Fibromyalgia is a condition that causes pain all over the body. This disease affects approximately four million Americans who suffer from some degree of it. When the disease is severe, it can keep you from living a normal life and from functioning in general.
You might not work as you did before your diagnosis. The pain can keep you from performing your job’s physical duties or consistently working an entire day.
Fibromyalgia May Qualify as a Disability
If you suffer from fibromyalgia and have an employer-sponsored long-term disability insurance plan, you should qualify for benefits if you cannot work. However, you must go through a complicated legal process first. An ERISA long-term disability insurance attorney can help you through what may be a difficult fight. You can expect that the insurance company will make life hard on you and try to avoid paying benefits whenever possible.
Often, the underlying injury or infection that led the fibromyalgia to develop is not disabling in itself, though the resulting fibromyalgia is certainly disabling. The right attorney can present your entire situation to the insurance company to demonstrate that even if your initial condition was not disabling, it resulted in a debilitating case of fibromyalgia that prevents you from working.
Fibromyalgia Can Greatly Restrict Your Physical Activity
The exact cause of fibromyalgia is not known. What is known is that it will make your life a lot more difficult. There is a high correlation between stress and fibromyalgia, but that does not tell the entire story. Even exiting a stressful situation does not cause the symptoms of pain to end.
People with fibromyalgia may experience:
- Widespread pain all over the body
- Difficulties with cognitive functions
- Trouble sleeping
- Mental and emotional distress
Fibromyalgia Is an Unpredictable Condition and Not Easy to Prove
Another difficulty with fibromyalgia is that its symptoms can come and go. There are periods when patients can live normally and times when they have flare-ups and can hardly function. The unpredictable nature of the condition makes it even more difficult to live a normal life.
Fibromyalgia claims are some of the more difficult long-term disability insurance claims. When you are dealing with an insurance company that may have millions of dollars on the line, you cannot expect a fair shake. You can expect every trick possible to keep you from getting the money you need, even if you qualify for benefits under the terms of your policy.
Fibromyalgia Does Not Show up on Test Results
Fibromyalgia is different from many other claims. If you have a physical injury that you can point to on test results, you will have a better chance of persuading the insurance company to grant your claim. However, claims for mental illnesses and other things that are not clear from a single specific diagnostic test result are far more challenging.
One 1996 decision from the Seventh Circuit Court of Appeals summed up some difficulties claimants may face when claiming benefits for fibromyalgia.
The court said that fibromyalgia is:
“[A] common, but elusive and mysterious, disease, much like chronic fatigue syndrome, with which it shares several features. Its cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective. There are no laboratory tests for the presence or severity of fibromyalgia.”
Insurance Companies Often Deny Fibromyalgia Claims
For years, insurance companies have fought fibromyalgia claims in general. They do not consider it to be a “real” illness that should cause people to stay home from work. Some courts have bought their arguments. In the past, some courts agreed that people with fibromyalgia should continue to work.
However, attorneys have made some progress convincing courts of fibromyalgia’s disabling and debilitating nature, regardless of what insurance companies say. One decision from the Seventh Circuit Court of Appeals recognized the seriousness of this condition and the fact that it can keep someone from working.
In this case, a judge cited an opinion from the American College of Rheumatology stating that fibromyalgia is not a long-term disabling condition. The insurance company relied on this opinion to terminate a woman’s benefits.
In response, the Seventh Circuit had this to say:
“There used to be considerable skepticism that fibromyalgia was a real disease. No more.”
Here, the Seventh Circuit granted the woman back benefits and ordered that her benefits be resumed. One dissenting judge’s opinion illustrated the challenges many claimants with fibromyalgia may face. That judge opined that people with fibromyalgia should work, even though that particular judge never had to live with the pain the plaintiff was experiencing.
Fibromyalgia Is a Subjective Condition that Relies on Patient Reports
Nonetheless, fibromyalgia claims are some of the more difficult ERISA long-term disability claims. The reason is that the patient is the one who is reporting the severe pain that they are experiencing.
Many fibromyalgia symptoms may not appear on the objective medical tests that insurance companies demand as proof of a disabling condition. The symptoms might show up in a physical examination when the doctor examines tender points on the patient’s body. However, there is still much that depends on the patient’s own word, and the rule of thumb is that the insurance company never trusts a patient to describe their own health.
Hire a Disability Lawyer Before You File a Fibromyalgia Claim
If you are suffering from fibromyalgia, you should recognize before you even file your claim that you may be in for a difficult time. From the outset, you should prepare yourself for a potentially lengthy legal process, knowing that the insurance company seldom approves any of these claims. While your insurer might surprise you and approve your claim from the get-go, this is rare for claimants with fibromyalgia.
