Long-Term Disability For Fibromyalgia

Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas. Scientists estimate that fibromyalgia affects millions of people in the US. Patients who find themselves unable to work because of their fibromyalgia may qualify for long-term disability (LTD) benefits. The insurance company will review their claim to see if they qualify under the conditions of that plan.

Understanding Fibromyalgia

Fibromyalgia is a condition that causes widespread musculoskeletal pain, along with issues like fatigue, sleep disturbances, and problems with memory and mood. Experts think that fibromyalgia makes painful sensations feel stronger by affecting how your brain and spinal cord process both painful and nonpainful signals.

Fibromyalgia is most common in women. However, men and children can also have the disorder. Individuals who have a family member with fibromyalgia may be more likely to have fibromyalgia themselves. People with certain other diseases may be more likely to have fibromyalgia. These diseases include:

• Osteoarthritis
• Rheumatoid arthritis
• Lupus

What Are the Symptoms of Fibromyalgia?

People with fibromyalgia may also have other symptoms, such as:

• Trouble sleeping.
• Morning stiffness.
• Headaches.
• Painful menstrual periods.
• Tingling or numbness in hands and feet.
• Problems with thinking and memory (sometimes called “fibro fog”).

To complicate things even further, those who have fibromyalgia tend to have a lower pain tolerance than most due to the condition itself. This can, in turn, intensify the symptoms and may have a significant impact on the patient’s quality of life. In some cases, dealing with fibromyalgia may cause mental problems such as depression, anxiety, and fatigue, in addition to the physical symptoms.

A person may also have two or more co-existing chronic pain conditions. Such conditions can include chronic fatigue syndrome, irritable bowel syndrome, interstitial cystitis, migraines, temporomandibular joint dysfunction, and postural tachycardia syndrome (POTS). It is not known whether these disorders share a common cause.

What Causes Fibromyalgia?

The causes of fibromyalgia are unknown. It can occur independently, or several factors could be involved. Fibromyalgia has been linked to:

• Stressful or traumatic events, such as car accidents.
• Repetitive injuries.
• Illness.
• Certain diseases.

How Is Fibromyalgia Diagnosed?

Most people are diagnosed during middle age. In the past, doctors checked 18 specific points on the body to see how many were painful when pressed firmly. New American College of Rheumatology guidelines no longer require this tender point exam. Instead, the main factor for diagnosing fibromyalgia is widespread pain throughout the body for at least three months.

To meet the criteria, you must have pain in at least four of these five areas:

• Left upper region, including shoulder, arm, or jaw
• Right upper region, including shoulder, arm, or jaw
• Left lower region, including hip, buttock, or leg
• Right lower region, including hip, buttock, or leg
• Axial region, which includes neck, back, chest, or abdomen

For a diagnosis, other possible causes for your symptoms should also be ruled out. A licensed physician will typically look for:

• A history of widespread pain lasting at least three months
• Confirmation that other conditions aren’t causing your symptoms
• Evidence of either:
  • Widespread tenderness when certain areas are pressed, or
  • Repeated occurrences of at least six symptoms associated with fibromyalgia (such as fatigue, memory or concentration problems, unrefreshing sleep, and other related signs)

In short, diagnosing fibromyalgia involves a combination of your medical history, symptom patterns, and a careful process of elimination, rather than relying solely on a physical exam.

How Is Fibromyalgia Treated?

Fibromyalgia can be hard to treat and often requires a team approach. The team may include your doctor, a physical therapist, and possibly other health care providers. A pain or rheumatology clinic can be a good place to get treatment.

It’s important to find doctors familiar with the disorder and its treatment. Many family physicians, general internists, or rheumatologists can treat fibromyalgia. Rheumatologists are doctors who specialize in arthritis and other conditions that affect the joints or soft tissues.

Claiming Long-Term Disability for Fibromyalgia

If you are suffering from fibromyalgia and wish to file a long-term disability claim, there are some things you need to know.

The Burden of Proof

Even if you are diagnosed with fibromyalgia, the battle for disability benefits is not over just because you’ve been diagnosed with the condition. In any disability insurance claim, the claimant has the “burden of proof” to prove he or she is disabled. Most insurance companies are denying LTD benefits because they know there are no tests to confirm the condition. Moreover, we are seeing more and more limitations placed on fibromyalgia claims in new LTD insurance policies. For example, many disability insurance policies now have a one or two-year cap on benefits for fibromyalgia claims.

Self-Reported Symptoms Limitation

Many insurance carriers are limiting disability insurance coverage for fibromyalgia under the self-reported symptoms limitation clause of the LTD policy. This clause is sometimes called the non-verifiable condition limitation. Here is some sample language that was taken from a Unum plan, which states:

“Disabilities, due to sickness or injury, which are primarily based on self-reported symptoms, and disabilities due to mental illness, alcoholism or drug abuse have a limited pay period up to 24 months.”

