Can an Insurer Deny AD&D Benefits When Death Results from Prescribed Medication?
Life can change in a heartbeat, and so can the interpretation of an insurance policy.
If a loved one died from prescribed medication and the AD&D insurer denied the claim under a 'medical treatment' exclusion, here's what the law says — and where beneficiaries can say ‘not so fast’.
Your spouse took medication exactly as prescribed by a doctor for a legitimate medical condition. The medication — or a combination of prescribed medications — caused a fatal reaction. You file a claim under the accidental death and dismemberment policy through your spouse's employer. The insurer denies it. The denial letter says the death was not an accident — it was the result of "medical or surgical treatment" of a sickness or disease, and the policy excludes that.
You are looking at a denial letter that feels deeply wrong. Your spouse did not choose to die. Your spouse followed a doctor's instructions. And the insurer is telling you that following a doctor's instructions disqualifies the death from coverage.
This is one of the most common — and most misunderstood — denial patterns in AD&D insurance. It turns on a clause called the medical treatment exclusion, and understanding how courts interpret it is the difference between accepting a denial and knowing whether you have a case.
What Is the Medical Treatment Exclusion?
Most AD&D policies contain a list of exclusions — circumstances under which the insurer will not pay benefits even if the death would otherwise qualify as accidental. The medical treatment exclusion is among the most consequential. In its most common form, the exclusion states that benefits will not be paid for any loss that is caused by or results from:
sickness, disease, bodily or mental infirmity, bacterial or viral infection, or medical or surgical treatment thereof
The key phrase is "medical or surgical treatment thereof." The insurer's position is that if a person dies from medication prescribed to treat a sickness, disease, or infirmity, the death resulted from the medical treatment of that condition — and the exclusion applies. The death does not need to be caused by the condition itself. It is enough that the death was caused by the treatment of the condition.
This exclusion appears in AD&D policies issued by LINA (Life Insurance Company of North America), Cigna, MetLife, and many other group insurers. If you are reading this because you received a denial citing this exclusion, you are far from alone.
Jensen v. LINA: What the Tenth Circuit Said
The Tenth Circuit addressed this exclusion directly in Jensen v. Life Insurance Company of North America, No. 24-4014 (10th Cir. Apr. 4, 2025). The facts are straightforward and deeply familiar to anyone who has received this kind of denial.
Steven Jensen suffered from chronic pain and anxiety. His doctors prescribed oxycodone for the pain and clonazepam for the anxiety. Both prescriptions were legitimate, written by licensed physicians, and taken as directed. On February 1, 2019, Steven's wife Jill found him dead. The autopsy determined the cause of death was combined toxicity of oxycodone and clonazepam. Neither drug was at a dose outside the therapeutic range individually, but together they proved fatal.
Jill Jensen filed for the $500,000 AD&D benefit under Steven's employer-sponsored plan. LINA denied the claim, citing the medical treatment exclusion. The medications were prescribed to treat Steven's chronic pain and anxiety — both of which are sicknesses or bodily infirmities under the policy. Therefore, LINA argued, his death resulted from medical treatment of those conditions, and the exclusion barred benefits.
Jensen fought the denial through the administrative process and then in federal court. She lost at both levels. The Tenth Circuit affirmed, finding the exclusion unambiguous.
The grammatical argument that almost worked
Jensen's primary argument was creative and linguistically sophisticated. She pointed to the structure of the exclusion clause and argued that under the "last-antecedent rule" — a canon of interpretation holding that a modifying phrase applies only to the term immediately preceding it — the phrase "medical or surgical treatment thereof" modified only "bacterial or viral infection," not the earlier items in the list (sickness, disease, bodily or mental infirmity).
If that reading were correct, the exclusion would only bar benefits when death resulted from medical treatment of a bacterial or viral infection — not from medical treatment of chronic pain, anxiety, or other non-infectious conditions.
