Table of Contents
Fibromyalgia is a chronic disorder characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas. Scientists estimate that fibromyalgia affects about 4 million US adults, about 2% of the adult population. 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.
What Is 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:
What Are the Symptoms of Fibromyalgia?
The primary complication of fibromyalgia is the extreme pain that the condition produces. People suffering from FM often experience painful joints and muscles throughout the body, causing joint pain and muscle spasms. People with fibromyalgia have “tender points” on the body. Tender points are specific places on the neck, shoulders, back, hips, arms, and legs. These points hurt when pressure is applied.
People with fibromyalgia may also have other symptoms, such as:
- Trouble sleeping.
- Morning stiffness.
- 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.
- 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
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 who are 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.
Filing for Long Term Disability with 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 “[d]isabilities, 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 that 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, 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 he or she thinks you have fibromyalgia, its severity, its duration, and the ways it functionally limits you.
Your file may be sent out for a medical or vocational review. These reviews involve qualified professionals thoroughly assessing the claimant’s medical records and objectively evaluating the individual’s condition, residual functional capacity, and what jobs they may be able to perform.
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 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
Filing for long-term disability due to fibromyalgia can be met with significant obstacles. One common challenge is proving the severity of the condition to the insurance provider. Fibromyalgia symptoms can fluctuate, making it difficult to demonstrate the consistent impact on one’s ability to work. Additionally, claimants may struggle to meet the stringent requirements of their insurance policy, leading to potential claim denials or delays.
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 just 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 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.
- 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.
- 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.
Has Your Disability Insurance Carrier Wrongfully Denied Your 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, your experienced disability attorney will be able to guide you through the process. They do not get paid until you win your case. 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 assist you in appealing your long-term disability denial.
- Mayo Clinic. “Fibromyalgia.” Retrieved from (https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780) Accessed on January 25, 2024.
- Centers for Disease Control and Prevention. “Fibromyalgia.” Retrieved from (https://www.cdc.gov/arthritis/types/fibromyalgia.htm) Accessed on January 25, 2024.
- National Institute of Health. “2016 Revisions to the 2010/2011 fibromyalgia diagnostic criteria.” Retrieved from (https://pubmed.ncbi.nlm.nih.gov/27916278/) Accessed on January 25, 2024.
Last Updated: January 25, 2024 // Reviewed and Edited by: Ortiz Law Firm