Long-Term Disability Benefits for Fibromyalgia

Fibromyalgia is a complex illness marked by chronic muscle and joint pain. Doctors aren't quite sure yet what causes fibromyalgia, but recent medical studies suggest that the disorder is the result of abnormalities in the neural (brain) pathways that transmit pain signals. Fibromyalgia has been often misunderstood by the public, including long-term disability insurers, who may dismiss the condition due to difficulty in arriving at a definitive diagnosis.

Is Fibromyalgia Now Considered a Long-Term Disability?

Despite advances in diagnostic techniques and increased awareness of the condition, long-term disability insurance companies routinely deny or limit claims benefits based on fibromyalgia. Because there is no objective "fibromyalgia test" and diagnosis is based largely on self-reported symptoms, many insurers specifically exclude fibromyalgia from coverage. Other carriers consider fibromyalgia primarily a mental disorder and will limit payments to 12 or 24 months.

Read your policy carefully to understand whether and for how long you can receive benefits based on fibromyalgia. The following language limiting eligibility is fairly typical.

Even if your policy doesn't specifically mention fibromyalgia as being excluded or limited, you should expect to meet substantial resistance if you file for long-term disability benefits based on fibromyalgia.

How Can I Get My Fibromyalgia Declared a Long-Term Condition?

Insurance companies are well aware that primary care physicians frequently diagnose fibromyalgia as a sort of "catch-all" when they can't pinpoint the source of a patient's pain. If you want your insurer to take your claim seriously, it's important that you receive regular treatment from a rheumatologist who is familiar with fibromyalgia, rather than a general practitioner.

Visiting a Rheumatologist

Rheumatologists are doctors who specialize in autoimmune disorders and muscle inflammation. Rheumatologists typically use several different diagnostic techniques when evaluating patients for fibromyalgia, including blood tests to rule out other illnesses and trigger point (also called tender point) tests to locate areas of pain and tenderness.

Trigger point tests are performed by having your doctor press down on several locations near your joints and seeing if they elicit a pain response. Generally, patients who report pain in at least 11 of the 18 trigger points will receive a fibromyalgia diagnosis. Don't self-diagnose by having a friend or relative conduct a trigger point test—you'll need a rheumatologist to perform the test and make a diagnosis using their medical expertise.

Having a rheumatologist treat your fibromyalgia will also help make sure that your diagnosis is taken seriously by your long-term disability provider. Although there isn't currently a cure for fibromyalgia, a rheumatologist may be better able to prescribe therapies (such as medication, exercise, and dietary changes) that can help you manage your symptoms.

Recording All Your Symptoms

While chronic pain is the characteristic symptom of fibromyalgia, many people with the disorder experience additional symptoms, such as:

• headaches
• numbness
• joint swelling
• fatigue
• irritable bowel syndrome (IBS)
• insomnia
• cognitive problems ("fibro fog")
• depression, and
• anxiety.

Keeping a detailed diary of all your symptoms—mental and physical—will help your doctors treat your illness, and can convince your insurer that your diagnosis is legitimate. The more specific you can be in your descriptions, the better. For example, "I have stabbing headaches lasting 30 minutes every other day" is more helpful than a vague statement like "My head hurts today."

Obtaining Opinions From Your Doctors

The opinion of your treating physician can make or break your long-term disability claim. It's especially important in cases involving conditions such as fibromyalgia that don't lend themselves to objective testing. You (or your attorney, if you have one) should ask your physician—preferably your rheumatologist—to write a letter describing any limitations you have in standing, sitting, walking, and lifting objects.

The purpose of the doctor's note is to identify any work-related functional limitations you have as a result of your fibromyalgia symptoms. For example, would you miss days of work or have to take unscheduled breaks during the workday due to pain, fatigue, or other issues? Would you need to recline or lie down during the day? Your doctor should be asked about any limitations that might prevent you from performing the demands of full-time work and what diagnostic testing supports those limitations.

If you're receiving mental health treatment for depression, you should also ask your psychologist or counselor for their opinion about what mental limitations you have, such as whether you can maintain regular attendance, sustain concentration, carry out basic instructions, and interact with other people.

Reports from third-parties such as friends, relatives, and former employers can also strengthen your disability claim, but only if they're based on first-hand observations of your limitations.

Can I Make a Critical Illness Claim for Fibromyalgia?

Critical illness coverage is a type of insurance plan that pays out a lump sum in the event that you experience a medical emergency. Major long-term disability providers such as Metlife and Blue Cross Blue Shield include strokes, comas, and organ transplants as examples of critical illnesses that warrant payouts.

Because fibromyalgia is a chronic condition, it's unlikely that you'll be able to make a critical illness claim based on the disorder alone. Some studies have shown a correlation between fibromyalgia and increased risk of heart disease, however, so you may wish to add critical illness coverage to your current long-term disability plan.

What Benefits Am I Entitled to With Fibromyalgia?

If your claim is approved, the exact type of benefits you'll receive depends largely on your long-term disability policy terms and conditions. Most plans will pay a certain percentage (between 50%-80%) of your previous earnings every month for a set period of time.

Depending on your specific insurance plan, you'll need to show that your fibromyalgia either prevents you from performing the fundamental duties of your regular work (in an "own occupation" policy) or from performing the duties of any job (in an "any occupation" policy). Many policies switch from "own occupation" to the stricter "any occupation" standard after around two years, so your benefits may be terminated at that time if you're able to work at an easier job than you're used to.

Getting Legal Help With Your Fibromyalgia Claim

Whether you have an individual long-term disability insurance policy or an employer-provided group plan, your policy is likely to be complex and riddled with exceptions, exclusions, and limitations. It's important—especially with notoriously challenging fibromyalgia claims—that you have an experienced attorney on your side to help you meet deadlines and pursue appeals while putting your case in the best possible light. And because long-term disability lawyers work on contingency, you'll have little (if any) out-of-pocket expenses.