Getting Long-Term Disability (LTD) for Fibromyalgia
If your insurer has denied your long-term disability (LTD) claim for Fibromyalgia, do not give up the fight. A denied claim is not the end of the road for you. We understand that the sometimes-debilitating effects of this condition can render you unable to continue working.
Fighting an insurance company for disability benefits can be an exhausting process for anyone, especially for a person suffering from the chronic pain and fatigue often associated with Fibromyalgia. Our attorneys can help you navigate the complex long-term disability appeals process.
Let us apply our years of experience handling ERISA-governed and individual insurance policy appeals to your case. Contact our office for a free consultation: 401-331-6300.
Fibromyalgia is a chronic neurological condition that causes widespread musculoskeletal pain and tenderness that tends to come and go. Researches do not yet fully understand what causes the pain associated with Fibromyalgia, however, theories suggest that the disorder may cause the central nervous system (CNS) to become overactive, resulting in an amplified response to pain; this is called central sensitization. Some medical professionals believe that this overactivity may be attributed to chemical imbalances in the brain, resulting in changes to how pain signals are processed throughout the CNS.[note]Fibromyalgia. (2017, August 11). Retrieved February 16, 2018, from https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780[/note],[note]Fleming, K. C., & Volcheck, M. M. (2015, April). Central Sensitization Syndrome and the Initial Evaluation of a Patient with Fibromyalgia: A Review. Retrieved February 16, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4422459/[/note]
It is estimated that over 5 million people in the United States suffer from Fibromyalgia. Of those affected, approximately 80% are women, with the average age of diagnosis ranging between 35 and 40 years old; people are, however, diagnosed outside of this age range.[note]Fibromyalgia. (2017, November 21). Retrieved February 16, 2018, from https://www.cdc.gov/arthritis/basics/fibromyalgia.htm[/note],[note]Who gets Fibromyalgia? (2017, September 25). Retrieved February 16, 2018, from https://www.womenshealth.gov/a-z-topics/fibromyalgia[/note]
What causes Fibromyalgia?
Currently, there is no definitive medical explanation for what causes Fibromyalgia. Scientists have been able to rule out autoimmune, inflammatory, joint, or muscle disorders as the cause. Studies have been able to reveal that certain risk factors or triggers make people more prone to developing the condition[note]Bhana, S., MD. (n.d.). Fibromyalgia. Retrieved February 16, 2018, from https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia[/note]:
Potential risk factors:
- Genetics— individuals with a history of Fibromyalgia in their family may be genetically predisposed to develop the disorder;
- Gender— women are about 4 times more likely to develop Fibromyalgia than men;
- Other disorders— those suffering from rheumatoid arthritis or Lupus are more likely to develop Fibromyalgia;
Potential triggers that may lead to the onset of Fibromyalgia:
- Traumatic physical injury such as car accidents;
- Emotional trauma/psychological stress— Fibromyalgia has been linked to post-traumatic stress disorder (PTSD) in some patients;
- Illness and infection can cause onset or worsen symptoms.[note]Fibromyalgia. (2017, August 11). Retrieved February 16, 2018, from https://www.mayoclinic.org/diseases-conditions/fibromyalgia/symptoms-causes/syc-20354780[/note],[note]Cherney, K., & Holland, K. (2014, October 7). Fibromyalgia: Causes, Trigger Points, Treatment, and More. Retrieved February 16, 2018, from https://www.healthline.com/health/fibromyalgia#fibromyalgia-causes[/note]
Symptoms of Fibromyalgia:
Chronic widespread pain that can migrate to all parts of the body is the most common symptom associated with Fibromyalgia. This pain, however, is not the same in each patient; its intensity and location varies per person. Pain caused by Fibromyalgia is classified as lasting for more than three months, with pain above and below the waist, and pain on both sides of the body. Widespread pain is not the only symptom of Fibromyalgia, however[note]Symptoms of Fibromyalgia. (n.d.). Retrieved February 16, 2018, from https://www.fmcpaware.org/symptoms.html[/note],[note]Diagnosing Fibromyalgia. (2014, December 19). Retrieved February 16, 2018, from https://www.fibrocenter.com/diagnosing-fibromyalgia[/note]:
- Extreme fatigue that does not improve with rest or sleep
- Cognitive and memory issues, sometimes referred to as “fibro fog”
- Difficulty sleeping
- Headaches or migraines
- Muscle fatigue, causing twitching or cramps
- Depression and anxiety
- Numbness or tingling in the hands or feet
- Digestive issues, such as irritable bowel syndrome (IBS)[note]Fibromyalgia. (2017, November 21). Retrieved February 16, 2018, from https://www.cdc.gov/arthritis/basics/fibromyalgia.htm[/note],[note]What are the Symptoms of Fibromyalgia. (2017, September 25). Retrieved February 16, 2018, from https://www.womenshealth.gov/a-z-topics/fibromyalgia#references[/note]
The effects of Fibromyalgia can result in disability and a lower quality of life. According to the CDC, some complications resulting from Fibromyalgia can include:
- Those with Fibromyalgia are twice as likely to require frequent hospitalization than someone without the disorder.
