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Digital EditionMedical Stop Loss Claims Trends: Million-Dollar Cases Double as Cancer Remains Dominant
Medical stop loss claims are undergoing significant shifts as cancer diagnoses remain dominant across all deductible levels while million-dollar claims have doubled in frequency over four years, driven by expensive treatments and rising disease prevalence among younger populations, according to analysis by QBE.
“As treatment options grow more advanced and costly, employers are facing rising pressure to control volatility in their self-funded healthcare plans,” said Tara Krauss, president of Accident & Health at QBE North America. “Our goal is to equip brokers, administrators and employers with actionable insights to navigate these changes with confidence.”
The medical stop loss landscape reveals several critical trends that are fundamentally altering claim patterns and costs.
Neoplasms continue to dominate as the top diagnosis across all deductible levels, though their impact varies significantly based on deductible amounts.
At $100,000 deductibles, malignant neoplasm of breast, or female breast cancer, accounts for 16% of cancer-related claims, but this drops to just 3% at $1 million deductibles. Conversely, lymphoid leukemia represents only 5% of claims at $100,000 deductibles but jumps to 32% at $1 million deductibles, the analysis found.
Blood cancers have emerged as the highest cost category at higher deductibles due to expensive treatments, such as CAR-T therapy, targeted therapies, immunotherapy, and stem cell transplants, which require extended hospital stays and monitoring, according to the report.
CAR-T cell therapy alone costs $500,000 to $750,000, potentially exceeding $1 million with complications, while other therapies range from $100,000 to $725,000 annually. These treatments require extended hospital stays and monitoring, driving up overall claim costs, QBE noted.
A particularly concerning trend is the sharp rise in frequency and severity of malignant neoplasms among younger populations under age 50, according to QBE. Early-onset cancers, including breast, lung, and pancreatic cancers, have increased among this younger population and often present more aggressive characteristics.
The most frequent early-onset cancers are colorectal, breast, prostate, uterine, stomach, and pancreatic cancers, requiring more aggressive and costly treatments, the report noted.
Circulatory diseases represent the second most common diagnosis by frequency, covering roughly 12% of claims at every deductible level. QBE’s analysis revealed a significant increase in both frequency and severity of circulatory disease claims, with heart failure emerging as the most common diagnosis for claims exceeding $1 million.
Million-dollar claims have shown alarming growth, with the frequency of such claims doubling over four years from 1.0 claims per 10,000 employees in 2020 to 2.0 in Q1 2024. After a pause in 2022 due to COVID, this dramatic rise resumed in 2023 and 2024, with conditions leading to the highest cost claims being neoplasms, premature births with related congenital anomalies, and circulatory issues, according to the analysis.
Emerging High-Cost Categories
Preterm infant claims present a complex trend pattern. While the March of Dimes reports the preterm birth rate remained stable at 10.4% in 2024, QBE observed growing frequency of claims for preterm births with associated congenital anomalies, particularly at $1 million and $2 million deductible levels.
These claims demonstrate a continuously escalating magnitude, with QBE’s largest preterm birth claim exceeding $5 million in 2023 and $3.9 million in 2024. By severity analysis, conditions originating from premature births average $499,000 in costs, according to the report.
The specialty pharmacy market, which represents one of the fastest-growing subsegments within pharmacy services, represents a potential source of high-cost claims. Comprised of biologics, gene therapies, and cancer treatments, this market experienced its most rapid growth in 2024 due to FDA approval of new drugs.
With average specialty medication costs now exceeding $5,000 annually, these expenses are placing major strain on health care plans, QBE noted. Gene therapies for rare conditions typically require one-time administration and can cost over $2 million, though claims remain infrequent.
Cell and gene therapy marked a standout year with seven new therapies approved in 11 months, according to the report. Two CAR-T cell therapies received approval as earlier lines of therapy, with Carvykti now serving as second-line therapy for multiple myeloma and Abecma approved as third-line therapy. CAR-T utilization expanded in 2024 for treating autoimmune diseases such as lupus, Crohn’s disease, and type 1 diabetes.
Despite this expansion, gene therapy claims have remained low, with just three gene therapy claims recorded through 2024 on nearly 2 million covered lives.
Industry Challenges and Opportunities
These trends create significant challenges for employers and insurers managing health care costs. The shift toward younger populations developing serious conditions, combined with expensive specialty treatments, is fundamentally altering risk profiles.
According to the report, environmental and lifestyle factors account for 90-95% of cancers, suggesting that addressing modifiable risk factors could help control rising cancer rates.
For example, the increase in circulatory diseases, driven by chronic conditions like diabetes, obesity, and hypertension, presents opportunities for targeted intervention programs, the report noted. Similarly, preterm birth risks can be reduced by addressing factors including smoking, hypertension, diabetes, and unhealthy weight.
View the full report here. &
