Context Over Grammar: Tenth Circuit clarifies that AD&D “medical treatment of sickness” exclusions reach prescription‑drug deaths, and the “unless prescribed” drug‑ingestion carveout preserves coverage only for medications treating accidental injuries

Introduction

In Jensen v. Life Insurance Company of North America, the Tenth Circuit affirmed the denial of accidental death and dismemberment (AD&D) benefits after a plan participant died from the combined toxicity of prescribed oxycodone (for chronic pain) and clonazepam (for anxiety). The insurer, Life Insurance Company of North America (LINA), relied on a policy exclusion for losses “caused by or result[ing] from … sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof.” The beneficiary argued the exclusion did not apply because, under the grammatical “last‑antecedent” rule, “medical or surgical treatment thereof” modified only “bacterial or viral infection,” not “sickness, disease, [or] bodily or mental infirmity.” She also argued that reading the medical‑treatment exclusion so broadly would nullify the policy’s separate voluntary‑ingestion exclusion’s “unless prescribed” carveout.

The court rejected both arguments. Applying de novo review to the merits (without resolving standard‑of‑review and choice‑of‑law disputes), it held the medical‑treatment exclusion unambiguously applies, and it harmonized the two exclusions by reading the “unless prescribed” carveout as preserving coverage when medications are prescribed for accidental injuries, not when they treat sickness, disease, or infirmity. The opinion aligns with the Third Circuit’s reading of the same LINA clause and emphasizes that, in AD&D policies, context can trump a purely grammatical construction that would expand coverage into illness‑related territory the product does not typically cover.

Summary of the Opinion

The court affirmed summary judgment for LINA on de novo review, holding that Steven Jensen’s death fell within the policy’s medical‑treatment‑of‑sickness exclusion.
It declined to decide contested issues about the enforceability of a discretionary‑authority clause (Utah’s anti‑discretion statute vs. the policy’s Delaware choice‑of‑law) because the outcome would be the same even under de novo review.
It rejected the beneficiary’s reliance on the last‑antecedent rule, finding that policy context and structure overcame the grammatical presumption.
It also rejected a claimed conflict between the medical‑treatment exclusion and the voluntary‑ingestion exclusion’s “unless prescribed” proviso, explaining that the proviso preserves coverage only for medications prescribed for accidental injuries, not for illnesses or infirmities.
Because the death resulted from medications prescribed to treat chronic pain and anxiety (sickness/mental infirmity), the medical‑treatment exclusion unambiguously barred benefits.
The court denied LINA’s request for judicial notice of corporate‑structure facts as irrelevant to the merits resolved on de novo review.

Background

Steven Jensen, an employee of Codale Electric Supply, Inc., was covered under Codale’s ERISA‑governed welfare plan providing AD&D benefits through a LINA policy with a Delaware choice‑of‑law clause. He had long‑standing chronic pain treated with oxycodone; six weeks before his death the prescription was renewed. On January 30, 2019, he received clonazepam for anxiety. On February 1, 2019, he was found deceased; an autopsy attributed death to oxycodone and clonazepam toxicity. The medical literature documents the danger of combining these drugs.

LINA denied the AD&D claim in December 2019, invoking exclusions for voluntary ingestion of drugs and for medical treatment of sickness. On administrative appeal in April 2020, LINA withdrew reliance on the voluntary‑ingestion exclusion but maintained that the medical‑treatment exclusion applied. The district court, reviewing de novo on the administrative record, granted summary judgment to LINA. The beneficiary appealed.

