Reinsurers and stop-loss insurance carriers bear much of the cost of very expensive health claims. These secondary payers provide backup coverage to first-dollar payers like health plans and employer-based self-funded plans. Because they see most of the really high cost claims, they tend to issue regular reports, the most recent of which is from Sun Life. It details the underlying conditions leading to the large health insurance claims. (Sun Life Report)
The top conditions in terms of total claims submitted to Sun Life were solid tumor cancers, cardiovascular conditions, orthopedic/musculoskeletal, newborns (premature births), blood cancers, respiratory (mostly COPD), gastrointestinal, sepsis and neurology. Congenital anomalies, some of which are treated with very expensive gene therapies, dropped down, while liver-related disease claims increased. The most individually high claims were for cancer, cardiovascular disease (usually heart failure), orthopedics and respiratory.
Since 2022 the number of claims over $1 million has increased by 46% and in 2025 there were 48 claims of $3 million or more. The top three conditions accounted for 40% of all claim dollars and the top ten for 73%. Seven drugs were responsible for claims of $300,000 or more for each claim. Twelve of the top twenty drugs seen on claims were for oncology. The weight loss drugs may have high usage and total spending, but they are not showing up much as individually high claims.
These reports are worth a skim to understand what drives most health spending. The overall picture indicates a strong need to get the costs of specialty drugs, especially for cancer, under control. And the other notable factor is the continued acute episode costs of diseases that are largely caused by poor health behaviors that lead to heart failure, heart attacks, kidney disease, COPD and other long-term chronic conditions.
Kevin, this is the time of the year when all of the stop loss carriers release their Large Claim reports which provides the shock value to the readers both inside and outside the industry. However, as you alluded weight loss drugs not being “large claims” doesn’t show up on the list. But when one looks at the total costs a bigger issue gets lost in the data. That weight loss drugs, which, by some estimates, are being used by 10%-15% or more of the adult population, have increased loss ratios more during the last 5 years than shock claims due to CGT, transplants and preemies.
Query: Does Trump’s new drug offering cover any of these drugs?
I think he is trying to cover some of the really expensive specialty drugs, but it is hard to get manufactures to do anything on those.