07/09/2025
High-Cost Medical Claims Surge in Employer Health Plans, Driven by Cancer and Heart Disease
A new report by Tokio Marine HCC – A&H Group reveals a dramatic increase in the size and frequency of medical stop loss claims among U.S. employer-sponsored health plans, highlighting the growing difficulty in maintaining affordable healthcare benefits amid rising claim costs.
Since 2014—when the Affordable Care Act removed caps on health benefit payments—stop loss claims exceeding $2 million have surged by 1,251%, once considered rare but now increasingly common. Over the past year alone, the frequency of large claims has jumped significantly across all major thresholds: claims above $200,000 rose 46%, above $500,000 by 75%, above $1 million by 112%, and those over $2 million by 247%.
The report identifies cancer (neoplasms) and cardiovascular conditions as the top cost drivers, together accounting for over 48% of stop loss claim costs in 2024, up from 44% in 2021. Musculoskeletal and digestive diseases also remained prominent. Emerging contributors to high-cost claims include nervous system, endocrine, metabolic, and infectious diseases, pointing to a broader and more complex risk landscape.
Jay Ritchie, president and CEO of Tokio Marine HCC – A&H Group, attributes the surge in claims to hospitals adjusting post-COVID and an industry shift driven by rising treatment costs and evolving AI technologies. The stop loss market is responding with stricter policy terms and increased premiums.
Similar trends are echoed by QBE and Sun Life, with both insurers reporting spikes in high-dollar claims—particularly from cancer treatments and cardiovascular conditions—indicating a continued hardening of the stop loss insurance market.
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