Self-reported symptoms mean the manifestations of your condition you report to your doctor that are not verifiable using tests, procedures, or clinical examinations typically accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to, headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness, and loss of energy.

The key language of the plan limits payment for “disabilities, due to sickness or injury, which are primarily based on self-reported symptoms.” The issue is whether the limitation on function is primarily based on self-reported symptoms or the diagnosis of the disease itself is primarily based on self-reported symptoms. Insurance companies argue that such clauses should be read literally so that the plural self-reported symptoms clause modifies the plural “Disabilities” rather than the singular “illness or injury,” suggesting that the limitation applies if the inability to perform work is self-reported. 

However, when the clause is considered in the context of actual application, the only viable conclusion is that the self-reported symptoms limitation applies to disabling illnesses or injuries that are diagnosed primarily based on self-reported symptoms rather than to all illnesses or injuries for which the disabling symptoms are self-reported. The contrary interpretation advanced by insurance companies would include virtually all diseases within the limitation, leaving only a small subset for coverage beyond the reduced period.

For most illnesses or injuries, the disabling aspect is not the disease itself but the pain, weakness, or fatigue caused by that illness or injury. Even diseases that are extremely likely to cause an inability to work, such as stage IV cancer or advanced heart disease, are disabling because of pain, weakness, or fatigue. Under an insurance company’s interpretation, however, those diseases would fall within the twenty-four-month limitation because pain, weakness, and fatigue are self-reported symptoms that are difficult, if not impossible, to verify using objective medical evidence.

How Will My Insurer Assess a Claim for Fibromyalgia?

Records From Your Treating Physicians

To assess the credibility of your complaints, the claims examiner may request medical records from your treating providers. The claims examiner may ask them to provide information about the extent and duration of your condition, his or her opinion of how well you can function with your condition, what treatments were tried, whether the treatments were helpful, whether the treatments and/or medications had negative side effects, and how long they expect your ability to work to be limited. The more medical records that include evidence of fibromyalgia symptoms and treatment, the better.

Do You Have Multiple Conditions?

Traditionally, when an LTD claims examiner received a case in which the only disability alleged in the claim was fibromyalgia, the outlook for an initial approval was poor. Unless a fibromyalgia diagnosis was made in conjunction with another medical diagnosis, such as arthritis or degenerative disc disease, a claimant with fibromyalgia had little chance of being approved for benefits.

For example, if a claimant made a disability claim and the chief impairments were fibromyalgia and rheumatoid arthritis. The fibromyalgia allegation automatically carries more weight when seen in combination with another impairment as opposed to fibromyalgia being evaluated on its own.

This may be because fibromyalgia is seen as a logical and plausible extension to what is generally considered as “more proven” impairments. However, it is not unheard of for a long-term disability claim for fibromyalgia to be approved. Nonetheless, it will be easier to have your claim approved if you also suffer from other disabling conditions.

How Was Your Condition Diagnosed?

How your condition was diagnosed will also play a role in the success of your long-term disability claim. A diagnosis by a family doctor or primary care physician does not carry as much weight as a diagnosis made by a rheumatologist or orthopedist. When a primary care physician diagnoses fibromyalgia without a corroborative diagnosis by a specialist, a disability examiner may interpret that to mean that the doctor gave the patient a label for lack of a better way to diagnose a patient’s pain. If multiple doctors agree that you have fibromyalgia, this makes your case stronger.

Other Medical and Vocational Experts

In long-term disability claims, other medical and vocational experts are crucial in evaluating and determining an individual’s ability to work. For example, your file may be sent out for a peer review or vocational assessment. These reviews involve qualified professionals thoroughly assessing the claimant’s medical records and objectively evaluating the individual’s condition and what jobs they may be able to perform. The adjuster may also send you for an “independent medical examination.” At the exam, you will be seen by a doctor who is paid by the insurance company and who will report on whether they think you have fibromyalgia, its severity, its duration, and the ways it functionally limits you.

Residual Functional Capacity Assessments

Residual functional capacity (RFC) refers to what an individual can still do despite the limitations resulting from their medical condition or conditions. It’s a key factor in determining eligibility for disability benefits. It assesses the individual’s physical and mental capabilities and limitations, including their ability to perform work-related tasks.

Your RFC will be based on your medical records, opinions from doctors and specialists, and statements from you. The RFC evaluation considers factors like lifting and carrying abilities, standing and walking limitations, and cognitive and emotional capabilities. This assessment is essential for accurately gauging the impact of a person’s medical condition on their ability to work and function in a work environment.

