Do Long-Term Disability Benefits Cover Fibromyalgia?

As part of an employment offer, many companies provide health benefits for their employees. One of these benefits, which is typically overlooked, is long-term disability (LTD) benefits, which pay benefits when an employee becomes disabled and is unable to work. However, as is the case with all dealings with insurance companies, getting the LTD insurance company to pay out benefits is not as easy as it should be. Retaining the services of an attorney experienced in dealing with disability benefits can be crucial in ensuring that the insurance company does, in fact, pay the benefits that they are required to pay. One condition which insurance companies are very stringent about is when the claimant is suffering from fibromyalgia. Due to its symptoms, which are not as objectively apparent as, say a broken bone, fibromyalgia sufferers have many obstacles to overcome in order to obtain LTD benefits. A discussion of how the Social Security Administration (SSA) evaluates Social Security Disability Insurance (SSDI) claimants who are suffering from fibromyalgia, as well as how LTD insurance companies conduct the same evaluation, will follow below.

Fibromyalgia as a Basis for an SSDI Claim

SSDI is another stream of disability benefits, in which a claimant applies for benefits through the SSA, based on his/her employment record. While it is distinct from LTD insurance policies, knowing the manner in which the SSA evaluates fibromyalgia sufferers can be crucial when submitting a claim for LTD benefits.

Generally, in order for an SSDI applicant to receive benefits based on fibromyalgia, that applicant must be able to provide proof of the following:

A history of widespread pain in all quadrants of the body, as well as axial skeletal pain, which has persisted for at least 3 months;
At least 11 positive tender points on physical examination, which must be found on both the left and right side of the body, above and below the waist; and
Proof that other disorders that could cause the same symptoms were excluded.

Fibromyalgia in the LTD Context

Traditionally, LTD insurance companies did not give much weight to a claim of fibromyalgia unless another severe medical condition was involved. Accordingly, many claims for LTD benefits based on fibromyalgia were ultimately denied. This is due to, as alluded above, that fibromyalgia is diagnosed primarily on a subjective nature, and, even today, the causes of fibromyalgia are not fully understood.

More recently, however, fibromyalgia, while it still may not be completely understood, has begun to receive recognition as a serious debilitating condition. For example, the American College of Rheumatology (ACR) has issued the following criteria to help LTD insurance companies determine whether an applicant has fibromyalgia (which are very similar to the SSDI factors listed above):

Evidence of chronic widespread pain, including pain in the back, neck, or chest;
Proof that a medical professional has ruled out other diseases that could cause the same symptoms; and
Either (1) tender points sites in at least 11 of 18 tender point areas of the body, occurring on both sides of the body and both above and below the waist, or (2) repeated manifestations of six or more fibromyalgia symptoms, signs, or conditions that often occur with fibromyalgia, such as fatigue, non-restorative sleep, cognitive or memory problems, depression, anxiety, or irritable bowel syndrome.

An experienced disability benefits attorney can help in framing the LTD claim so that it has the best chance of success.

If you, or someone you love, are considering filing for LTD benefits due to fibromyalgia, and are curious about how this complicated condition can be the basis for filing LTD benefits, contact a disability benefits attorney as soon as possible. The legal team at Farrell Disability Law has the experience to help you. After analyzing your claim, we will work with you on the LTD application to get you the benefits you deserve as soon as possible. Contact our Jacksonville office today.

Resource:

ssa.gov/OP_Home/rulings/di/01/SSR2012-02-di-01.html