Fibromyalgia, also called fibromyositis, is a chronic condition that is characterized by musculoskeletal pain, fatigue, and tenderness in localized areas. But when is fibromyalgia a disability according to the LTD company, and what you can expect in terms of being eligible for long-term disability benefits?
Historically, LTD insurance companies have given little weight to claims that involve only fibromyalgia. The condition is mainly based on the subjective complaints of the claimant, which can be disputed in a claim.
If another severe medical condition was also involved, such as arthritis or degenerative disc disease, you may have better chance at getting your claim approved. Fibromyalgia is often seen as a logical extension of these other conditions, which are more easily proven with diagnostic tests. As a result, many fibromyalgia claims are made in conjunction with other conditions in order to be eligible for disability benefits.
Fibromyalgia is diagnosed primarily based on the subjective complaints of the claimant. Furthermore, the causes of fibromyalgia are largely unknown. Although fibromyalgia is a legitimate disability, its symptoms and causes very widely from person to person. Because the medical community still has yet to figure out the causes of fibromyalgia, LTD insurance companies are unsure of how to evaluate these claims and often deny them.
When a patient has complaints that relate to fibromyalgia, a primary care physician may automatically diagnose the person without consulting with a specialist. In these situations, a disability examiner may think that a doctor gave the fibromyalgia diagnosis as a general label for lack of a better or more specific diagnosis.
Because disability examiners have seen what they think as routine diagnoses of fibromyalgia, they are skeptical of the diagnosis. Fortunately, as doctors become more familiar with fibromyalgia, they are being more careful in their diagnoses. However, a diagnosis or corroborative medical report from an orthopedist or rheumatologist is still more credible than a one-time diagnosis from a primary care physician, internist, or family doctor.
Because of the subjective nature of the condition, providing medical evidence can be difficult. Reports of pain, fatigue, and “fibro fog” may not be enough. Disability examiners want to see medical reports that include tests and objective findings. Do your best to explain your symptoms to your doctor and describe all of your limitations to the disability insurance company.
According to the American College of Rheumatology (ACR), a fibromyalgia diagnosis requires evidence of:
A claims examiner will evaluate your “medical signs” of fibromyalgia. Medical signs are any abnormality that can be documented by clinical diagnostic techniques that are accepted by the medical profession. Medical signs of fibromyalgia should be accepted as sufficient evidence of the condition.
Your LTD insurance claims examiner will want to see all medical records that you have indicating your diagnosis and the severity of it. They will also likely want to see records from psychologists, psychiatrists, physical therapists, and any other doctors or treatment professionals. They will take all of the information they obtain into consideration for your claim.
The insurance adjuster may ask you to submit to an “independent medical examination” (IME). This is an exam by a doctor who is paid by the insurance company. They will review your medical documentation, perform a physical exam, and make a determination as to the existence of the condition, its severity, its duration, and your limitations because of it.
Your doctor can help you by completing a residual functional capacity (RFC) form, which details your abilities and limitations. It assesses your ability to perform work activity as well as activities of daily living. More specifically, it asks your doctor to detail whether you can perform fine motor skills, lift, walk, sit, and more. This RFC will be used by the LTD insurance company to determine if you are able to work.
Is fibromyalgia a disability? If it prevents you from being able to work, yes. But proving your claim to the LTD insurance company will be difficult. CJ Henry Law Firm PLLC can help.