Why Has the Disability Insurance Company Denied my Fibromyalgia Claim for Benefits?

Disability insurance companies are known for denying claims for people suffering from Fibromyalgia, also known as FMS – Fibromyalgia Syndrome – a chronic disease causing pain, stiffness, tenderness in the joints, memory loss and many additional physical, cognitive, and often emotional challenges.

Insurance companies do not fully appreciate the impact of fibromyalgia upon a worker, and often challenge these claims.  If you are about to file or have already filed a long term disability insurance claim because you can’t work because of fibromyalgia, you may be concerned about whether or not your long term disability insurance benefits will be paid. You are right to worry – there is ample evidence of disability insurance companies treating claimants with fibromyalgia as either malingerers who are not really sick, or simply suffering mental health challenges. This is grossly unfair, and why Fibromyalgia Disability Attorney Jason Newfield represents so many FMS claimants in his practice.

Fibromyalgia is a challenging disability claim because there are no subjective tests to prove a person has the disease and suffers impairment as a result.   Even with trigger points in multiple locations to further the diagnosis, proving impairment is often challenging.  This lack of specific markers is a problem for claimants, who are absolutely suffering from a disease but can’t get an MRI, PET scan, CT scan or lab work to prove they are sick. The diagnosis is typically made by a doctor, usually a rheumatologist, who relies on a clinical assessment of the patient’s symptoms along with subjective complaints. 

Research has revealed that fibromyalgia affects the way the brain and spinal cord process pain signals. The Mayo Clinic notes that fibromyalgia symptoms also include tension headaches, temporomandibular (TMJ) joint disorders, Irritable Bowel Syndrome (IBS) and anxiety and depression.  One person can experience a severe trauma, surgery, infection, or extremely stressful event and develop fibromyalgia whereas another person can experience the same exact event and never develop fibromyalgia.

Fibromyalgia often occurs to patients already suffering from a number of diseases, including Chronic Fatigue Syndrome, Migraine Headaches, Interstitial Cystitis (painful bladder syndrome) and Postural Tachycardia Syndrome or POTs, to name only a few co-morbid conditions.

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What is “Trigger Point Proof” for a Fibromyalgia Diagnosis

Part of the requested information from the disability insurance claims adjuster may be Tigger Point Proof – that is, when a doctor presses on certain specific points on the body with enough pressure that the doctor’s fingernail turns white. This is also known as a “Tender Point Exam” and while the American College of Rheumatology no longer requires this for a fibromyalgia diagnosis, you want to support your claim with as much information as possible.  While not a formal test any longer, it still helps to support findings on clinical examination, to buttress the other evidence developed.

Why are Fibromyalgia Disability Claims Denied, and What Can I Do to Protect My Claim?

Disability insurance claims adjusters flag fibromyalgia claims as problematic, even when the person knows they are severely ill and unable to concentrate, sit comfortably in a chair or complete complex tasks. There are steps you can take to protect your claim, including contacting an experienced disability insurance attorney who has worked with many FMS claimants.

A Robust Medical History is Critical for the FMS Claim

To have a chance of your disability claim succeeding, you will need to demonstrate a strong medical history revealing the severity of your fibromyalgia. Often, someone has worked for some period while suffering from fibromyalgia.  Showing a worsening in those cases is often important.

A description of your symptoms -without more – from a treating physician is not enough with an FMS claim. Even being treated by an internist could put your claim at risk. A doctor who specializes in FMS and a history of being treated by the specialist over a period of time will form the foundation of your fibromyalgia disability claim.  In addition to a diagnosis from a rheumatologist and records of doctor’s visits and treatments, your doctor may order some tests simply to rule out any other conditions. These may include complete blood count, thyroid function tests, cyclic citrullinated peptide test, rheumatoid factor, and Vitamin D levels.  Doctors generally will require a patient to experience muscle and bone pain for at least three months as well as ruling out any other conditions before coming to the conclusion that you have fibromyalgia. 

Since there is no specific test for how one is impaired due to fibromyalgia, your medical records will need to record your symptoms in detail, including severity of pain, and other symptoms, prescribed medications, any kind of treatment you have undergone to attempt to manage your disease and a narrative record of how your symptoms have stopped you from being able to perform the tasks of your occupation as well as the tasks of daily living.

You cannot self-diagnose fibromyalgia for a long term disability insurance claim, regardless of the accuracy of your diagnosis. This holds true for any disability, but especially so for fibromyalgia, Chronic Fatigue Syndrome, and other diseases where lab tests or diagnostic imaging cannot be used to prove the diagnosis.

Whether your disability insurance is a group LTD (ERISA) policy or private or individual disability insurance, you can expect your fibromyalgia claim to be challenged.  To have your claim succeed, you will also need to have information about your occupation, the specific tasks required to perform your occupation and a detailed analysis of the way fibromyalgia prevents you from performing these tasks. 

If all of this sounds like a lot of effort to prove something that you know is true, we understand. Newfield Law Group works with fibromyalgia claimants just like you who are doing the best they can to manage their illness. The firm helps claimants prepare to file claims by gathering up all of the doctor’s reports, coordinating occupational evaluations and submitting the claim to the long term disability insurance company.

We invite you to call Fibromyalgia Disability Attorney Jason Newfield to discuss your situation and learn how Newfield Law Group may be able to help you with your disability insurance claim.

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