Fibromyalgia patients are routinely denied disability benefits. This is a source of great frustration for patients and their families. Long term disability insurance companies consider fibromyalgia claims suspect.
While a diagnosis of cancer is based on the presence of specific cells, until recently, there was limited empirical evidence of the presence of fibromyalgia beyond its debilitating symptoms. The causes of fibromyalgia are still not clear, but fibromyalgia is better understood today, and while there is no specific cure, there are treatments that provide some degree of relief in managing symptoms.
In 2013, a prominent neurologist at Massachusetts General Hospital in Boston published two studies showing that more than half the cases of fibromyalgia examined revealed a condition affecting the nerves described as “small-fiber neuropathy.”(1) Tiny nerves located throughout the body, including those in internal organs, were shown to be sending faulty signals to the brain, resulting in the symptoms of fibromyalgia.
The same year, a team at Albany Medical College led by neuroscientist Frank Rice reported that fibromyalgia patients have excessive nerve fibers lining the blood vessels of the skin – further proof that fibromyalgia is a physical condition and not psychosomatic.
Two additional studies reported in 2013 with different focus continued the search for proof that fibromyalgia is a physical disease. The Fibromyalgia Research Foundation research found that deficient thyroid hormone regulation was a contributing factor to fibromyalgia, while a study from the United Kingdom claimed that processes located in the pituitary gland or hypothalamus, two important parts of the endocrine system located in the brain, are the primary cause of fibromyalgia.(2)
As medical research continues to build an increasing understanding of the physiology of fibromyalgia and treatment modalities, it would seem that disability insurance companies should already have begun to treat fibromyalgia claims as any other disease.
Despite this growing body of research, insurance companies still consider fibromyalgia a “subjective condition” or syndrome or condition, not an illness. Even the Center for Disease Control (CDC) describes fibromyalgia as a “disorder” and not a disease.(3) Tell that to the five million Americans suffering from fibromyalgia, who are unable to enjoy their lives fully and suffer the twin impact of a debilitating condition and an atmosphere of skepticism about their illness.
Where there is a diagnosis of fibromyalgia or small-fiber neuropathy, proper preparation of a disability claim is extremely important. Both diagnoses will cause a claim to be red-flagged, and the claim will be subject to increased scrutiny, particularly if the monthly benefit amount is high.
How can you protect yourself?
One of the biggest hurdles to a successful LTD claim is not falling into the pitfalls of the claims process.
The diagnosis of fibromyalgia must be carefully documented in your medical records. But, as important is an articulation of the functional limitations that one suffers resulting from fibromyalgia. This requires cooperation on the part of your primary treating physician, rheumatologist and any other specialists treating you. We occasionally find a physician with a number of fibromyalgia patients who understands the importance of documenting the issues in the medical records for disability claims, but most do not have the fine appreciation for how important such documentation is to the claim. That’s understandable – their focus is medicine, not preparing documents for a claim file. But medical records can seriously damage or altogether sink a claim if not properly developed.
It is not a diagnosis of fibromyalgia that will make you eligible for disability insurance. Claims adjusters are looking for language concerning restrictions and limitations caused by fibromyalgia. To meet this standard, the medical record must include a clear picture of the tasks and duties of your occupation – with great specificity – and clear statements as to how and why you can no longer perform these tasks.
When working with physicians on our clients’ claims, we explain that the individuals who review medical records for disability insurance companies know nothing (and sometimes less than nothing) about fibromyalgia. They may be nurses, non-practicing physicians, or claims handlers with little or no medical exposure. Given the high volume of claims, it is also possible that the claims are scanned using software that looks for particular phrases before shuttling the claim along to a human.
Talk with your treating physician about test reports that can be used to support your claim. Insurance companies are looking for empirical data, and any kind of test that can be used to measure functional deficits created by fibromyalgia will be useful.
Make sure that your physician does not simply pass along your request to a low-level staff person. We work closely with our clients and their treating physicians to make sure that their medical records will support their disability claim. Doing the work before the claim is filed leaves you with far more options than after the claim is filed.
Be careful that your medical record does not include any opinions not related specifically to fibromyalgia. A simple observation that “patient is anxious” can impact a claim. One of the common tactics used by disability insurance companies to limit benefits is to convert a fibromyalgia claim into a mental/nervous claim, which may be subject to a limited pay period for mental health claims, and provide benefits for only two years.
Working with experienced legal professionals, the fibromyalgia patient will have a greater likelihood of filing a successful claim. If you have questions, call our office at 877-LTD-CLAIM (877-583-2524) to learn how we can help.
1 – USA Today
2 – Washington Times