Can You Fight Insurance Denial for Fibromyalgia?

March 20, 2024 | J. Price McNamara
Can You Fight Insurance Denial for Fibromyalgia
Can You Fight Insurance Denial for Fibromyalgia?

Living with fibromyalgia means facing pain, fatigue, and a host of other challenging symptoms daily. Often, this debilitating condition leaves you unable to work or even live your everyday life. This leads many people to apply for disability benefits to provide financial support once their income stream comes to a halt.

Unfortunately, disability insurance companies frequently deny claims based on fibromyalgia. This is an often misunderstood and underestimated condition, which can lead insurers to deprive policyholders of the long-term disability benefits they truly need and deserve. When insurance companies deny benefits, it can feel like a lifeline was pulled away from you.

If this happened to you, it likely led you to wonder: can you fight the denial? Is it possible to challenge this denial and win? Absolutely, if you hire an experienced disability insurance claims attorney.

Why Do Insurance Companies Deny Disability Benefits for Fibromyalgia?

Fibromyalgia is a complex and often debilitating condition that can significantly decrease a person's ability to work and carry out daily activities. For individuals with fibromyalgia, disability insurance can provide financial support during times when they cannot work due to their symptoms. However, insurance companies may deny disability claims for fibromyalgia for many reasons.

Lack of Objective Medical Evidence

Documents required for claim

One of the main challenges in obtaining disability benefits for fibromyalgia is the lack of objective medical evidence. Unlike other conditions that can be diagnosed through medical tests or imaging, fibromyalgia is primarily diagnosed based on a person's reported symptoms and physical examination findings.

Insurance companies may have strict requirements for objective evidence, such as diagnostic tests or imaging results, and may deny a claim if they feel that there is insufficient evidence to support the diagnosis and severity of the condition.

To increase the chances of a successful disability claim, you must have a comprehensive medical record that clearly documents the symptoms, physical findings, and functional limitations caused by fibromyalgia.

This can include medical reports, treatment records, and statements from healthcare providers that support the diagnosis and confirm the impact of the condition on the individual's ability to work.

Inconsistent Documentation

Another common reason for disability claims denial is inconsistent or incomplete documentation. Insurance companies carefully review the medical records and supporting documentation provided with the claim, looking for any discrepancies or contradictions.

Inconsistencies can include differing statements from healthcare providers, inconsistencies between medical records and the individual's reported symptoms, or incomplete documentation of medical treatment and functional limitations.

To avoid claims denial due to inconsistent documentation, always ensure that all medical records and supporting documentation are complete, accurate, and consistent.

You can achieve this by coordinating with healthcare providers to ensure you provide thorough information that aligns with the individual's reported symptoms, functional limitations, and treatment history.

Failure to Meet the Policy's Definition of Disability

Disability insurance policies have specific definitions of disability, and it is important to meet these criteria to qualify for benefits. Insurance companies may have different definitions of disability, such as an inability to perform the duties of one's own occupation or any occupation for which the individual is reasonably suited.

Some policies require individuals to be completely unable to work, while others may consider partial disability. Insurance companies may deny claims if they believe that the individual's functional limitations are not severe enough to meet the policy's definition of disability.

Therefore, hire a disability insurance lawyer who can carefully review the policy and understand its definition of disability to ensure that the claim accurately reflects the impact of fibromyalgia on your ability to work.

Disability insurance claims for fibromyalgia can be challenging due to the lack of objective medical evidence, inconsistent documentation, and the need to meet the policy's definition of disability.

To increase the chances of a successful claim, it is essential to ensure proper documentation, including comprehensive medical records that support the diagnosis and functional limitations due to fibromyalgia.

Working with an experienced disability attorney can provide valuable guidance and support throughout the claims process, increasing the likelihood of a favorable outcome and ensuring that individuals with fibromyalgia receive the benefits they are entitled to.

However, if you have already received a denial and do not yet have representation from a disability claims attorney, consult one immediately.

Why ERISA Governs Most Disability Appeals

ERISA Governs Most Disability Appeals

When you have a disability claim, it is important to recognize the legal framework that governs the appeals process. In most cases, disability claims are governed by the Employee Retirement Income Security Act (ERISA).

ERISA is a federal law that establishes the standards for employee benefit plans, including disability insurance policies offered through an employer. Understanding ERISA and its implications can be crucial in navigating the appeals process successfully.

One of the key aspects of ERISA is that it sets strict deadlines for filing an appeal. If you have been denied benefits, you typically only have 180 days to submit your appeal. Failure to meet this deadline can result in a loss of your right to appeal. That's why you need to act promptly and seek legal assistance to file an appeal for your disability claim.

ERISA also sets forth certain requirements for the appeals process. Insurance companies should provide a full and fair review of your claim and explain their reasoning behind any denials. They must also provide you with the opportunity to submit additional evidence or arguments in support of your claim. If your appeal contains any deficiencies, such as a failure to follow ERISA requirements, it may provide grounds for a denial.

Navigating the ERISA appeals process can be difficult and overwhelming, especially if you are dealing with the challenges of a disability. That's why you should always have an experienced disability attorney by your side. An attorney can explain your rights under ERISA, gather the necessary evidence to support your claim, and guide you through the appeals process step by step.

By working with an attorney, you can increase your chances of a successful outcome and secure the disability benefits you deserve.