Analysis

1) Precedents Cited and Their Influence

Firestone Tire & Rubber Co. v. Bruch (U.S. 1989): Establishes the default ERISA standard of review—de novo unless the plan grants discretionary authority, in which case abuse‑of‑discretion (arbitrary and capricious) applies. The Tenth Circuit acknowledged this framework but proceeded on de novo review without deciding if the plan’s discretionary clause was enforceable.
LaAsmar v. Phelps Dodge (10th Cir. 2010): Clarifies ERISA summary‑judgment procedure and that the court’s task is to review the benefits decision on the administrative record, not to draw ordinary Rule 56 inferences. LaAsmar also articulates the need to first identify the standard of review—though, as here, courts may bypass a disputed standard if the result is the same.
Ian C. v. UnitedHealthcare (10th Cir. 2023): Emphasizes that appellate review targets the plan administrator’s decision, not the district court’s reasoning. It also illustrates that courts often decline to resolve standard‑of‑review disputes when the outcome is unaffected.
Weber v. GE Group Life (10th Cir. 2008): Reiterates the focus on the plan administrator’s decision as the object of review.
Miller v. Monumental Life (10th Cir. 2007) and Carlile v. Reliance Standard (10th Cir. 2021): Provide interpretive principles—read plan documents as a whole, give terms their common and ordinary meaning as a reasonable plan participant would, apply unambiguous provisions as written; construe genuine ambiguities contra proferentem (against the drafter).
Admin. Comm. of Wal‑Mart v. Willard (10th Cir. 2004): Source for the “reasonable participant” lens when assigning ordinary meaning.
Spradley v. Owens‑Illinois (10th Cir. 2012) and Glista v. Unum (1st Cir. 2004): Limit review to the rationale actually given by the administrator; require transparent, meaningful dialogue in denial letters; discourage “sandbagging” claimants with new rationales on appeal. Here, LINA consistently relied on the medical‑treatment exclusion after dropping voluntary ingestion during the administrative appeal.
Lockhart v. United States (U.S. 2016) and Barnhart v. Thomas (U.S. 2003): Articulate the last‑antecedent rule and its key caveat—it is a rebuttable canon that yields to contrary contextual or structural signals.
Payless Shoesource, Inc. v. Travelers (10th Cir. 2009): Reinforces that courts will not privilege a grammatically “correct” reading when context and evident sense indicate a different construction fits the policy’s structure and purpose.
Senkier v. Hartford Life & Accident (7th Cir. 1991): Explains the fundamental design of AD&D insurance—to draw a line between injuries caused by accidents and losses linked to illness, with injuries from illness treatment commonly grouped with illness rather than accident.
Viera v. LINA (3d Cir. 2011): Involving the same LINA medical‑treatment clause, the Third Circuit rejected the very comma/last‑antecedent argument raised here, reading the exclusion to embrace treatment of all listed maladies, not just infections. The Tenth Circuit found Viera persuasive and aligned its reasoning.

2) The Court’s Legal Reasoning

a) Standard of review and scope: Although the plan contained a discretionary‑authority clause, the court did not resolve whether Utah’s 2018 anti‑discretion law or Delaware law governed, nor any retroactivity or ERISA preemption issues. It proceeded on de novo review and confined its analysis to the rationale LINA preserved—the medical‑treatment exclusion.

b) Policy context and definitions: The court emphasized bedrock AD&D concepts embedded in LINA’s policy:

“Covered accident” is “a sudden, unforeseeable, external event” that results “directly and independently of all other causes” in a covered injury or loss and “is not contributed to by disease, sickness, [or] mental or bodily infirmity.”
“Covered injury” and “covered loss” are likewise confined to results “directly and independently of all other causes.”

These definitions make clear that the product insures accident‑only risks, disentangled from sickness‑related causes or contributions. This structural backdrop, the court held, strongly informs the reading of adjacent exclusions.

c) Last‑antecedent rule rejected: The medical‑treatment exclusion bars benefits for loss “caused by or resulting from … sickness, disease, bodily or mental infirmity, bacterial or viral infection or medical or surgical treatment thereof.” While a literal application of the last‑antecedent canon might tie “thereof” to “bacterial or viral infection” alone, the court held that context “overcomes” the canon. Nothing in the policy suggests bacterial or viral infections are uniquely subject to the medical‑treatment clause while other illnesses (e.g., chronic pain, anxiety) are not. Such a reading would anomalously cover accidents arising from treatment of most illnesses while excluding only treatment of infections—an implausible allocation for AD&D insurance. The court therefore read “medical or surgical treatment thereof” to apply to the entire series—sickness, disease, bodily or mental infirmity, and bacterial or viral infection—consistent with Viera and the policy’s accident‑only architecture.

d) No ambiguity created by the voluntary‑ingestion exclusion: The voluntary‑ingestion exclusion precludes losses “caused by or result[ing] from … voluntary ingestion of any narcotic [or] drug … unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage.” The beneficiary argued that if the medical‑treatment exclusion already eliminates coverage for losses caused by taking prescribed medications for illness, then the “unless prescribed” proviso is meaningless and creates ambiguity to be resolved contra proferentem.

The court harmonized the provisions. The “unless prescribed” clause is purpose‑neutral on its face; it does not say “prescribed to treat sickness.” By contrast, the medical‑treatment exclusion is expressly tied to treatment of enumerated maladies—sickness, disease, bodily or mental infirmity, or infection. Read together:

The “unless prescribed” proviso preserves coverage for a narrow set of cases where medication is prescribed for an accidental injury (for example, pain medication following a broken bone), taken as directed, and death results. Such losses are accident‑centric and not illness‑centric.
But when medication is prescribed to treat sickness, disease, or bodily or mental infirmity, losses fall within the medical‑treatment exclusion and are not saved by the voluntary‑ingestion proviso.

Crucially, the court rejected the argument that “infirmity” includes accidental injury. Relying on dictionary definitions, it explained that “infirmity” denotes feebleness, weakness, or disease, not traumatic injury. Thus, medication prescribed for an accidental injury is not “medical treatment of a bodily infirmity,” leaving room for the “unless prescribed” proviso to operate without contradiction. Because the exclusions can be read in harmony, there is no ambiguity, and contra proferentem does not apply.

e) Application: Steven Jensen’s death resulted from medications prescribed to treat chronic pain and anxiety—maladies squarely within “sickness” and “mental infirmity.” Under the unambiguous medical‑treatment exclusion, benefits were not payable.