- Studies show that women with Fibromyalgia may suffer a 40% reduction in physical function, and a 67% impairment of mental health.
- Adults with Fibromyalgia are three times more likely to suffer from major depression than those without the condition.
- There is an increased likelihood that those with Fibromyalgia will also be diagnosed with other disorders such as rheumatoid arthritis, and systemic lupus erythematosus.[note]Fibromyalgia. (2017, November 21). Retrieved February 16, 2018, from https://www.cdc.gov/arthritis/basics/fibromyalgia.htm[/note]
Diagnosis and Testing:
As of now, there is no objective medical test used to diagnose Fibromyalgia; because of this, diagnosing the condition can be quite difficult and can potentially take years. To begin the diagnostic process, blood tests and X-rays are conducted in order to rule out the possibility of other conditions that cause similar symptoms.
The most currently accepted method for diagnosing Fibromyalgia was set in place by the American College of Rheumatology in 2010; this two-step process uses a widespread pain index (WPI) and symptom severity (SS) score. The widespread pain index measures how many of the 19 specified pain regions the patient is experiencing symptoms; these areas include the legs, arms, back, neck, and more. WPI scores range from 0 to 19.
The second step to Fibromyalgia’s diagnostic procedure uses a symptom severity (SS) score, in which, patients rate the severity of common symptoms they are experiencing. These symptoms include fatigue, waking unrefreshed, cognitive problems, and a number of other somatic symptoms (e.g. muscle pain, IBS, etc.) on a scale of 0 to 3, with three being the most severe. Symptom severity scores range from 0 to 12.[note]How Is Fibromyalgia Diagnosed? (n.d.). Retrieved February 20, 2018, from https://www.webmd.com/fibromyalgia/guide/fibromyalgia-diagnosis-and-misdiagnosis#2[/note]
Physicians combine the WPI and SS scores in order to establish a Fibromyalgia diagnosis. Patients matching or exceeding the following criteria will most likely receive a Fibromyalgia diagnosis:
- WPI score ≥ 7 and SS ≥ 5; OR
- WPI score between 3 and 6 and SS ≥ 9; AND
- Have been experiencing symptoms at a similar level of severity for at least 3 months; AND
- Have not been diagnosed with another condition that may be causing reported symptoms.[note]Bhana, S., MD. (n.d.). Fibromyalgia. Retrieved February 16, 2018, from https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia[/note],[note]Wolfe, F., Clauw, D. J., Fitzcharles, M. A., Goldenberg, D. L., Katz, R. S., Mease, P., Yunus, M. B. (2010, May). The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Retrieved February 20, 2018, from https://www.ncbi.nlm.nih.gov/pubmed/20461783[/note]
Although no lab test can confirm a Fibromyalgia diagnosis, patients exhibiting symptoms may have to undergo a variety of blood tests to rule out other conditions:
- Erythrocyte sedimentation rate
- Complete blood count
- Vitamin D levels
- Thyroid function tests
Physical examinations of the muscles and joints, neurological exams, and sleep studies are often conducted in patients exhibiting signs of Fibromyalgia, depending on the symptoms being experienced.[note]Fibromyalgia: Understand the diagnosis process. (2017, August 19). Retrieved February 20, 2018, from https://www.mayoclinic.org/diseases-conditions/fibromyalgia/in-depth/fibromyalgia-symptoms/art-20045401?pg=2[/note]
Treatment options for those with Fibromyalgia can vary depending on which symptoms are most prevalent or severe in the patient. According to the American College of Rheumatology, treatment regimens can include medication-based therapies as well as options not reliant on medication; combining both treatment options may yield the most favorable outcomes.
- Physical exercise is thought to be an effective way of improving quality of life in those with Fibromyalgia. Therapies such as Yoga can serve as a low-impact exercise regimen that increases endorphin levels, which can reduce pain and help with depression. Physical exercise is also an effective way of improving sleep quality.
- Alternative therapies such as meditation and breathing exercises can reduce stress, which is thought to trigger Fibromyalgia pain.