You should begin your work before you file your claim in the documentary record that you will begin to build. Since some doctors do not even believe that fibromyalgia is a serious condition, to begin with, you should see a physician that understands the seriousness of this disease. In addition, you should focus on documenting your file with evidence of your condition.
You should find as much evidence as possible to corroborate your self-reported symptoms. Although the insurance company will focus the most on medical records and statements from a physician, you should also include statements from people who have seen you on a daily basis and know what you are experiencing.
Still, the fact that fibromyalgia is an invisible condition will usually lead to difficulties with your initial claim. The insurance company rarely grants benefits for fibromyalgia claims without a fight. Even if the insurance company has initially approved benefits, they will frequently cut them off after a certain period of time.
The Insurance Company May Terminate Benefits that You Are Already Receiving
Insurance companies review your benefits after 18 to 24 months. They are looking for ways to cut off your payments and save themselves money. Around that time, the definition of disability in your plan documents will change. Initially, you may qualify for benefits if you cannot perform the duties of your job or occupation (depending on the language of your policy).
Eventually, you will need to prove that you cannot perform the duties of any gainful employment. This standard is a much higher one, and the insurance company often tries to come up with some type of argument to cut off your benefits to force you into a fight. They are even more likely to argue that you can do some type of work when you have a condition such as fibromyalgia.
You Can Appeal an Unfavorable ERISA Claim Decision
You have legal options when the insurance company has either denied your initial claim or has determined to end the benefits you are already receiving. The problem is that ERISA has built a system that allows the insurance company to fight on their own home turf.
However, insurance companies are not all-powerful and are certainly not invincible. With an experienced and dedicated ERISA long-term disability attorney, you can find a denial of your claim or termination of your benefits.
You Must First Appeal a Denial or Termination to the Insurance Company
Your first step when you receive any unfavorable decision from the insurance company is to file an appeal directly with them. The insurance company assigns a team different from the one that made the initial decision to review whatever determination they initially reached.
You should not have confidence that the first stage of the appeal process will go your way. The insurance company is not keen on reversing its decision with any frequency.
Nonetheless, you must participate fully and vigorously in the insurance company appeal because it is the mandatory first step of the process under ERISA. You must take this appeal seriously because it is the only chance you will get to build a viable record for your case.
If you lose the appeal, you may take the case to a federal court. Still, ERISA limits the judge to reviewing the same record that the insurance company saw—you will not get an opportunity to add any new evidence to the record. Therefore, you should hire an experienced ERISA attorney for the insurance company appeal to give yourself the best possible chance of success.
How an ERISA Long-Term Disability Attorney Can Help You
Your attorney might include in your appeal file:
- The backing documentation that the insurance company reviewed when deciding to deny or terminate your benefits (they are legally obligated to provide this to you)
- A confirmation of your diagnosis based on the American College of Rheumatology 2010 preliminary diagnostic criteria for fibromyalgia
- Detailed medical records over a period of time to show a lengthy struggle with the conditions (symptoms of the condition can wax and wane over time)
- Affidavits and statements from people who have seen your daily symptoms
- A statement from your treating doctor
- A narrative statement of your own condition
- A journal that details your daily condition and your struggle with fibromyalgia
Begin Working With an Attorney Early in the Claim Process
If you believe you cannot work because of fibromyalgia, and your doctors agree, you should contact an attorney early in the process. Hire an attorney to prepare your claim, especially if you received a denial of your claim or if the insurance company terminated your benefits.
You will have limited time to appeal of the insurance company’s decision. When you do, you will need to fight against a company that devotes significant resources to defeating your claim. Insurance companies know the value of a long-term disability claim and try to avoid paying them whenever possible. These companies often look for ways to save money at your expense, disregarding your rights under your long-term insurance policy and placing their own interests ahead of yours.
Working with an experienced long-term disability attorney, you can fight the insurance company under the ERISA procedures. You do not need to pay your attorney anything unless you win your case. When the insurance company puts up hurdles, an experienced long-term disability insurance attorney can help you overcome them.
Following graduation from Loyola Law School in New Orleans in 1990, Price McNamara served as a Federal Judicial Law Clerk to the Honorable John M Shaw, Chief Judge, United States District Court Western District of Louisiana.
Mr. McNamara founded J. Price McNamara ERISA Insurance Claim Attorney, and began putting his past experience to work for the injured and disabled clients he now represents against the insurance companies in personal injury and long term disability and other insurance disputes in both federal and state courts