3) Impact and Practical Consequences

Although issued as a nonprecedential order, the decision carries persuasive weight and is likely to influence AD&D litigation in and beyond the Tenth Circuit in several ways:

Alignment with Viera: The opinion expressly tracks the Third Circuit’s interpretation of LINA’s identical clause, fostering cross‑circuit consistency. Claimants are less likely to succeed on comma‑placement or last‑antecedent arguments that would limit “medical or surgical treatment thereof” to infections alone.
Clear demarcation between illness and accident: The court reiterates AD&D’s core premise—coverage exists for accidents “directly and independently” of all other causes, not for accidents intertwined with illness or its treatment. Losses resulting from prescribed medications for sickness (including mental health conditions) are presumptively excluded by medical‑treatment clauses written like LINA’s.
Harmonizing exclusions: The opinion articulates a coherent framework for reconciling voluntary‑ingestion exclusions with medical‑treatment exclusions. The “unless prescribed” carveout preserves coverage only for medications prescribed for accidental injuries and taken as directed, not for medications treating sickness or infirmity.
Drafting and claims administration:
- Insurers: The decision validates medical‑treatment exclusions with the “thereof” phrasing, even where punctuation might invite last‑antecedent arguments. Nevertheless, drafters may wish to eliminate ambiguity by saying “medical or surgical treatment of any of the foregoing” to further reduce litigation risk.
- Plan administrators: Ensure denial letters commit to the specific exclusion(s) and explain the rationale; courts will limit review to preserved grounds (Spradley). Dropping an exclusion during appeal is acceptable if the insurer consistently relies on the remaining ground.
- Claimants: Arguments hinging solely on last‑antecedent grammar face headwinds where policy context and purpose point the other way; to trigger contra proferentem, competing interpretations must be reasonable in context.
Unresolved standard‑of‑review issues: The panel sidestepped significant questions about the effect of state anti‑discretion statutes and choice‑of‑law clauses for old policies renewed after such statutes. Future Tenth Circuit panels may need to address these questions squarely; for now, Jensen shows courts will often resolve on the merits where possible.

Complex Concepts Simplified

Last‑antecedent rule: A grammar‑based canon suggesting a trailing modifier (“thereof”) usually applies only to the immediately preceding term (“bacterial or viral infection”). It is a default rule that yields to context. Courts will not apply it when the policy’s structure and purpose indicate a broader modifier.
Contra proferentem: If an insurance term is genuinely ambiguous—reasonably susceptible to more than one meaning—it is construed against the drafter (here, the insurer). This doctrine does not apply where one reading is implausible in context or where provisions can be harmonized.
“Directly and independently of all other causes”: A common AD&D limitation that requires the accident, standing alone, to cause the loss. If sickness or its treatment contributes, coverage typically fails—either by definition or via exclusion.
Medical‑treatment exclusion: A clause excluding losses caused by the treatment of enumerated maladies (sickness, disease, infirmity, infection). It allocates illness‑related risks—including adverse outcomes of medical care—to health or life insurance, not AD&D.
Voluntary‑ingestion exclusion with “unless prescribed”: Excludes losses caused by voluntarily taking drugs, unless taken under a physician’s direction and as prescribed. Here, the proviso salvages coverage only when the prescribed medication treats an accidental injury, not an illness or infirmity.
ERISA standard of review: Courts review benefits denials de novo unless the plan grants discretionary authority, which triggers abuse‑of‑discretion review. State laws can impact such discretion, but federal preemption and choice‑of‑law issues complicate the analysis. Jensen resolved the case without deciding these questions.
Spradley “no sandbagging” principle: Insurers must state the reasons for denial during the administrative process; courts will review the decision based on that stated rationale, not new justifications offered later in litigation.

Conclusion

Jensen reinforces a clear, context‑driven reading of AD&D policies. The Tenth Circuit held that the medical‑treatment exclusion reaches losses resulting from prescription medications used to treat sickness, disease, or bodily or mental infirmity, rejecting a grammatical argument that would have limited the exclusion to infections alone. At the same time, it harmonized the voluntary‑ingestion exclusion’s “unless prescribed” proviso by confining its rescue to medications prescribed for accidental injuries and taken as directed. This approach preserves the essential character of AD&D insurance—coverage for accidents independent of illness—while aligning with the Third Circuit’s interpretation of the same LINA clause.

For plan sponsors and administrators, the opinion validates reliance on well‑drafted medical‑treatment exclusions in prescription‑drug death cases involving treatment of illness. For claimants, it underscores that successful ERISA challenges must grapple with policy structure and purpose, not grammar alone. Although the ruling is nonprecedential and leaves standard‑of‑review questions open, its reasoning offers a persuasive and pragmatic template for resolving similar disputes across jurisdictions.