Fibromyalgia

Being unable to work due to a disability can be devastating, both financially and emotionally. However, this unfortunate setback is further compounded if your disability claim is denied, which is often the case for those living with Fibromyalgia.

This article dissects why fibromyalgia disability claims are often denied, and what can be done to ensure you get the disability benefits you deserve!

Key Takeaways

• Insurers frequently deny fibromyalgia claims due to the lack of objective medical tests or biomarkers to validate symptoms.
• Insurance companies use the “any occupation” standard to argue that claimants can still perform other types of work, regardless of prior job limitations.
• Documentation gaps, non-compliance accusations, and subjective symptom reporting contribute to high denial rates for long-term disability claims.
• Claimants often require extensive medical records, a consistent treatment history, and sometimes legal assistance to overcome skepticism from insurers.

What is Fibromyalgia?

Fibromyalgia is a chronic condition caused by environmental, genetic, and neurobiological factors that affects millions of people worldwide. 

In Canada alone, it is said to affect 2-3% of the population, or nearly a million Canadians.

Fibromyalgia is often marked by widespread musculoskeletal pain, fatigue, sleep disturbances, cognitive issues, and other fluctuating symptoms. It is a serious, debilitating condition that, for many, is life-altering. 

Yet, when people with fibromyalgia apply for long-term disability (LTD) benefits, they are often faced with a lot more skepticism than those with other types of conditions.

Why is this so? The main reason: fibromyalgia is hard to prove.

Why is Fibromyalgia Hard to Prove?

Unlike other illnesses that can easily be proven by blood tests or imaging scans, fibromyalgia is diagnosed primarily through subjective reporting of symptoms and medical history. 

It is this lack of “hard evidence” that makes disability insurance providers and adjudicators skeptical or hesitant to approve claims, even when the impact on a person’s life and work is undeniable. 

This often results in many valid claims being denied despite legitimate suffering.

Lack of Objective Medical Evidence Hurts Credibility

While fibromyalgia would qualify as a disability in anyone’s book, the fact that it doesn’t have clear diagnostic tests and relies on symptom self-reporting makes it problematic for insurance providers.

In essence, anyone can say they have fibromyalgia, as its symptoms are easy to fake and quite subjective.

In most cases, when filing for a long-term disability claim, insurers require objective evidence, like X-rays or lab results, that offer comprehensive proof that the disability in question directly impacts a person’s ability to work, not just in their current occupation, but in “any occupation”.

In the case of fibromyalgia, this form of objective and concrete evidence simply doesn’t exist, which is why some insurance providers exclude fibromyalgia from their coverage policies altogether. 

Even in cases where fibromyalgia isn’t omitted, adjudicators may deny claims on the basis of deeming treating physician reports as opinion-based or insufficient.

This lack of credibility can be offset through functional capacity evaluations that do offer objective measurements, but even these are inconsistently accepted.

This makes fibromyalgia diagnosis extremely challenging, and in most cases, claimants require detailed accounts of their medical history as well as the assistance of attorneys and insurance brokers when filing for a claim or challenging a denial. 

The Added Burden of The “Any Occupation” Standard

If these hurdles weren’t enough, many disability insurance policies also require objective evidence that a claimant’s disability doesn’t allow them to work, not just in their previous occupation, but in “any occupation”.

This means that even if you prove that fibromyalgia doesn’t allow you to do your old job, your claim can still be denied on the basis that you can still work in a sedentary position.

As many of fibromyalgia’s symptoms are subjective, and test results are often “normal”, adjudicators often deem claimants capable of working other jobs. 

To get past this, claimants have to prove how their symptoms, like fibro fog, fatigue, or pain, impair not just their ability to do their previous job but any job.

Other Reasons for High Denial Rates for Fibromyalgia-Based LTD Claims

While lack of objective evidence and meeting the “any occupation” standard are the predominant reasons for denial, they are not the only ones. 

In many cases, denials stem from a bias that fibromyalgia isn’t “serious enough” to warrant benefits. As fibromyalgia symptoms don’t always show outwardly, insurers can often underestimate their severity and dismiss fibromyalgia as a manageable or treatable condition.

Insurers can also deny a claim if they deem symptoms aren’t severe enough or not well-documented. To do this, insurers often utilize private surveillance and social media to challenge reported limitations or use exaggerated skepticism from private investigators to refute a claim.