- Cognitive behavioral therapy (CBT), a talk therapy, is intended to encourage lifestyle changes (e.g. exercise and stress reduction) in addition to treating underlying depression
- Physical therapy is thought to reduce pain and stiffness in Fibromyalgia patients by teaching pain-relieving stretches and helpful exercises.[note]Fibromyalgia. (2017, November 21). Retrieved February 16, 2018, from https://www.cdc.gov/arthritis/basics/fibromyalgia.htm[/note],[note]Fibromyalgia Treatments. (n.d.). Retrieved February 20, 2018, from https://www.webmd.com/fibromyalgia/guide/fibromyalgia-treatments#1[/note]
Medication selection can vary on a case by case basis for those with Fibromyalgia, depending on which symptoms are most affecting your life. For example, one person may be suffering most with chronic fatigue, and another with widespread pain. Commonly prescribed FDA-approved medications for treating Fibromyalgia include:
- Duloxetine (Cymbalta) and Milnacipran (Savella) to change serotonin and norepinephrine levels in the brain to help control pain.
- Pregabalin (Lyrica) or gabapentin (Neurontin) to block the overactivity of nerve cells. These medications can also improve sleep.
- Antidepressants to increase serotonin levels, improve sleep and relieve pain; prescribed amounts of this medication can be increased if the patient is also experiencing depression.
Other treatment options are available for more individualized symptoms, such as those also suffering from related conditions such as IBS and migraine headaches. Always consult your treating physician before beginning any new treatment regimens.[note]Bhana, S., MD. (n.d.). Fibromyalgia. Retrieved February 16, 2018, from https://www.fmcpaware.org/treatment.html[/note]
CCK Understands Fibromyalgia Disability Claims
Those living with Fibromyalgia may experience a wide array of physical and cognitive impairment as a result of their condition. Since pain caused by Fibromyalgia can flare and resolve, a person with the condition may be able to carry on their normal job duties one week, but not be able to leave bed the next. Severe, frequent pain caused by Fibromyalgia can greatly impact a person’s ability to remain working, especially for those working in physically demanding jobs.
Fibromyalgia can also lead to impaired cognitive function, such as trouble concentrating and memory loss; the effects of this “fibro fog” can make administrative tasks much more difficult and can dramatically impact your ability to perform in the workplace as you once did. In addition, the fatigue caused by Fibromyalgia sometimes does not improve, even with a full night of sleep. Regular full-time work can prove to be incredibly challenging to maintain when suffering cognitive deficiencies and severe fatigue.
If your long-term disability claim for Fibromyalgia has been denied by the insurance company, consider consulting an experienced ERISA or LTD attorney as soon as possible.
How can CCK help you with your long-term disability appeal?
Let the experienced team at Chisholm Chisholm & Kilpatrick LTD fight for your long-term disability benefits. We take a comprehensive approach to preparing and filing your appeal so that you may focus on maintaining your best quality of life possible.
Find insurance company errors
To look for legal errors on the insurer’s part, we gather any and all insurance documents surrounding your LTD claim. Your denial letter, policy documents, the insurance company’s claim file, and other plan-governing documents may hold the key to winning your appeal. We will incorporate our knowledge of ERISA law, U.S. Department of Labor laws, and insurance policies into your appeal in order to identify errors the insurance company may have made.
Communicate with doctors during the appeal process
Often times, doctors can be so busy in their day-to-day medical practices that they do not adequately communicate the severity of your condition with the insurance company. This is why we facilitate the flow of information between the two entities, as to ensure that all documents and necessary records are completed sufficiently and submitted on time. Since effective communication on all parts is key throughout the appeals process, we will be sure that you know how to communicate with your doctor about your Fibromyalgia, and how it impacts your daily life.
Gather evidence and write the appeal
At CCK, our skilled attorneys know what evidence to collect in order to build the best evidence record possible for you. Common forms of evidence we gather are:
- Medical records
- Test results
- Reports from treating physicians
- Expert opinions
- Witness statements from you, your family, friends, co-workers, etc.
Preparing an exhaustive evidence record to file with your appeal is critical for winning your case. Gathering all necessary documentation is especially important with ERISA-governed policies because the administrative appeal stage is often the final opportunity you have to submit substantive evidence into the record. We make sure that the evidence we gather is submitted thoroughly and on time for our clients. Our evidence-supported arguments will work to prove that you meet your policy’s definition of disabled.
Call Chisholm Chisholm & Kilpatrick LTD Today
Let us put our years of knowledge and experience to work for you. Call 401-331-6300 for a free consultation.