Fibromyalgia is a serious disease that features chronic, painful muscles that hurt all over, along with tiredness. Many patients also experience cognitive dysfunction, commonly called “fibro fog.” These symptoms occur unpredictably and vary in intensity. Unfortunately, this makes it impossible for many patients to work full-time. As a result, many have to consider Long-Term Disability (LTD) benefits.
Because fibromyalgia lacks a definitive objective test and diagnoses depend so heavily on patient-reported symptoms, getting LTD approved is very difficult. Insurance companies can be aggressive, requiring extensive paperwork and may even limit your benefits to the policy language restricting “self-reported” conditions.
To navigate this process successfully, you must prepare accordingly, provide medical evidence, and clearly show how you cannot work because of your limitations. The following information will guide you on how to achieve this to enjoy the long-term benefits of fibromyalgia.
Why Insurance Companies Often Deny Fibromyalgia Claims
Many fibromyalgia long-term disability claimants get immediately denied. This can be very frustrating for a lot of people. Insurance companies aim to make a profit and routinely target conditions without visible physical markers to reduce their payout. A fibromyalgia denial letter usually contains two main arguments:
- Lack of objective evidence
- The nature of subjective symptoms
Fibromyalgia cannot be determined through an X-ray, MRI, or regular blood test. Insurers jump on this, claiming you have not offered “objective medical evidence” demonstrating your condition's severity. They liken the condition to something like breaking a bone, which can be easily verified.
The second problem is that fibromyalgia symptoms, including widespread pain, crippling fatigue, and cognitive issues (fibro fog), are subjective in nature and depend primarily on your own description. The claims adjuster could argue that the symptoms can never be put through a lab test. Hence, your disability is not medically verifiable under the policy. This uncertainty concerning an invisible illness puts a great burden on you to bring forth steady, detailed, and convincing medical records that bridge the gap between your reported pain and an established inability to work.
The Foundation of Your Claim
The most significant supporting document for your fibromyalgia LTD claim is a medically appropriate diagnosis that meets professional criteria, preferably from a rheumatologist or specialist knowledgeable about the condition. A diagnosis alone is not enough. It has to be demonstrably thorough.
The doctor’s notes should indicate that they have considered the American College of Rheumatology (ACR) criteria for fibromyalgia. The framework consists of important conditions to show that your condition is real and disabling.
The diagnosis must document:
- The widespread pain index (WPI) — This is a count of painful areas of the body (19 spots are noted)
- Symptom Severity Scale (SSS) — This scale assesses the severity of fatigue, unrefreshed sleep, and cognitive symptoms ("fibro fog")
- Symptoms have been present at a similar level for at least three months.
Most importantly, your doctor must rule out other conditions that mimic fibromyalgia, including rheumatoid arthritis, lupus, and thyroid disease, with lab work and other testing before they make the diagnosis. Without this formal, criteria-based diagnosis, the insurance company can easily dismiss your claim as unsubstantiated.
What Benefits Am I Entitled to With Fibromyalgia?
Long-term disability benefits can help when you can no longer work because of your fibromyalgia symptoms. To maximize a claim and ensure long-term financial stability, understanding the various components of your policy is vital.
The Monthly Disability Payment
If you are unable to work due to fibromyalgia, your long-term disability plan is meant to replace some of your income. The main benefit you receive is usually only a percentage of your pre-disability earnings, 60% to 70%. Your individual or group policy documents define the exact percentage and maximum benefit amount. For example, if the policy pays 60% of your $5,000 monthly salary, your gross LTD benefit equals $3,000. Understanding this initial calculation is the first step in evaluating your financial coverage.
The Social Security Disability Insurance (SSDI) Offset
The Social Security Disability Insurance (SSDI) offset considerably complicates matters. This essential provision is found in nearly all private and employer-sponsored LTD policies. Typically, your insurance company will ask you to apply for SSDI benefits. While fibromyalgia is a recognized and qualifying condition of the Social Security Administration (SSA), it can be challenging to prove that you meet the requirements.
After the SSA determines you are disabled, you will receive a monthly benefit. In response, your private LTD carrier will lessen its payment by that amount.
Using the previous example, say your LTD payment is $3,000, and SSA is paying you $1,500 in SSDI. In this case, your LTD insurer will only pay you $1,500. This process does not improve your total monthly income. However, it is a necessary process that moves a large part of the payment responsibility from the private insurer to the government, and it is a key part of your claim.
Waiver of Premium for Other Benefits
An approved LTD claim provides an often overlooked financial benefit, the waiver of premiums for other benefits. Most group LTD plans have this clause automatically included, so when you become approved for disability, the insurance company will pay the premiums on any other benefits you obtained from your employer. It is a key benefit as it saves you from losing important coverage.
If you become disabled, this waiver usually pays your group life insurance premium. Sometimes, part of your medical or dental insurance premium will also be paid, so you do not lose coverage while disabled.
