For many long-term disability claimants suffering from fibromyalgia, obtaining benefits is only the beginning of the fight. Even after a claim has been approved, insurers frequently revisit files searching for reasons to terminate benefits.
That is precisely what happened to one Newfield Law Group client, a longtime utility industry executive whose disabling fibromyalgia, chronic headaches, fatigue, cognitive dysfunction, and anxiety prevented her from performing the duties of her occupation.
MetLife initially approved her claim. It then terminated her benefits. After Newfield Law successfully appealed, the claim was reinstated. One year later, MetLife terminated the claim again.
Once again, Newfield Law challenged the decision. Once again, the evidence demonstrated that the claimant remained disabled. And once again, MetLife was forced to reinstate benefits.
The case highlights a recurring problem in the disability insurance industry: insurers often rely on paper reviews conducted by physicians they hire and pay, while minimizing the opinions of treating physicians who have followed a claimant for years. For claimants with fibromyalgia—an illness characterized primarily by pain, fatigue, cognitive dysfunction, and other symptoms that cannot always be measured through traditional testing—the consequences can be devastating.
A Highly Accomplished Professional Forced From Work
Before disability ended her career, our client spent nearly four decades working for one of New York’s largest utility companies. Over 38 years, she advanced into management positions and earned a reputation as a respected leader. She managed high-profile projects, served as a liaison between business and information technology departments, and led initiatives designed to improve customer satisfaction. Her performance reviews were consistently positive, and she was identified as a high-potential emerging leader.
Nothing in her employment history suggested a person unwilling to work.
In July 2022, however, her health began deteriorating significantly after she suffered a concussion at home. Although she returned to work several weeks later, she experienced increasing difficulty completing tasks, concentrating, remembering procedures, and maintaining productivity.
At the same time, her fibromyalgia symptoms worsened dramatically.
The combination of widespread pain, exhaustion, headaches, cognitive dysfunction, anxiety, and depression eventually became overwhelming. By early 2023, she could no longer function effectively at work or at home. Her treating physicians documented persistent and severe symptoms that interfered with even basic daily activities.
Fibromyalgia Is Real—and Often Misunderstood
Fibromyalgia remains one of the most misunderstood conditions in long-term disability law. Insurance companies frequently focus on the absence of definitive laboratory tests, imaging studies, or other objective findings. Yet both the medical community and numerous courts recognize that fibromyalgia does not lend itself to diagnosis through traditional objective testing.
Instead, physicians diagnose fibromyalgia through accepted clinical criteria, including a patient’s medical history, symptom patterns, widespread pain, fatigue, cognitive complaints, physical examinations, and the exclusion of other conditions that could explain the symptoms.
The hallmark symptoms of fibromyalgia include:
- Widespread musculoskeletal pain
- Severe fatigue
- Cognitive dysfunction (“fibro fog”)
- Sleep disturbances
- Headaches
- Joint stiffness
- Tenderness throughout the body
Courts throughout the country have repeatedly recognized that requiring objective proof of pain from fibromyalgia claimants is often unreasonable because the condition itself does not produce the type of evidence insurers routinely demand.
In this case, the claimant’s treating physicians consistently documented symptoms entirely consistent with established fibromyalgia diagnoses.
Functional Testing Confirmed Significant Limitations
This was not a claim supported solely by subjective complaints. The claimant underwent functional capacity testing that revealed significant physical restrictions. Subsequent testing demonstrated that her condition had deteriorated rather than improved.
Medical providers documented that she could not sustain activity on a reliable or predictable basis. She experienced severe fatigue, chronic pain, headaches, and cognitive impairment. Her physicians reported that she could not:
- Consistently sit for prolonged periods
- Remain seated long enough to perform sustained computer work
- Reliably lift or carry even modest amounts of weight
- Maintain full-time attendance
- Perform activities on a predictable schedule
She also suffered from chronic headaches requiring medication, rest, and periods of lying down in a dark room. These episodes occurred unpredictably, making regular employment impossible.
MetLife Relied on Flawed Reviews to Terminate Benefits
Despite substantial evidence supporting disability, MetLife terminated benefits, relying heavily on physicians retained to perform file reviews.