For example, if you cannot lift more than 10 pounds, that would eliminate all jobs that require you to lift and carry more than 10 pounds. Let’s say your RFC form also says you need to take frequent rest breaks. This would further limit the types of jobs you can do. Similarly, if you cannot use your hands for fine motor movements, this would further restrict the types of jobs you can do.

Appealing a Denied Long-Term Disability Claim

Fibromyalgia symptoms can fluctuate, making it difficult to demonstrate the consistent impact on one’s ability to work. Some claimants may struggle to meet the stringent requirements of their insurance policy, leading to long-term disability claim denials. Common symptoms that may qualify someone for disability benefits include:

• Chronic, widespread pain that limits your ability to lift, carry, sit, stand, or walk
• Unpredictable pain flare-ups that disrupt daily routines
• Severe fatigue that makes it challenging to maintain focus or complete tasks
• Cognitive problems—often called “fibro fog”—that can affect memory, concentration, and decision-making
• Sleep disturbances that exacerbate other symptoms
• Depression and anxiety stemming from persistent pain
• Muscle stiffness or weakness
• Headaches and sensitivity to light, sound, or touch

Because fibromyalgia can affect people in so many ways—physically, mentally, and emotionally—it’s essential to clearly document how these symptoms limit your ability to function at work. Even if your symptoms are severe, providing thorough and consistent evidence of their impact is critical when pursuing disability benefits.

If your initial claim is denied, you should not give up on receiving long-term disability benefits for your fibromyalgia condition. Many people are denied benefits the first time they apply. However, that does not mean you cannot successfully appeal the denial of your claim.

Many claimants who have been denied at the initial application stage based on a diagnosis of fibromyalgia go on to appeal the decision and win benefits. Getting expert help is often the difference between being denied or approved for benefits.

How a Long-Term Disability Attorney Can Help with Your Claim

If your long-term disability insurance claim for fibromyalgia has been denied or terminated, an experienced ERISA disability attorney at Ortiz Law Firm can assist you. We’ve successfully obtained long-term disability benefits for numerous clients, many of whom had fibromyalgia.

Fibromyalgia Case Study

For example, our client “Ashley” was a WalMart office associate for over ten years. During her employment, she was diagnosed with fibromyalgia, migraine headaches, syncope, left ear deafness, vertigo, generalized anxiety disorder, and morbid obesity.

Her symptoms progressively became worse, and eventually, she was unable to perform the duties of her occupation. Fortunately, she had previously enrolled in Wal-Mart’s group employee benefits plan, which included disability insurance coverage through Liberty Mutual.

Ashley’s claim for short-term disability benefits was approved, and as she approached the end of her STD claim, she began the process of transitioning to long-term disability. Liberty Mutual also approved her claim for LTD benefits.

Unfortunately, the approval of her LTD claim was short-lived. Her benefits were terminated six months later when a consulting physician reviewed the claim and found no “objective documentation of any restriction, limitation, or impairment.”

Ashley decided to call Ortiz Law Firm to schedule a free case review with attorney Nick Ortiz to discuss the details of her claim and how we could help. With a better understanding of the challenges to overcome, we quickly developed a comprehensive strategy for a successful appeal.

The Problems:

• The Consulting Physician Never Examined or Spoke to the Claimant: The consulting physician who determined Ashley was no longer disabled never examined or spoke with the claimant.
• The Consulting Physician Did Not Consult with All The Claimant’s Relevant Specialists: Despite repeated attempts to contact Ashley’s treating physicians, the consulting physician only received one response from Ashley’s cardiologist – she could work “from a cardiology perspective.” The cardiologist did not comment on whether Ashley could work from any other perspective.
• The Consulting Physician Misconstrued Evidence in the Claimant’s File: The consulting physician noted the claimant’s subjective complaints but stated that her ability to attend multiple provider office visits and give a detailed medical history contradicted her claim.

The Solutions:

• Obtaining Additional Evidence: We gathered the claimant’s office treatment notes and diagnostic test results, prepared custom forms for her medical providers, and obtained statements from her doctors explicitly refuting the claims of the consulting physician. We also helped the claimant prepare a sworn statement regarding her daily activities.
  
  To make the strongest case possible, we ensured the file included not just medical reports, but also comprehensive documentation of her fibromyalgia symptoms. This meant collecting a diagnosis from a specialist—ideally a rheumatologist—who could clearly document tender points and rule out other possible conditions. We compiled detailed treatment records, medication histories showing what had been tried (and how she responded), and even sleep study results to address the chronic fatigue component. Recognizing that mental health can play a critical role, we included therapy notes and psychological assessments, as well as physical therapy records outlining her limitations and any progress.
  
