What you need to know

Fibromyalgia is a rheumatic disease resulting in a number of symptoms that include, but are not limited to, generalized pain, fatigue, trigger points, disturbed and disrupted sleep (a.k.a. non-restorative sleep), brain fog, and confusion etc.

A person suffering from Fibromyalgia is forced pursue legal action against the insurer because the insurers refuse to accept this diagnosis especially if the illness is caused due to a motor vehicle accident or a traumatic event.  The insurers are not prepared to accept that such an illness could be caused by an accident or a traumatic event.  In the case of Long Term Disability, it is difficult to convince the insurers that Fibromyalgia is a “subjective illness” that can cause a permanent disabling condition.

We represent a large number of clients who have been denied benefits due to similar reasons.  We strive to obtain the necessary medical evidence to prove the disability as contemplated by the policy in question.

There are a few basic things that a Long Term Disability insurer looks for in a claim arising out of Fibromyalgia.

The insurer first looks for the objective evidence of the diagnosis of Fibromyalgia.  We commonly see that a claim is plainly denied in the first instance stating that you have not provided any objective evidence of your disability from Fibromyalgia.

Secondly, the insurer looks if the objective evidence of Fibromyalgia is causing physical restrictions and limitations that are, in fact, disabling.  Therefore, it is important that the objective medical evidence is developed to show that you have physical restrictions and limitations.  And most importantly, these restrictions and limitations forbid you to engage in either your own occupation, or, any occupation.

Thirdly, there must be a causal relationship between your diagnosis, your disability, and your inability to work, otherwise your claim will be denied.  The insurers know there are many people with Fibromyalgia that are able to work, and unfortunately, they evaluate Fibromyalgia claims through that mindset.

Fibromyalgia is a complex illness.  It carries with it physical as well as psychological manifestations.  We usually see that people emphasize more on the physical aspect of the illness, and hardly ever probe into the psychological aspect of the illness.  We believe, it is as important to seek psychological assistance as well.  The reason is two pronged:  psychological intervention and / or psychological methods of pain management might help you function better.  It might actually assist you in getting back to work.  And secondly, this will strengthen your case leaving little or less room for the insurer to deny you summarily.

On the other hand, if you are receiving disability benefits on account of Fibromyalgia, and reaching the 24 month period, be prepared to receive a letter indicating that your claim will be reviewed before the end of the 24 month term.  This is because you are at the stage where your claim is changing from “own occupation” to “any occupation”.  In legal terms we call it “definition change”.

What that means is that the insurer will now inquire into the possibility of you being able to do any kind of gainful employment.  At this point expect an Independent Medical Examination, a Functional Capacity Evaluation, Video Surveillance, etc.  This might be preceded with appointments with Occupational Therapists who would assist you in a possible retraining for any other kind of work that might be suitable for you in your circumstances.  In short, they will make every effort to prove that you are able to do some kind of work just because Fibromyalgia is a “subjective illness”.

We have seen over the years that most claims that are accepted in the first instance do hit a road-block at the 24 month stage.  It is crucial that you must have been complaint with all the medications and the recommendations of your physicians and other treatment providers.  You must have made consistent and honest efforts to get better, and to re-enter the workforce.  The insurers are always looking into all these factors with minute detail to find any possible reason to deny you your benefits.