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Central Sensitization Syndrome (CSS) is a complex neurological disorder characterized by increased sensitivity to pain and other stimuli. This increased sensitivity is not only painful, but often debilitating, making it difficult or impossible to maintain employment. Despite its serious impact, individuals with CSS often face challenges in securing long-term disability (LTD) benefits due to misconceptions about the condition, a lack of awareness, or the limitations in how insurance policies handle invisible illnesses.
This article discusses the symptoms and complications of CSS, the medical evidence needed to support a disability claim, the challenges claimants face, and how an experienced long-term disability attorney can help.
Understanding Central Sensitization Syndrome
Central Sensitization Syndrome occurs when the central nervous system (CNS) becomes overly sensitive, amplifying both painful and non-painful stimuli. This heightened state can cause symptoms that overlap with other chronic conditions. It is closely associated with:
- Fibromyalgia
- Chronic Fatigue Syndrome (CFS)
- Irritable Bowel Syndrome (IBS)
- Temporomandibular Joint Disorder (TMJ)
- Post-COVID Syndrome (Long Covid)
According to the National Institutes of Health (NIH), CSS is associated with chronic overlapping pain conditions, a term used to describe several coexisting conditions that often result from central sensitization.
Symptoms and Work Restrictions
The hallmark symptom of CSS is chronic, widespread pain that does not correlate with an observable injury. In addition, individuals may experience:
- Cognitive Impairments: Memory problems, difficulty concentrating, and brain fog.
- Sleep Disturbances: Unrefreshing sleep or insomnia.
- Fatigue: Severe exhaustion that does not improve with rest.
- Mood Disorders: Anxiety and depression, often secondary to chronic pain.
- Sensitivity: Hypersensitivity to stimuli such as light, sound, and touch.
These symptoms can severely limit your ability to perform work-related tasks. For example:
- Cognitive Impairments: May prevent you from multitasking, solving problems, or concentrating on detailed tasks.
- Pain and Fatigue: May make physical activities, even those considered sedentary, intolerable.
- Emotional Distress: Anxiety or depression resulting from CSS may further impair performance at work.
Challenges in Securing LTD Benefits for CSS
Insurance companies often deny claims for CSS based on mental and nervous condition limitations. For example, policies may limit benefits for conditions deemed “psychosomatic” to 24 months, as in the case of Watson v. Reliance Standard Life Insurance Company. This limitation can unfairly restrict claimants who suffer from physical conditions such as CSS but lack definitive objective evidence.
Additional hurdles include:
- Subjective Reporting: Insurers may dismiss symptoms as exaggerated or unfounded.
- Policy Language: Vague definitions of “disability” and mental health exclusions can complicate claims.
- Misinterpretation of Medical Records: Normal test results, such as MRIs, do not rule out disabling conditions like CSS but are often used to deny claims.
Legal Precedents Supporting CSS Claims
Cases such as Watson v. Reliance Standard Life Insurance Company demonstrate how courts can side with claimants when insurers fail to adequately consider physical limitations resulting from conditions such as fibromyalgia and CSS. In Watson, the court emphasized that subjective symptoms (e.g., pain, fatigue) must be evaluated alongside objective evidence and cannot be dismissed out of hand.
Proving Disability with CSS
CSS is notoriously difficult to document and prove due to its subjective nature. However, successful disability claims often rely on the following:
- Diagnosis: Confirmed by a specialist, such as a neurologist or rheumatologist.
- Functional Capacity Evaluations (FCEs): Provide an objective measure of how symptoms limit physical and cognitive abilities.
- Residual Functional Capacity (RFC) Forms: These forms detail the claimant’s inability to perform work tasks, such as sitting, standing, or concentrating for long periods of time.
- Independent Medical Evaluations (IMEs): While insurers often rely on IMEs to dispute claims, obtaining an impartial IME or second opinion can strengthen a case.