The fact that fibromyalgia is an “invisible illness” doesn’t help the cause. As symptoms are often hidden or subjective, it is hard for even medical practitioners to accurately judge the severity and functional limitations caused by this disability. 

Inconsistent or Incomplete Medical Treatment Records

Claims can also be denied for “non-compliance,” which can include:

• Not following all treatment plans or exploring every therapy.
• Having gaps in between treatments (this can be misinterpreted as evidence of wellness).
• Patterns that challenge the severity or consistency of symptoms.
• Inaccuracy of medical records and lack of follow-through with referrals.

That’s why consistent documentation is so important. A clear treatment record that shows regular doctor visits and the use of therapies, and physician support can make a significant difference in how a claim is viewed.

How To Build a Strong Case for Fibromyalgia to Avoid Denial

While there is no denying that denial rates for fibromyalgia-related disability claims are much higher than for other conditions, it is by no means a lost cause.

Fibromyalgia disability claims do get accepted if you have a strong enough case and have done things right. Also, even if a claim is denied at first, that doesn’t mean the process ends there. 

You can always appeal and succeed, especially when supported by strong legal and medical advocacy. 

Insurance advisors and disability lawyers help claimants navigate the complex policy language, manage deadlines, and create strategies for appeal that can strengthen their case and chances of acceptance.

But there are things you can do as well.

1. Document Everything! 

This doesn’t just include thorough medical records, but also additional documents like pain diaries and functional notes. It also helps to have family members and colleagues provide supporting statements on how your disability is impacting your daily life and ability to work to help bridge the gap between subjective experience and insurer expectations.

2. Provide Detailed Medical Reports & Supporting Documents 

Detailed letters from treating physicians that focus on functional limitations carry a lot of weight. Providing specific examples of how pain, fatigue, or cognitive issues are hampering a claimant’s work and personal life on a daily basis, rather than just the diagnosis itself, gives a much clearer picture of severity to adjudicators. 

It is also recommended to include independent medical exams or second opinions when filing for an appeal or claim. This can help counter biased reviews that are often commissioned by insurers to refute a claim.

3. Be Consistent!

More importantly, your case needs to be consistent. You need to ensure that all information, including Residual Functional Capacity (RFC) forms, vocational reports, and occupational therapist evaluations, align and that nothing contradicts. 

Remember, insurers will often use surveillance or monitor claimants’ online activity. A social post or short video of you at the mall or a smiling photo of you at a family event is all it takes for adjudicators to argue that your condition isn’t as limiting as reported.

Thus, you need to be careful and mindful of what you share publicly. What you post online needs to be consistent with your claims, and you need to be prepared, if necessary, to explain how these occasional activities differ from the demands of regular employment.

What It Takes to Win a Fibromyalgia Disability Claim

Winning a fibromyalgia disability claim is difficult but possible. To have the best chance for acceptance, your application needs to provide credible evidence, be consistent, and provide clarity on how your symptoms are impacting your ability to perform any work. 

While it may feel unfair, given the pain and struggle you are already going through, it is important not to lose focus. With the right support, guidance, persistence, and understanding of how the system works, many denials can be successfully overturned.

To learn more about group benefits, disability insurance, or life insurance, call Pat McIver at 1-902-220-3279 or click here to book a free meeting.

FAQs

Q1) Why is fibromyalgia considered difficult to prove for disability benefits?

The main reason it is hard to prove is that it lacks objective tests. This leads to denials based on insufficient medical evidence, even when symptoms are severe.

Q2) Can you get disability benefits if you’ve been diagnosed with fibromyalgia?

Yes, but it can be challenging. Diagnosis alone is not enough, so you need to have a strong case that clearly shows your condition limits your ability to do any work.

Q3) What kind of evidence strengthens a fibromyalgia claim?

Having detailed and consistent medical records, in-depth physician statements, carefully maintained pain journals, and RFC assessments can all help strengthen your case.

Q4) What is the “any occupation” test, and how does it affect my claim?

This test requires claimants to prove they can’t perform any type of work, not just their old job. It’s a major reason fibromyalgia claims are denied.

Q5) What should I do if my fibromyalgia claim is denied?

Consider hiring a disability lawyer or speaking with an insurance advisor. They can guide you through the appeals process and help present the medical and functional evidence needed to overturn the decision.