The Tenth Circuit acknowledged that a straightforward application of the last-antecedent rule supported Jensen's position. But the court held that the rule was overcome by context. Three contextual factors drove the decision:
The purpose of AD&D insurance. The court emphasized that AD&D policies are designed to cover losses resulting solely from accidents — not losses contributed to by sickness or its treatment. The policy's own definition of "covered accident" required that the event occur "directly and independently of all other causes" and not be "contributed to by disease, sickness, or mental or bodily infirmity." Reading the medical treatment exclusion to cover only bacterial and viral infections would be inconsistent with this broader structure.
The practical absurdity problem. Jensen could offer no reason why the policy would exclude benefits for death caused by medical treatment of a bacterial infection but pay benefits for death caused by medical treatment of chronic pain, cancer, heart disease, or any other non-infectious condition. The distinction made no practical sense, and the court declined to adopt an interpretation that produced it.
Third Circuit precedent on identical language. In Viera v. Life Insurance Co. of North America, 642 F.3d 407 (3d Cir. 2011), the Third Circuit examined the same LINA policy language and reached the same conclusion — the last-antecedent rule did not control because the overall context of the policy made the insurer's reading the only reasonable one.
The "sliver of daylight" — when the exclusion does NOT apply
The most practically important part of the opinion is a passage that most readers of the case will miss — and that most case summaries omit entirely.
Jensen argued that the medical treatment exclusion conflicted with a separate exclusion in the policy: the voluntary ingestion exclusion, which bars benefits for death caused by voluntary ingestion of drugs "unless prescribed or taken under the direction of a Physician and taken in accordance with the prescribed dosage." Jensen's argument was logical: if the medical treatment exclusion already bars benefits for any death caused by prescribed medication, then the "unless prescribed" carve-out in the voluntary ingestion exclusion is meaningless. Why would the policy preserve coverage for prescribed medications in one clause and eliminate it in another?
The Tenth Circuit's answer identifies a critical distinction that beneficiaries and their attorneys need to understand:
The medical treatment exclusion applies only when the medication was prescribed to treat sickness, disease, or bodily or mental infirmity. It does not apply when the medication was prescribed to treat an accidental injury.
The court defined "infirmity" by its common meaning — a state of weakness or disease — and held that it does not encompass injuries caused by accidents. This means: if a person is injured in a car accident, is prescribed opioids for the resulting pain, and dies from an adverse reaction to those medications, the medical treatment exclusion does not apply, because the medication was prescribed for an accidental injury, not for a sickness or infirmity. The voluntary ingestion exclusion's "unless prescribed" carve-out preserves coverage for exactly that scenario.
This distinction — treatment for sickness versus treatment for injury — is the doctrinal line that separates covered from excluded deaths under these policies. It is the single most important takeaway from the Jensen decision for AD&D beneficiaries.
What This Means Through a Litigation-Back Lens
In the framework I use to evaluate every ERISA benefit denial, the outcome of a case depends on two axes: the strength of the insurer's process and the strength of the claimant's evidence. Jensen illustrates both.
The insurer's process was strong. LINA cited the exclusion clearly. When it initially invoked two exclusions (medical treatment and voluntary ingestion), it reconsidered and dropped the weaker one — demonstrating a reasoned, deliberate claims process. The denial letter identified the specific policy provision. The court found no procedural deficiency.
The claimant's legal arguments were creative but could not overcome unambiguous policy language. Jensen's last-antecedent argument was sophisticated — the court acknowledged it had surface-level grammatical support — but the broader policy context was too strong. The claimant's evidence on the merits (that Steven died from prescribed medications) was not in dispute; the problem was that those undisputed facts fell squarely within the exclusion as interpreted by the court.
This places Jensen in the red box of the matrix: insurer's process strong, claimant's position weak. But — and this is the critical litigation-back insight — the outcome might be different with different facts, different policy language, or a different framing of the cause of death.
