Long-term disability (LTD) insurance companies routinely deny or limit claims for long-term disability benefits based on fibromyalgia, a complex illness marked by chronic muscle and joint pain. Because there is no objective test for fibromyalgia 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.
Benefits will be terminated after 24 months for those with disabilities which are based primarily on self-reported symptoms, and disabilities due to alcoholism, drug abuse, or mental illness. Self-reported symptoms include manifestations of your condition that are not able to be verified using tests, procedures, or examinations commonly accepted in the practice of medicine, including headaches, pain, fatigue, soreness, numbness, dizziness, ringing in the ears, and loss of energy.
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 LTD benefits based on fibromyalgia. Here are a few things to remember that could increase your chances of a successful claim.
Insurance companies are well aware that primary care physicians frequently diagnose fibromyalgia as a sort of "catch-all" when they cannot pinpoint the source of an individual's pain. If you want your insurer to take your fibromyalgia claim seriously, it's critical that you receive regular treatment from a rheumatologist, not just your family physician. Rheumatologists typically employ several different diagnostic techniques when evaluating a patient for fibromyalgia, including blood tests to rule out other illnesses and trigger point tests to locate areas of pain and tenderness. Generally an individual who reports pain in at least 11 of the 18 trigger points will receive a diagnosis of fibromyalgia. (Also see our article on getting Social Security for fibromyalgia, which discusses criteria used by the American College of Rheumatology (ACR) to determine when a patient has fibromyalgia.)
In addition to making a more accurate and credible diagnosis, a rheumatologist may be better able to prescribe therapies for your particular symptoms. Although there is no cure for fibromyalgia, it is often possible to control the pain and accompanying fatigue through medication, exercise, and a proper diet.
In addition to chronic pain, many fibromyalgia sufferers also experience headaches, numbness, swelling, fatigue, IBS, and difficulty sleeping. Fibromyalgia may also adversely affect a person's mental health, causing cognitive problems (often called "fibro fog"), depression, stress, and anxiety. Keeping a diary of all your symptoms, both mental and physical, will help your physicians diagnose and treat your illness, and may help to persuade your insurer that your condition is legitimate.
The opinion of your treating physician can literally make or break your LTD case, and it's especially important in cases involving fibromyalgia, chronic fatigue syndrome, and other conditions that don't lend themselves to objective testing. You or your attorney should ask your physician (preferably your rheumatologist) to identify the extent of your work-related limitations, especially in the following areas:
Also, 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. It is also be helpful for your rheumatologist to explain what diagnostic testing was performed and why she ultimately believed a fibromyalgia diagnosis was supported by the medical evidence.
If you're receiving mental health treatment for depression, also ask your doctor or psychologist for an opinion as to your mental limitations, including your ability to maintain regular attendance, sustain attention and concentration, understand and carry out instructions, and interact with supervisors, co-workers, and the general public.
Your lawyer should be able to supply a fibromyalgia assessment form for your doctor that encompasses all your possible limitations. Do not rely on the forms used by your insurance company, as they are often designed to elicit responses that could form the basis for a denial.
Reports from third-parties such as friends, family members, and former colleagues can also help bolster an LTD disability claim, but only if they're limited to first-hand observations of your condition rather than opinions about your medical issues.
Whether you have an individual LTD 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 in notoriously challenging claims involving fibromyalgia, that you have an experienced LTD attorney on your side to help you meet deadlines and pursue your appeals while putting your case in the best possible light. You should be able to set up a free consultation with an LTD lawyer before you hire one.
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