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5 top stop-loss enemies

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Politicians and consumers tend to talk about heart transplants, liver transplants and other transplants when thinking about costly medical catastrophes, but health insurance advisors know the big cost drivers are other, less-publicized conditions.

Employers that use stop-loss insurance to limit exposure to self-insured health plans have a keen interest in understanding and guarding against the medical bills resulting from those catastrophes.

Drafters of the Patient Protection and Affordable Care Act of 2010 (PPACA) intensified that concern, but prohibited any PPACA-compliant major medical plans, including employer-sponsored self-insured plans, by imposing annual or lifetime benefits limits.

Analysts at Sun Life (TSX:SFC) have tried to help employers, benefits advisors and policymakers understand the conditions that lead to catastrophic claims in the 2015 Sun Life Catastrophic Claims Report.

To create a list of the conditions leading to the highest total percentage of paid stop-loss claims, for example, the analysts used Sun Life U.S. stop-loss claims data from claims filed from 2011 through 2014.

Transplants ranked 11th on the list of generators accounting for catastrophic stop-loss claims, accounting for only about 2 percent of stop-loss claims at Sun Life during the period studied.

Two categories of cancer — malignant neoplasms and a group of conditions that includes leukemia, lymphoma and multiple myeloma — accounted for a total of almost 26 percent of the stop-loss claims paid.

See also: The new solution for coping with critical illness

The other conditions that made the top five, and each accounted for 3 percent to about 8 percent of claims, were kidney disease, birth defects, and conditions resulting from premature birth or low birth weight.

Sun Life’s Experience

  Conditions that led to claims, 2011-2014
Malignant neoplasm 18.0%
Leukemia/lymphoma 8.1%
Kidney disease 7.8%
Conditions present at birth 4.3%
Gestation problems 3.2%
Everything else 59.0%
Source: 2015 Sun Life Catastrophic Claims Report


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