The problem with this approach is not merely that the reviewing physicians disagreed with the treating doctors. The problem is that the reviews themselves failed to account for critical evidence contained within the claim file.
In several instances, the reviewers acknowledged the existence of documented symptoms and impairments yet failed to translate those findings into meaningful workplace restrictions. One reviewer allegedly recognized limitations reflected in the medical records but nevertheless concluded that the claimant could perform full-time work.
Another review focused largely on psychological issues despite the fact that the primary disabling conditions involved fibromyalgia, chronic pain, fatigue, headaches, and physical functional limitations.
Most troubling, certain conclusions appeared entirely inconsistent with the documented medical evidence. At one point, MetLife’s consultants suggested the claimant remained capable of functioning at a level that simply could not be reconciled with the functional testing, treating physician opinions, and symptom history contained in the file.
The Inherent Conflict of Interest in Disability Insurance Claims
Cases like this expose an inherent conflict built into many disability insurance plans. MetLife serves as both the entity responsible for paying benefits and the entity responsible for determining whether benefits should continue.
Every dollar paid to a claimant is a dollar that affects the insurer’s financial obligations.
Federal courts have long recognized this structural conflict of interest. While the existence of a conflict does not automatically invalidate a claim decision, courts routinely consider it when evaluating whether an insurer provided the full and fair review required under ERISA.
The concern becomes particularly significant when an insurer repeatedly relies on consultants it hires and compensates to evaluate disability claims. No one disputes that insurers may obtain independent medical reviews. The problem arises when those reviews selectively emphasize evidence favoring denial while minimizing or ignoring evidence supporting disability.
A fiduciary’s obligation is not to search for reasons to terminate benefits. Its obligation is to conduct an objective review of all evidence and make a fair determination.
ERISA Requires Insurers to Consider Subjective Symptoms
Fibromyalgia presents a unique challenge because pain, fatigue, and cognitive dysfunction cannot always be measured through objective testing. For that reason, courts have repeatedly held that disability insurers may not simply disregard subjective complaints.
ERISA requires claim administrators to provide a full and fair review of the evidence. That includes evaluating a claimant’s reports of pain, fatigue, headaches, cognitive difficulties, and other symptoms when those complaints are consistent with the medical record. In this case, MetLife’s position effectively discounted symptoms that every treating provider recognized as legitimate and disabling.
The claimant consistently reported widespread pain, exhaustion, headaches, inability to sustain concentration, and significant cognitive dysfunction. Her physicians repeatedly documented those complaints and concluded she could not maintain full-time employment.
A fair review required meaningful consideration of those findings.
Newfield Law Successfully Challenged the Denial—Twice
After MetLife terminated benefits the first time, Newfield Law prepared an extensive appeal supported by medical evidence, physician statements, and functional testing.
MetLife ultimately reinstated benefits. That should have ended the matter, but approximately one year later, MetLife again terminated the claim despite continued medical support, updated physician opinions, and additional evidence demonstrating ongoing disability.
Newfield Law once again challenged the decision. The appeal highlighted the deficiencies in MetLife’s reviews, the consistency of the treating physicians’ opinions, the objective functional testing that supported disability, and the insurer’s failure to properly evaluate the claimant’s symptoms and limitations.
Our appeal succeeded. For the second time, MetLife reinstated benefits.
Why This Case Matters
This case illustrates several important realities about long-term disability claims involving fibromyalgia. First, approval of benefits does not guarantee future security. Insurers frequently revisit claims and attempt to terminate benefits even when medical conditions remain unchanged.
Second, fibromyalgia claims require careful documentation from knowledgeable physicians who understand how the condition affects functional capacity.
Third, disability insurers cannot lawfully ignore subjective symptoms simply because they are difficult to measure through laboratory testing or imaging studies.
Finally, claimants should remember that a denial is not necessarily the end of the process.
Our client’s benefits were terminated twice. Both times, the medical evidence demonstrated that she remained disabled. Both times, the insurer’s decision was challenged. And both times, the benefits were restored.
For disability claimants facing similar circumstances, the lesson is clear: persistence, strong medical evidence, and effective legal advocacy can make the difference between losing essential benefits and securing the protections promised under a disability insurance policy.