring they can choose additional solutions that drive the best care for their employees.

“Additionally, the data informs our health and risk product development team as they create solutions and programs that directly support the health and wellness of our members, regardless of whether their condition has resulted in a high-cost claim.”

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