Long Term Disability Claims for Fibromyalgia & Chronic Fatigue (ME/CFS)
“But you don’t look sick.” It’s a phrase you’ve heard a dozen times. Your illness is “invisible,” but your suffering is real. So why did your insurer deny your claim?
Fibromyalgia and Chronic Fatigue Syndrome (ME/CFS) are two of the most misunderstood and wrongfully denied conditions in the world of long-term disability insurance. You are not “just tired.” You are not “making it up.” You are suffering from a complex, neuro-immune condition that causes debilitating pain, crushing fatigue, and severe cognitive impairment.
Insurance companies are built to fight these “invisible illness” claims. They have a standard playbook designed to dismiss your symptoms, discredit your doctors, and prove you are capable of working. At Uscher, Quiat, Uscher & Russo, P.C., we have seen this playbook hundreds of times. We know these conditions are real, and we know how to build the specific, objective evidence needed to win your appeal.
Why Fibromyalgia & ME/CFS are Genuinely Disabling
An insurance adjuster who has never experienced a “crash day” cannot comprehend your reality. They don’t understand that simple tasks can be exhausting or that “brain fog” is a real cognitive impairment.
These conditions make a 40-hour work week impossible by causing:
- Widespread, Chronic Pain: Fibromyalgia is characterized by chronic, widespread pain and tenderness. This is not the “soreness” an adjuster imagines. It is a constant, distracting, and exhausting pain that makes it impossible to sit, stand, or concentrate for long periods.
- Debilitating, Pervasive Fatigue: This is the hallmark of ME/CFS. It is a profound, unexplained exhaustion that is not relieved by sleep. It’s a “bone-deep” tiredness that makes a full day of work, or even getting out of bed, impossible.
- Post-Exertional Malaise (PEM): This is a critical symptom. It means that any minor physical or mental exertion (like a long meeting or even a shower) can result in a severe “crash” or relapse of all symptoms, lasting for days or weeks. This makes a consistent work schedule impossible.
- Severe Cognitive Dysfunction (“Fibro Fog”): Both conditions cause significant cognitive impairment, including memory loss, an inability to find words, poor concentration, and slow processing speed. This “brain fog” is not just “forgetfulness”; it’s a disabling impairment that prevents any high-level professional work.
How They Deny “Invisible” Illnesses
The insurance company’s entire strategy is based on one word: “objective.”
Tactic 1: “No Objective Evidence” (The Primary Weapon)
Since there is no single blood test or X-ray for Fibromyalgia or ME/CFS, insurers will call your disability “subjective” and “self-reported.” They will claim there is no “objective” medical proof of your condition or your limitations. This is their main line of attack, and it is a powerful one if you don’t know how to fight it.
Tactic 2: Attacking the Diagnosis
Fibromyalgia is often a “diagnosis of exclusion,” meaning doctors rule out other conditions (like Lupus or MS) first. The insurer will use this to their advantage. Their “paper-only” doctor will claim you don’t meet the *exact* diagnostic criteria (e.g., the 1990 American College of Rheumatology tender point criteria), even if your specialist has made a clear, clinical diagnosis based on the modern, updated criteria.
Tactic 3: The “Mental Health” Limitation
This is a cynical and damaging tactic. The insurer will argue that your Fibromyalgia is “caused or contributed to by” your (understandable) depression and anxiety. Why? Because many policies have a 24-month cap on benefits for “mental/nervous” conditions. By re-characterizing your physical, neuro-immune illness as a mental one, they can save themselves hundreds of thousands of dollars.
Tactic 4: The “Good Day” Surveillance Trap
Insurers love using private investigators for these claims. They will film you on a “good day” walking your dog or getting groceries. They will then present this 5-minute clip as “proof” that you are faking your fatigue and pain, completely ignoring the reality of post-exertional malaise and the “crash” that likely followed that activity.
How We Build a Winning Appeal for Fibromyalgia & ME/CFS
When your insurer denies your claim, you have one chance to appeal. This appeal, governed by a federal law called ERISA, is your one and only opportunity to build your case. A weak appeal is a fatal mistake.
So, how do you “objectify” a subjective illness? You build a fortress of evidence they cannot ignore.
1. We Prove the Diagnosis
We work with your rheumatologist or specialist to create a detailed narrative report. This report will meticulously walk through the diagnostic criteria, showing how you meet them. It will detail your history, your “tender points,” and the other conditions that were ruled out, establishing a firm, clinical diagnosis that is hard to attack.
2. We Gather the *Right* Objective Evidence
We use specific tests to counter their “no objective evidence” claim. A **Functional Capacity Evaluation (FCE)** provides objective data on your physical limitations. More importantly, a **Neuropsychological Evaluation** provides hard data on your cognitive “brain fog,” measuring your memory, processing speed, and concentration. This is powerful “objective” proof of a “subjective” symptom.
3. We Document Your Limitations
We will have you keep a detailed “symptom and activity log” for several weeks. This log documents your pain, fatigue, and cognitive struggles on a daily basis, and clearly shows the “crash” (post-exertional malaise) that follows activity. This log, when certified by your doctor, becomes critical medical evidence.
4. We Use Your “True” Occupation Against Them
We hire a vocational expert to write a report on the *actual* demands of your job. This report will highlight the *cognitive* and *stamina-based* requirements of your career, proving that even a “sedentary” desk job is impossible with your level of fatigue and brain fog.
You Know What You Feel. We Know How to Prove It.
We have successfully represented countless clients with Fibromyalgia and ME/CFS. We believe our clients. We understand the science. And we know how to translate your debilitating, “invisible” illness into the hard, objective evidence the law requires.
The insurer is betting you’ll be too tired and overwhelmed to fight. Let us take the fight to them. If your disability claim has been denied, contact us today for a free, confidential consultation.
New Jersey Office