  Beyond medical evidence, we encouraged the claimant to keep a daily symptom diary tracking pain levels, fatigue, and the impact on her daily activities. We also gathered statements from family members and coworkers who had directly observed the effects of her condition. Finally, we reviewed her work records to highlight any attendance or performance issues tied to her health challenges.
• Writing a Detailed Appeal Letter: It was time to prepare the medical summary and legal analysis for the appeal letter once we had all the evidence. We summarized the medical evidence and how it supported Ashley’s claim for benefits. We also included a detailed legal analysis that cited case law from previous disability insurance claims.

Liberty Mutual completed its appeal review and overturned its prior decision to terminate the claim. Ashley’s claim was reopened and returned to a disability case manager for payment. Now, she could focus on what truly matters – her health.

How Fibromyalgia Is Evaluated in Social Security Disability Claims

Although this page focuses on long-term disability insurance benefits, many people with fibromyalgia also ask whether the condition can qualify for Social Security Disability benefits. The Social Security Administration evaluates fibromyalgia under a different legal standard than private disability insurance companies, with its own medical rules and evidentiary requirements.

Social Security’s Rules for Fibromyalgia Claims

The Social Security Administration does not include fibromyalgia as a standalone impairment in its Listing of Impairments (often called the “Blue Book”). Instead, fibromyalgia claims are evaluated under Social Security Ruling (SSR) 12-2p, which establishes how the condition may be recognized as a medically determinable impairment.

Under SSR 12-2p, fibromyalgia may be considered when medical records show:

• A clear diagnosis of fibromyalgia from a licensed physician.
• Evidence of widespread pain lasting at least three months.
• Documentation that other potential causes of the symptoms have been ruled out.
• Objective clinical findings showing either:
  • Tenderness in at least 11 of 18 designated tender points, or
  • Recurrent fibromyalgia-related symptoms such as chronic fatigue, cognitive dysfunction (“fibro fog”), sleep disturbance, or mood changes documented over time.

Because fibromyalgia does not have a definitive diagnostic test, longitudinal medical records and consistent treatment notes play a critical role in how these claims are evaluated.

Functional Limitations Social Security Considers in Fibromyalgia Cases

Rather than focusing on the diagnosis alone, Social Security evaluates how fibromyalgia affects a person’s ability to perform work-related activities on a sustained basis. Medical records are reviewed for evidence of functional limitations such as:

• Chronic, widespread pain affecting stamina or movement.
• Persistent fatigue that interferes with regular activity.
• Cognitive difficulties, including problems with concentration, memory, or mental processing speed.
• Sleep disruption that contributes to reduced alertness during the day.
• Increased sensitivity to physical or environmental stimuli.

These limitations must be reflected in medical documentation, not just self-reported symptoms. The emphasis is on whether the condition prevents consistent, reliable work activity over time.

How Your Ability to Work Is Evaluated

In fibromyalgia cases, Social Security often relies on a Residual Functional Capacity (RFC) assessment to determine what activities a person can still perform despite their symptoms. This assessment considers factors such as:

• The ability to sit, stand, walk, or perform physical tasks for extended periods.
• Whether pain or fatigue interferes with attendance, productivity, or pace.
• Cognitive capacity to understand instructions, maintain focus, and adapt to workplace demands.

If fibromyalgia does not meet or equal another listed impairment, benefits may still be approved through a medical-vocational analysis, which evaluates RFC alongside age, education, and work history to determine whether any sustained work is realistically possible.

Why Social Security Approval Does Not Guarantee LTD Approval

Even when Social Security recognizes fibromyalgia as disabling, that decision does not automatically result in approval of long-term disability insurance benefits. LTD insurers apply policy-specific definitions of disability and often demand more detailed functional evidence than Social Security requires.

Long-term disability insurers frequently scrutinize fibromyalgia claims for:

• Objective support for subjective symptoms.
• Consistency between medical records and reported limitations.
• Evidence of functional impairment specific to the policy’s definition of disability.

For this reason, a successful Social Security claim does not replace the need for LTD-specific medical and functional evidence.

A Note on Scope

This section is intended to explain how fibromyalgia is evaluated under Social Security disability standards. Long-term disability insurance claims are governed by different rules, policy language, and legal standards, which are addressed in the sections above.

Get Help with Your Fibromyalgia Disability Claim

Working with an experienced disability attorney will give you the best chance of getting the benefits you deserve for your fibromyalgia. While the process can be daunting, an experienced disability attorney will be able to guide you through it. We do not get paid until you win your case, so you can seek help without worrying about upfront costs or unexpected bills.

The Ortiz Law Firm has successfully represented people in disability cases across the United States. If you would like to talk to an experienced disability lawyer about your fibromyalgia and its impact on your ability to work, call us at (888) 321-8131. We would be happy to evaluate your case and discuss how we can help you get the benefits you deserve.