Cost of Living Adjustment (COLA)
Checking if your policy has a COLA rider is also a good idea. Not every policy includes this feature, but the ones that do can prevent inflation. If the plan has a COLA provision, your monthly benefit will increase by a fixed percentage (2% or 3%) for each year you stay on claim. These changes seem insignificant at first. However, they ensure that the buying power of your payment does not completely erode over the years that you receive disability income. This is particularly true for a long-term, chronic illness.
Vocational Rehabilitation Services
Ultimately, many LTD policies will include vocational rehabilitation services. The insurer might suggest or mandate that you participate in a program to return you to work in a different role. In essence, you do not have to go back to your previous job. The program may instead offer career counselling, retraining, or education for a different occupation that matches your physical and cognitive limitations. This could be a less physically demanding part-time job.
By accessing these services, even if you are unsure if you want to return to work, you show that you are playing by the rules of the policy and will thus strengthen your claim overall.
How to Build Your Case to Prove You Qualify for These Benefits
To show that your fibromyalgia qualifies as a disability under an LTD policy, you must prove your limitations functionally with persuasive, consistent evidence. As your condition is mainly “invisible,” you must comprehensively and objectively record its effect.
One of the most important tools you have at your disposal is your pain and symptom journal. Maintain a daily or weekly diary, not just a pain rating of 1 to 10. Write down:
- Your symptoms (pain, fatigue, fibro fog, sleep, among others)
- Triggers for flare-up
- How it impacts you in the present moment in daily life
This long-term record can help turn subjective experience into a pattern of impairment over time that can be substantiated. This can help defeat the insurer’s subjective symptoms argument.
Next, you must focus on functional limitations. Insurance companies do not pay benefits just because you have a diagnosis. They pay because your condition stops you from doing the most significant parts of your job. You need to show how your symptoms are linked to your inability to work. Instead of just stating that you have bad pain, share how it affects you. State, for example, that you cannot sit more than 20 minutes at a time because of the chronic pain and stiffness, or that you lose your concentration after 45 minutes because of the fibro fog, so you cannot do complex spreadsheets. This analysis should clearly raise the issue of what you can and cannot do regarding sitting, standing, walking, lifting, concentrating, and maintaining a regular schedule.
For maximum impact, you need your doctor's support. Have the doctor who treated you write a detailed letter to the insurance company about your condition. Your doctor must state your diagnosis and confirm that you have had one or more standard treatments, but they have failed. Most importantly, you require an opinion on your Residual Functional Capacity (RFC). Your letter must clearly spell out any functional restrictions or limitations preventing you from working full-time. A simple note from your doctor is insufficient. A complete report is necessary to confirm your journal and functional statements.
Furthermore, corroborate your limitations with witness letters. Third-party statements from family, friends, or former colleagues can be highly valuable. These individuals can objectively testify to the changes in your physical and cognitive abilities over time. For example, they can confirm:
- That there has been a frequent need to rest
- Issues with memory or increased absenteeism
When a third party makes observations of your symptoms or limitations, it will help your claim. It shows the insurer that your limitations are real and observable, not merely self-reported.
What to Do If Your Benefits Are Denied
It can be disheartening to receive a denial for your fibromyalgia LTD claim. You need to understand that many insurers will issue an initial denial, especially for fibromyalgia, which does not have objective markers. Do not give up on your claim. The denial is just the start of the legal process you will need.
Federal law, the Employee Retirement Income Security Act (ERISA), governs your claim. The law governs most disability plans your employer offers. It is important to understand your ERISA rights because ERISA places very restrictive rules on the appeal process that differ significantly from court cases. According to ERISA, you must first file a mandatory internal administrative appeal with the insurance company before filing suit.
You should immediately act when you receive the denial letter to comply with the critical appeal deadline. According to ERISA, the window to file your administrative appeal is very short (180 days from when the denial letter is sent). If you miss the deadline, your claim is often barred because it prevents you from exhausting your administrative remedies and waives your right to sue in federal court later.
The last opportunity to formally introduce evidence is through the ERISA administrative appeal process. This is the single most critical aspect of the appeal. When a federal judge looks at a denied ERISA case, the judge is typically limited to what is noted in the insurer’s “administrative record.” This is the file you created on the initial claim and the administrative appeal. You cannot present new evidence, produce witnesses, or ask for a jury trial in court.
For this reason, you must fully “build the record” during the 180-day appeal period by submitting all necessary expert reports, updated functional capacity statements, and corroborating medical evidence that your claim was missing. At this stage, many claimants engage an experienced disability lawyer, since successful ERISA appeals require highly strategic and detailed evidence gathering.
Find a Long-Term Disability Attorney Near Me
It often takes a lot of paperwork and legal wrangling to get LTD benefits for fibromyalgia. Many people are denied at first. If you want to achieve success, then you will have to show that your pain and fatigue cause specific functional limitations that prevent you from working. Do not face the powerful insurance carriers alone. They strive to limit payouts, but fighting for your right to financial stability is undoubtedly worthwhile.
If you receive a fibromyalgia denial or if you are preparing to file your claim, you must enlist the aid of a California lawyer. Consider contacting Leland Law for a consultation to help you build the strongest possible administrative record and protect your future. Contact us at 866-449-6476.