Remember, the ERISA appeals process can be time-sensitive and complex. It's crucial to consult an experienced disability attorney as soon as possible to ensure you meet all deadlines and have the best possible chance of success.

Don't go through the process alone – let a knowledgeable attorney advocate for you and navigate the maze of ERISA requirements.

Steps to Appeal a Disability Insurance Claim Denial for Fibromyalgia 

If your claim for fibromyalgia disability benefits has been denied, it is important not to lose hope. With the assistance of a disability attorney, you can navigate the appeals process and increase your chances of a successful outcome.

The following are some steps you can expect during the appeals process.

You can focus on your physical condition while your disability claims lawyer handles this process.

  1. Evaluate Your Denial Letter: The first step in appealing a denial is to carefully review the denial letter you received from the insurance company. This letter will provide important information about the reasons for their decision and any additional documentation or evidence they may require. Your disability attorney can interpret this letter and determine the best course of action.
  2. Gather Additional Medical Evidence: One of the most common reasons for disability claim denials is insufficient medical evidence. To strengthen your case, work with your treating physicians to gather comprehensive medical records, including test results, treatment history, and prognosis. Your disability attorney can assist you in obtaining and organizing this evidence, ensuring that it meets the specific requirements of the appeals process.
  3. Meet Deadlines: The appeals process is time-sensitive, and missing a deadline can result in your claim being denied again. Your disability attorney will be familiar with the applicable timelines and will ensure that all necessary paperwork is submitted on time. They will also handle any correspondence with the insurance company, alleviating the stress of dealing with the administrative aspects of your appeal.
  4. Prepare a Strong Appeal: Crafting a persuasive appeal is crucial to overturning a denial. With the guidance of your disability attorney, you can present a well-documented argument that highlights the severity of your fibromyalgia symptoms and their impact on your ability to work. Your attorney will craft a clear and concise narrative that effectively communicates your case to the decision-maker.
  5. Request a Hearing, if Necessary: If your initial appeal is denied, you have the right to request a hearing before an administrative law judge. This is an opportunity to present your case in person and provide additional evidence and testimony. Your disability attorney will guide you through the preparation process, gather expert witnesses if needed, and advocate for your rights at the hearing.

Working with a disability attorney significantly increases your chances of success during your appeal.

Attorneys who regularly handle disability claims have a deep understanding of the law, the appeals process, and the tactics insurance companies may use to deny claims. They can advocate on your behalf, evaluate the strength of your case, and provide guidance that empowers you to make informed decisions throughout the process.

Navigating the appeals process for a fibromyalgia disability claim denial may feel overwhelming, but you don't have to face it alone. By seeking the assistance of a disability attorney, you can protect your future and increase your chances of receiving the benefits you deserve.

Don't give up—take action and fight for the financial support you need to navigate life with fibromyalgia.

What to Expect When You Consult an ERISA Disability Claims Attorney

ERISA Disability Claims Attorney

Navigating the process of filing and appealing disability claims under ERISA can be difficult, especially when you’re already dealing with the challenges of fibromyalgia.

If you find yourself facing this complex and often frustrating journey, consulting with an ERISA disability claims attorney can provide the guidance and support you need. Here's what you can expect when you seek their assistance.

When you consult an ERISA disability claims attorney, they will first take the time to listen to your unique situation and understand the details of your fibromyalgia disability. They understand the complexities surrounding this condition and have the knowledge and experience to evaluate your case. They will ask you about your medical history, any treatment you have undergone, and the impact your fibromyalgia has had on your daily life and ability to work.

Based on the information you provide, the attorney will assess the strength of your claim and determine the best course of action to pursue. They will explain the relevant laws and regulations that apply to your situation, including the specific requirements set forth by ERISA. This will help you understand your rights and what you need to do to have a successful claim.

One of the key benefits of consulting an ERISA disability claims attorney is their experience in handling the intricate paperwork involved in the disability claims process.

They will guide you through the completion of the necessary forms and ensure that all required documentation is submitted accurately and on time. This attention to detail can significantly increase your chances of a successful claim.

Throughout the appeals process, an ERISA disability claims attorney will be your advocate. They will gather additional evidence to strengthen your case and present it in a compelling manner.

J. Price McNamara, Disability Insurance Attorney
J. Price McNamara, Disability Insurance Lawyer

They will also handle all communication with insurance companies and protect your rights throughout the process. With their knowledge and experience, they know the strategies to employ to maximize your chances of success.

Consulting with an ERISA insurance claims attorney can provide you with the support and guidance you need during this challenging time. They will bring their knowledge, experience, and compassion to your case, helping you navigate the complex system and fight for the benefits you deserve.

Remember, you don't have to face this journey alone – there are legal professionals ready to be by your side every step of the way.

Case evaluations are free with no obligation, so never delay having a trusted attorney review your denial today.

J. Price McNamara Author Image

J. Price McNamara


Losing my own brother, then my father and sister after long, disabling illnesses just a few months apart drove a career change for me. Before that experience, I never truly understood the place you’re in. I never understood the dramatic impact that receiving (or not receiving) the disability and life insurance benefits you paid for and counted on can have on your life especially when you need to focus on family and healing. What I experienced with my own family now drives the way I view my clients and my work, and I will never forget it!

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