Where Beneficiaries Can Fight Back
Jensen is a loss for the claimant, and I am not going to pretend otherwise. But the decision itself identifies several avenues that remain open in other cases — and that an experienced AD&D attorney evaluates at intake:
Was the medication prescribed for an injury or for a sickness?
This is the Jensen distinction. If the decedent was prescribed medication to treat an injury from an accident — a workplace injury, a car accident, a fall — rather than a chronic illness or disease, the medical treatment exclusion may not apply. The voluntary ingestion exclusion's "unless prescribed" carve-out would preserve coverage. This is a factual question that turns on what the prescribing physician documented in the medical records as the reason for the prescription. The records need to say "prescribed for pain resulting from [accidental injury]," not "prescribed for chronic pain." That kind of documentation is something a litigation-back attorney thinks about before the claim is even filed.
Is the policy language identical to the LINA language in Jensen?
Not all medical treatment exclusions are worded the same way. Some are narrower. Some use different punctuation or structure that may make the last-antecedent argument stronger. Some define "sickness" or "infirmity" in ways that create genuine ambiguity. The Jensen court emphasized that its analysis was specific to the policy language before it. A different policy with different wording could produce a different result — particularly in circuits that have not yet addressed this issue.
Does the policy's choice-of-law provision matter?
Jensen raised but the court did not decide a significant subsidiary question: whether Utah's ban on discretionary-authority clauses in insurance contracts overrides the policy's Delaware choice-of-law provision. The court sidestepped this by ruling under de novo review, but in a closer case — one where the policy language is ambiguous — the standard of review could be outcome-determinative. Under de novo review, ambiguity is construed against the insurer through contra proferentem. Under abuse-of-discretion review, the insurer's reasonable interpretation prevails even if another interpretation is also reasonable. Whether you get de novo or abuse of discretion can depend on state law, and an attorney who understands this evaluates it before the administrative appeal closes.
Was the cause of death correctly characterized?
This is the most underappreciated variable in AD&D claims. The medical treatment exclusion requires that the death was "caused by or results from" medical treatment of sickness. If the cause of death can be characterized as something other than a direct result of medical treatment — for example, an unforeseeable drug interaction that the prescribing physician did not anticipate and could not have predicted — there may be an argument that the death was accidental even though medications were involved. This is fact-intensive and depends heavily on the medical evidence, the autopsy findings, and the expert opinions in the record.
What did the administrative record look like?
Jensen's administrative appeal is not discussed in detail in the opinion, which usually means it was procedurally adequate but substantively thin. In a litigation-back approach, the administrative appeal is where the case is built. Medical records that document the prescribing physician's characterization of the condition, expert opinions on foreseeability, policy interpretation arguments grounded in contra proferentem, and document requests for the full policy and administrative record — all of this needs to be in the file before it closes. Once the administrative decision issues, the record is generally locked.
Practical Guidance for AD&D Beneficiaries
If you have lost a loved one to a medication-related death and the AD&D insurer has denied the claim — or if you are about to file a claim and want to understand the risks — here is what I recommend:
Get the full policy, not just the certificate or summary. The exclusion language matters word by word. Differences in punctuation, structure, and defined terms can change the analysis. You have a right to the full policy document under 29 U.S.C. § 1024(b)(4). Request it in writing.
Look at what the prescribing physician documented as the reason for the prescription. "Chronic pain" and "pain from [date] workplace injury" are clinically similar but legally different under the medical treatment exclusion. If the medication was prescribed for an accidental injury, the exclusion may not apply.
Preserve arguments about ambiguity during the administrative appeal. If the policy language is susceptible to more than one reasonable reading, the doctrine of contra proferentem requires that ambiguity be construed against the insurer — but only if the argument is raised. Do not wait for litigation to make this argument.
Do not accept the denial at face value. The fact that the insurer cited an exclusion does not mean the exclusion applies. Exclusions are affirmative defenses — the insurer bears the burden of proving they apply. The factual predicates (Was this treatment of a "sickness"? Was the medication the proximate cause of death?) must be established, not assumed.
