Fibromyalgia is often labeled a “subjective” condition by long term disability insurers because the diagnosis relies heavily on self-reported symptoms, which may include chronic fatigue, widespread pain, and cognitive issues without the benefit of consistent, objective biomarkers or definitive diagnostic tests. The diagnosis of fibromyalgia emphasizes symptom patterns rather than verifiable evidence, which allows insurers to reject long term disability (LTD) claims despite a claimant’s inability to work.
Lack of Objective Medical Evidence
For example, let’s consider an employee’s journey when seeking long-term disability benefits due to fibromyalgia. The employee may find that upon looking at their policy that the plan defines disability as the “inability to perform job duties supported by objective evidence” such as lab results, imaging, or other verifiable tests. Although the employee may have a diagnosis from their doctor showing severe pain, fatigue and cognitive issues associated with the condition, the employee cannot provide objective medical tests to back up their claim and may be denied.
Own Occupation vs Any Occupation
Another possible scenario includes an employee who is initially approved for LTD benefits, but are later denied benefits after transitioning from not being able to perform duties in their “own occupation” to not being able to perform the duties of “any occupation“, a distinction detailed in their policy.
For example, during the “own occupation” period (typically 1-2 years as specified in the policy), a claimant may be considered disabled if they cannot perform the material and substantial duties of their specific occupation – a surgeon who cannot operate or an office worker who cannot type reports. However, at the 12-24 mark, the policy shifts to the “any occupation” standard, where a claimant is considered disabled only if they cannot perform the duties of “any occupation for which they are reasonably qualified”.
The stricter criteria can result in the denial of benefits because conditions such as fibromyalgia lack objective evidence to prove an inability to work in “any occupation”. Many LTD policies include exclusions or limitations for subjective conditions like fibromyalgia, especially in the “any occupation” phase.
Strategies to Counter LTD Denials
If you are suffering from fibromyalgia and are unable to work, it can be financially devastating if the LTD benefits you thought you could rely on are denied. It is important to work with an experienced attorney who can review your LTD policy for specific definitions and exclusions, building a strong case based on the reason for your denial. As part of building a strong LTD denial case, your attorney may obtain detailed reports from specialists documenting functions limitation and their impact on work capacity, which may include functional capacity evaluations that quantify limitations underscoring your inability to work. Your attorney may also support your claim by providing additional medical evidence, including statements from multiple providers and more detailed patient records. If your denial is based on insurer surveillance suggesting an exaggerated claim, your attorney can counter any misrepresentation of your disability with facts.
Contact an LTD Benefits Denial Lawyer for Help
Because of the subjective nature of the condition, fibromyalgia claims face higher denial rates particular under the “any occupation” standard. However, a robust response including medical evidence, specialist input, and expert legal assistance can overcome a denial resulting in the payment of benefits. It is worthwhile to discuss your case with an attorney that specializes in denied LTD benefit claims who will advise you on the strength of your case and provide highly skilled and knowledgeable legal representation to get your LTD benefits paid. Contact our LTD denial attorneys for help today by telephone at 262-785-9606 or via our contact form. Be sure to visit our getmyltdbenefits.com website for additional information regarding your LTD claim.
