Contextual Clarity: Medical-Treatment Exclusion Precludes AD&D Benefits for Prescription-Drug Deaths

Introduction

Jensen v. Life Insurance Company of North America (10th Cir. April 4, 2025) addresses whether an accidental‐death and dismemberment (AD&D) policy issued under an ERISA plan must pay benefits when a beneficiary dies from doctor-prescribed medication toxicity. Plaintiff-appellant Jill Jensen sought AD&D benefits after her husband, Steven Jensen, died of oxycodone and clonazepam toxicity in February 2019. The insurer (LINA) denied benefits under an exclusion for “medical or surgical treatment” of sickness. The district court agreed that the policy language was unambiguous, and the Tenth Circuit affirmed.

Key issues:

• How to interpret the “medical‐treatment exclusion” in an ERISA‐governed AD&D policy
• Whether the “last‐antecedent rule” or the policy’s broader context controls construction
• Whether any ambiguity triggers contra proferentem against the insurer

Parties:

• Appellant: Jill L. Jensen, widow and beneficiary under the Plan
• Appellee: Life Insurance Company of North America (LINA), AD&D insurer
• Plan Administrator: Codale Electric Supply, Inc., under ERISA

Summary of the Judgment

The Tenth Circuit affirmed the district court’s grant of summary judgment in favor of LINA. The court held that:

1. The “medical or surgical treatment” exclusion unambiguously precluded AD&D benefits when death results from prescribed medications taken to treat sickness, disease, or infirmity.
2. Contextual evidence—policy language defining “covered accident” as excluding losses “contributed to by disease” and a cover page disclaimer—overcomes any presumption in favor of the last‐antecedent rule.
3. There is no conflict between the medical‐treatment exclusion and the voluntary‐ingestion carve-out (“unless prescribed and taken as directed”), because that carve-out preserves benefits only for medications prescribed to treat an accidental injury, not sickness.
4. No ambiguity arose that would require construing the exclusion against the insurer under contra proferentem.

Analysis

1. Precedents Cited

• LaAsmar v. Phelps Dodge Corp. (605 F.3d 789, 10th Cir. 2010): Established that ERISA‐plan interpretations are reviewed de novo absent a discretionary clause.
• Firestone Tire & Rubber Co. v. Bruch (489 U.S. 101, 1989): Held that ERISA fiduciaries’ benefit‐denial decisions receive abuse‐of‐discretion review if the plan grants discretionary authority.
• Lockhart v. United States (577 U.S. 347, 2016): Described the last‐antecedent canon and its limitations when context points to a broader meaning.
• Miller v. Monumental Life Ins. Co. (502 F.3d 1245, 10th Cir. 2007): Defined how to interpret ERISA‐plan terms by a reasonable participant standard.
• Viera v. Life Insurance Co. of N. Am. (642 F.3d 407, 3d Cir. 2011): Concluded that identical medical‐treatment exclusion language could not be read narrowly under the last‐antecedent rule.

2. Legal Reasoning

The court’s reasoning followed these steps:

1. Standard of Review: Although the policy contained a discretionary‐authority clause, the Tenth Circuit assumed de novo review because the ultimate outcome would be the same under any standard.
2. Plain‐Language Analysis: Under Miller and Carlile, unambiguous terms are enforced as written. The medical‐treatment exclusion—“no benefits for loss … caused by … medical or surgical treatment thereof”—on its face covers treatment of any listed illness, including sickness, disease, and infirmity.
3. Last‐Antecedent Rule: Jensen argued that the absence of a comma meant the “medical or surgical treatment” phrase modified only “bacterial or viral infection.” The insurer conceded the grammar but pointed to contextual language that contradicted such a confined reading.
4. Context Overrides Grammar: The policy’s cover page states, “does not pay benefits for loss caused by sickness.” Definitions of “covered accident” exclude losses “contributed to by disease, sickness, [or] mental or bodily infirmity.” These provisions demonstrate the insurer’s intent to carve out all treatment‐related losses from accidental coverage—not just those for infections.
5. Unitary Interpretation of Exclusions: The voluntary‐ingestion exclusion (“unless prescribed … and taken in accordance with the prescribed dosage”) preserves benefits only for prescription medication taken to treat an accidental injury, not sickness. Therefore, no irreconcilable inconsistency arises.
6. No Ambiguity for Contra Proferentem: Because the only reasonable interpretation is that the medical‐treatment exclusion applies, there is no ambiguity to construe against the drafter under ERISA’s contra proferentem principle.

3. Impact

This decision clarifies several points for insurers, plan administrators, and litigants in the ERISA AD&D context:

• Clear policy definitions and cover‐page disclaimers can override grammatical canons in exclusionary clauses.
• Insurers may rely on broad exclusions for “medical or surgical treatment” to deny benefits when prescribed drugs result in fatal accidents, provided the policy language is unambiguous in context.
• Beneficiaries challenging such exclusions must demonstrate a genuinely reasonable alternative interpretation, not merely a grammatical possibility.
• Contra proferentem will not apply where contextual indicators affirm the insurer’s intended scope of an exclusion.

Future litigants should ensure administrative denials explain both the grammatical and contextual bases for exclusionary interpretations to withstand appellate scrutiny.

Complex Concepts Simplified

• Last‐Antecedent Rule: A grammatical principle that a modifying phrase (e.g., “medical treatment thereof”) normally applies only to the immediately preceding item in a list. It can be displaced by clear contextual indicators.
• Contra Proferentem: An interpretive doctrine that ambiguous contract terms are construed against the drafter (often the insurer). It applies only if genuine ambiguity remains after considering context.
• De Novo vs. Abuse‐of‐Discretion Review: Under ERISA, courts review denial of plan benefits de novo unless the plan grants the administrator discretionary authority. Abuse‐of‐discretion review is more deferential.
• Covered Accident vs. Treatment‐Related Loss: AD&D policies are designed to cover unforeseen injuries from accidents alone; losses “contributed to by” illness or treatment typically fall outside.

Conclusion

Jensen v. Life Ins. Co. of North America reaffirms that in ERISA-governed AD&D plans, a well-drafted medical-treatment exclusion unambiguously bars benefits when death results from prescribed drugs taken to treat sickness. The decision underscores the primacy of policy context over narrow grammatical canons and limits the applicability of contra proferentem when an insurer’s intended scope is clear. As a persuasive authority, Jensen will guide future disputes over prescription-drug fatalities and the interpretation of exclusionary language in employee benefit plans.