Fibromyalgia And The Disability Insurance Claims Process

Those suffering from a severe case of Fibromyalgia know that it can cause widespread, debilitating pain, cognitive problems such as memory loss or difficulty with concentration, and overwhelming fatigue. Unfortunately, the cause of fibromyalgia remains unclear and there are no definitive diagnostic tests (such as X-rays or blood tests) that can be used to confirm the diagnosis or its severity. Additionally, because there is little in the way of “objective” evidence to confirm a diagnosis of fibromyalgia, it is often evaluated as a psychiatric condition by many insurance companies (all in the insured’s head) and not considered a truly disabling illness. Moreover, insurance companies realize that some people experience only mild symptoms and can work despite their symptoms. However, what many insurance claims examiners fail to recognize is that for some people, the pain is quite severe and often prevents them from doing simple things like going for a walk, household chores, and going to work. If you have fibromyalgia and are unable to work, navigating the disability process can be difficult and frustrating.

The best chance of filing a successful fibromyalgia claim with your long term and/or private disability insurance carrier is to make sure you understand the relevant terms of your insurance policy and that you work closely with your doctor. Some long term disability companies attempt to limit claims involving illnesses such as fibromyalgia or chronic fatigue to 2 years. While some policies explicitly limit benefits to 24 months for named illnesses such as fibromyalgia and chronic fatigue, others attempt to hide this limitation by using terms that limit disability benefits for conditions that are primarily based on “self-reported” symptoms. Thus, understanding what’s in your policy may mean the difference between a twenty-four month period of benefits and benefits to age 65 or for life.

It is also important that you coordinate with your doctor to make sure that your fibromyalgia symptoms are being accurately documented and that the medical records detail the number of tender points that are sensitized and where they are located; the level of your pain, cognitive and memory problems, and any activities that you are unable to do as a result of this pain. Most long term disability carriers look for objective evidence of the diagnosis of fibromyalgia as well as for evidence that it is causing physical restrictions and limitations that result in the inability to work. A common claim by many LTD carriers is that the insured has not provided any “objective evidence” of disability. However, it should be noted that many federal courts have acknowledged that cases involving illnesses like fibromyalgia or chronic fatigue are distinguishable from other illnesses because, while it is a credible diagnosis, there are no laboratory tests to positively confirm such diagnoses. Additionally, while many disability carriers may challenge a fibromyalgia claim at the onset and throughout the claims process, courts and the Social Security Administration now rely on criteria issued by the American College of Rheumatology to determine whether an insured has fibromyalgia and are thus “disabled” under the policy. Thus, it is imperative that you develop the necessary medical proof to establish that you have fibromyalgia and that the resulting physical restrictions and limitations prevent you from engaging in your own occupation, or where applicable, any gainful occupation.

In many cases where the LTD carrier has accepted the diagnosis of fibromyalgia, they will request an “independent medical review” by a physician they have hired to review the medical records. It is also quite possible that the insurer will request an “independent medical examination” (IME) of the insured. As discussed in more detail in other articles on this blog about insurance company claim denial tactics, these “independent” physicians are usually quite biased in favor of the insurance company (who is paying them to review the claim) and tend to overwhelmingly conclude that the insured, while ill, still has the capacity to function in his or her own occupation or in a sedentary occupation.

Just as important as the physical limitations is the fact that those suffering from fibromyalgia often have difficulties with fatigue, memory, concentration, and other cognitive issues. These problems are not usually addressed during the IME (or are blatantly ignored) and are instrumental reasons why the insured cannot function in any work setting. These symptoms, while debilitating, are often tricky to measure, as psychological testing does not analyze concentration, the ability to handle complex tasks, the ability to multitask, fatigue, and concentration. In fact, many who suffer from fibromyalgia are quite intelligent.

Providing the insurance company with the proper information and proof of disability is extremely important and can be the difference between a successful claim for benefits, or a successful appeal if your claim has been denied, and a failed claim. Seeking legal counsel is an important way to understand your rights under your policy and secure the benefits to which you are entitled.

If you suffer from fibromyalgia, chronic fatigue or some other debilitating illness or injury and intend to file a claim for disability benefits, or have already filed a claim and are either waiting for approval or have been denied benefits, please contact our firm, DI L aw Group, at (954)-989-9000 or www.dilawgroup.com for a free consultation.