How the Ortiz Law Firm Can Help You Appeal a Long-Term Disability Denial
Navigating a denied long-term disability (LTD) claim is a complex, frustrating process, but the Ortiz Law Firm offers comprehensive support to help turn your denial into an approval. With over 20 years of experience handling thousands of disability cases, Nick Ortiz and his dedicated team have developed a strategy to create the most compelling appeal possible. Our team will:
- Identify Procedural Errors and Policy Misinterpretations: Insurers often deny claims based on a misapplication of the terms of your policy or an incomplete evaluation of your evidence. We identify these issues and use them to build a strong counterargument.
- Request Updated Medical Records: We promptly request the most recent medical records from all of your treating physicians.
- Customize Residual Functional Capacity (RFC) Forms: These forms are designed specifically for your condition and address your limitations in detail. We work with your doctors to ensure the forms are accurate and compelling.
- Prepare Your Sworn Statement: We prepare affidavits that highlight your struggles and demonstrate how your condition directly affects your daily life and ability to work.
- Research Legal Precedents: Drawing on relevant case law, we demonstrate how subjective symptoms such as chronic pain and fatigue cannot be dismissed out of hand and must be carefully considered.
- Prepare a Comprehensive Appeal: Combining our findings, we prepare a detailed appeal document—typically 14-20 pages—that addresses the medical, vocational, and legal errors made in the denial. We argue why your condition meets the policy’s definition of disability and how the insurer failed to fairly evaluate your claim.
This approach strengthens your case by presenting your condition and limitations in a clear, authoritative manner and ensures that we leave no gaps in our appeal, providing a robust challenge to the insurer’s denial.
Why Choose the Ortiz Law Firm for Your LTD Appeal?
Choosing the right legal team for your long-term disability appeal can make all the difference. Here is why claimants across the country choose the Ortiz Law Firm:
Ongoing Communication and Support
We understand that the process of appealing a denial can feel overwhelming, which is why we prioritize clear and transparent communication. With the Ortiz Law Firm, you’ll receive:
- A dedicated paralegal and legal assistant for personalized support.
- Access to a secure client portal for 24/7 updates on the status of your case.
- Flexible communication options, including phone, text, or email—whatever works best for you.
Our No Recovery, Zero Fee Guarantee
We believe in results, which is why we work on a contingency basis. You pay no upfront fees, and you only owe us if we successfully recover for you. This means there’s no financial risk for you.
Proven Experience
With over two decades of experience and a track record of handling thousands of long-term disability claims, our firm is uniquely positioned to navigate the complexities of LTD appeals. Whether your denial involves procedural errors, insufficient evidence, policy misinterpretations, we have the expertise to help you fight back.
Contact the Ortiz Law Firm to Take the Next Step
Long-term disability claims for conditions like Central Sensitization Syndrome are inherently challenging due to their subjective nature. Insurers often rely on a lack of objective testing or interpret symptoms as psychosomatic. If your LTD claim has been denied, don’t lose hope. Many claimants face similar challenges, but with the right strategy and support, it is possible to secure the benefits you deserve.
With our meticulous process, we ensure that your appeal is as strong as possible, giving you the best chance of securing the benefits you deserve. Contact the Ortiz Law Firm today to learn how we can help you fight back and get the benefits you’re entitled to. Call (888) 321-8131 today for a free case evaluation.
Sources
- Cleveland Clinic Journal of Medicine. “Central sensitization, chronic pain, and other symptoms: Better understanding, better management.” Retrieved from: https://www.ccjm.org/content/90/4/245. Accessed on January 31, 2025.
- National Library of Medicine. “Central Pain Syndrome.” Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK553027/. Accessed on January 31, 2025.
- Mayo Clinic. “What is central sensitization and how does it relate to pain?.” Retrieved from: https://mcpress.mayoclinic.org/living-well/what-is-central-sensitization-and-how-does-it-relate-to-pain/. Accessed on January 31, 2025.