Consult an attorney before the administrative appeal deadline. The record closes when the final administrative decision issues. An attorney experienced in AD&D denials can evaluate the policy language, the medical records, and the denial rationale — and can help ensure the administrative record contains everything a federal court will need to see.
Frequently Asked Questions
Can an AD&D insurer deny benefits if my loved one died from prescribed medication?
In many cases, yes — if the medication was prescribed to treat a sickness, disease, or bodily infirmity and the policy contains a medical treatment exclusion. The Tenth Circuit upheld exactly this kind of denial in Jensen v. LINA. However, if the medication was prescribed to treat an injury from an accident rather than a sickness, the exclusion may not apply.
What is the difference between the medical treatment exclusion and the voluntary ingestion exclusion?
The voluntary ingestion exclusion bars benefits for death caused by voluntary drug use, but carves out an exception for medications taken as prescribed. The medical treatment exclusion bars benefits for death caused by medical treatment of sickness, disease, or infirmity — even when the medication was prescribed. The two exclusions overlap but are not identical: the voluntary ingestion exclusion preserves coverage for prescribed medications used to treat accidental injuries, while the medical treatment exclusion does not extend to injury-related treatment.
Does the medical treatment exclusion apply in every AD&D policy?
No. The exclusion is common but not universal, and its exact wording varies across insurers and policies. Some policies use broader language, some narrower. The analysis in Jensen is specific to the LINA policy language at issue. A different policy with different wording — or in a different circuit — could produce a different result.
What is contra proferentem, and does it help?
Contra proferentem is a doctrine requiring that ambiguous contract language be construed against the drafter — in this case, the insurer. If the medical treatment exclusion is genuinely ambiguous (reasonably susceptible to more than one interpretation), this doctrine requires the court to adopt the interpretation that favors coverage. In Jensen, the Tenth Circuit found no ambiguity, so contra proferentem did not apply. But in cases with different policy language, this doctrine can be decisive.
Does it matter whether the court reviews my claim de novo or for abuse of discretion?
It can matter enormously. Under de novo review, the court decides the merits independently and construes ambiguities against the insurer. Under abuse of discretion review, the court defers to the insurer's reasonable interpretation — even if another interpretation is also reasonable. Whether you get de novo or deferential review depends on the policy language, applicable state law, and sometimes the specific plan documents. This is a question an experienced ERISA attorney evaluates early.
Closing Thoughts
Jensen v. LINA is a case the claimant lost. I include it here not because it supports a particular result, but because it clarifies the law in a way that is genuinely useful for anyone facing this kind of denial. The medical treatment exclusion is real, it is enforceable, and the Tenth Circuit has now confirmed — consistent with the Third Circuit — that it applies to deaths caused by medications prescribed for sickness or disease. That is the honest state of the law.
But the decision also identifies, for anyone reading carefully, the line where the exclusion stops: treatment for accidental injury. That distinction — documented in the prescribing physician's records, preserved in the administrative appeal, and argued in federal court — is the kind of detail that changes outcomes. It is exactly the kind of detail that a litigation-back approach is designed to identify and act on before the record closes.
If you have received an AD&D denial citing a medical treatment exclusion, or if you are preparing to file a claim after a medication-related death, I would welcome the opportunity to review the policy language and the facts with you. Contact Dorian Law for a consultation.
This article is for informational purposes and does not constitute legal advice. Every AD&D claim turns on its specific policy language, facts, and applicable law; readers facing a benefit denial should consult counsel experienced in ERISA and AD&D litigation.
Primary case discussed:
Jensen v. Life Insurance Company of North America, No. 24-4014 (10th Cir. Apr. 4, 2025) (unpublished)
Additional authorities cited:
Viera v. Life Insurance Co. of North America, 642 F.3d 407 (3d Cir. 2011)
Senkier v. Hartford Life & Accident Ins. Co., 948 F.2d 1050 (7th Cir. 1991)