Case Review Corner: Accidental Death vs. Medical Treatment - A Tenth Circuit Ruling on Policy Exclusions

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Introduction:

Accidental Death and Dismemberment (AD&D) policies are designed to provide benefits when loss occurs due to a sudden and unexpected event—sometimes it must be an external event. However, these policies often contain exclusions that can significantly impact coverage. Our latest "Case Review Corner" examines the published Tenth Circuit Court of Appeals opinion in Jill L. Jensen v. Life Insurance Company of North America (LINA), a case that delves into the interpretation of a "medical treatment" exclusion in an ERISA-governed AD&D policy. This ruling underscores the importance of understanding the specific language of insurance policies and how courts interpret those terms.

Reviewing the Facts: Chronic Pain, Prescribed Medications, and a Tragic Outcome

Jill Jensen's husband, Steven Jensen, suffered from chronic pain and anxiety for which his doctors prescribed oxycodone and clonazepam. In February 2019, Steven tragically died from the toxicity of these drugs. Jill Jensen, as the beneficiary of Steven's AD&D policy through his employer, Codale Electric Supply, Inc., filed a claim with LINA. However, LINA denied the claim, citing an exclusion in the policy for loss "caused by or results from... sickness, disease, bodily or mental infirmity... or medical or surgical treatment thereof."

The Legal Issue(s): Did the Medical Treatment Exclusion Apply to Death from Prescribed Medication?

The central legal issue before the Tenth Circuit was whether LINA properly denied AD&D benefits based on the policy's exclusion for loss caused by "medical or surgical treatment" of sickness, disease, or bodily or mental infirmity. Specifically, the court considered whether Steven Jensen's death, resulting from the use of prescribed medications to treat his chronic pain and anxiety, fell within this exclusion.

What Was the Court's Reasoning? Affirming the Denial of Benefits

The Tenth Circuit Court of Appeals affirmed the district court's judgment in favor of LINA, concluding that the medical treatment exclusion unambiguously applied to Steven Jensen's death. The court reasoned as follows:

• De Novo Review: The court reviewed the district court's summary judgment ruling de novo, meaning they considered the matter anew.

• Policy Language: The court focused on the common and ordinary meaning of the policy language as a reasonable person in the position of the plan participant would have understood it.  

• Rejection of Last-Antecedent Rule Argument: Jensen argued that under the last-antecedent rule, the phrase "medical or surgical treatment thereof" only applied to "bacterial or viral infection," the last item in the list. The court rejected this argument, stating that the rule is not absolute and can be overcome by other indicators of meaning, such as the context of the policy.

• Context of AD&D Policy: The court emphasized that AD&D insurance is intended to provide benefits for loss resulting solely from an accident, not for losses contributed to by sickness or medical treatment of sickness. The policy itself excluded benefits for loss caused by sickness.  

• Consistency of Exclusions: The court also addressed Jensen's argument that the medical treatment exclusion conflicted with the voluntary ingestion exclusion's exception for prescribed medications. The court clarified that the voluntary ingestion exclusion's "unless prescribed" clause was broader and could apply to medications prescribed for accidental injuries, thus creating no conflict with the medical treatment exclusion for sickness or infirmity.  

What the Claimant Did Right:

• Jill Jensen, as the beneficiary, filed a claim for AD&D benefits following her husband's death.

• She pursued an administrative appeal with LINA after the initial denial.

What the Claimant Could Have Done Better:

• While the outcome hinged on the court's interpretation of the policy language, understanding the scope and limitations of an AD&D policy, particularly exclusions related to medical treatment and the underlying cause of the treatment (sickness vs. accident), is crucial for beneficiaries when assessing potential claims.

For Legal Professionals: Tenth Circuit Clarifies "Medical Treatment" Exclusion in ERISA AD&D Policy

The Tenth Circuit's published opinion in Jensen v. LINA offers valuable clarity on the interpretation of "medical or surgical treatment" exclusions in ERISA-governed Accidental Death and Dismemberment policies. The court's rejection of the last-antecedent rule argument and its emphasis on the broader context of an AD&D policy – which typically excludes losses caused by sickness or the treatment thereof – provides a significant precedent. This case underscores the importance of analyzing the policy language as a whole and considering the overall purpose of AD&D coverage when evaluating such exclusions. Practitioners should note the court's distinction between medical treatment for sickness or infirmity and treatment for accidental injuries in the context of the policy's voluntary ingestion exclusion.

Conclusion:

The Tenth Circuit's decision in Jensen v. LINA serves as an important reminder of the limitations inherent in Accidental Death and Dismemberment insurance policies. The unambiguous medical treatment exclusion in this case, as interpreted by the court, precluded benefits for a death resulting from prescribed medications taken to treat underlying medical conditions. Understanding these policy exclusions is essential for both policyholders and beneficiaries in assessing the scope of AD&D coverage.

Facing a denial of Accidental Death and Dismemberment benefits? Dorian Law PC can provide experienced guidance and evaluate your case under ERISA law. Contact us for a review of your policy terms.

***Please note that this blog provides Useful Tips, Emerging Trends, and Thoughtful Insights regarding LTD, Life, and AD&D Insurance, including summaries of reported legal decision and does not constitute legal advice. Since posting, this blog has not been updated to reflect any subsequent changes in the law. Usually the cases discussed in Case Review Corner were handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit or bad faith insurance claim, Dorian Law P.C. may be able to advise you, so please contact us.***