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Fibromyalgia remains an ERISA long-term disability minefield

On Behalf of | Dec 29, 2022 | ERISA

People submitting long-term disability claims for fibromyalgia are frequently denied benefits and those who have taken their claims to court have found that judges often side with insurers. Why is fibromyalgia so frequently viewed as a non-disabling condition?

Niemuth v. The Epic Life Ins. Co

In this most recent example of a claimant being denied long-term disability benefits for fibromyalgia, the court sided with Epic Life, saying Ms. Niemuth’s doctors did not “offer any objective support for the limitations endorsed on their functional assessments and that they were merely parroting Niemuth’s subjective complaints.” In other words, lack of evidence.

The root of the problem is that it is virtually impossible to quantify the severity of fibromyalgia symptoms with “objective medical measures.” As such, courts feel free to minimize the subjective complaints from the patient, even if these complaints are real and truly debilitating. To justify its decision, the judge in Niemuth quoted dicta from a 1996 case, Sarchet v. Chater, which purported to find that most people with fibromyalgia are still able to work and truly disabling cases are rare. Indeed, the defense on this type of claim frequently argues that the best way to overcome the disabling symptoms of FIBROMYALGIA is through increased physical activity–a point which has never been proven, but fits nicely into an insurer’s argument that such patients are better off working than not. Simply stated, despite the fact that Fibromyalgia has been fully recognized by the CDC, Social Security and many courts around the country, as a legitimate cause of long term disability, there is still much underlying skepticism articulated by the insurance industry, who simply does not want to pay these claims, and use the “no objective” evidentiary hurdles to justify the denial of benefits.

Self-reported and subjective symptoms

Fibromyalgia remains a medico/legal dilemma. While the condition is widely recognized as legitimate, the problem is that symptoms (pain sensitivity, stiffness, sleeplessness, fatigue, cramping) cannot be objectively measured and therefore tend to be dismissed or understated. This subjectivity makes it easy for insurers to reject fibromyalgia claims outright, knowing that many of these cases cannot meet the required burden of proof under the arbitrary and capricious standard of review.

In fact, a growing number of policies now expressly exclude any disability claim based only on subjective complaints, without objective evidence. Even though ERISA requires that courts credit a patient’s subjective complaints, when the policy language targets such claims for denial, it is much more difficult for the court not to follow suit.

Fibromyalgia policy exclusions

Without measurable, observable evidence of the severity or even the presence of fibromyalgia, many disability insurance policies explicitly exclude it from their plans.

Insurers that don’t exclude fibromyalgia still reliably hand out quick denials, as filing claims with the requisite medical proof that the claimant’s condition qualifies for long-term disability is difficult. It can be done, but it is not easy.

An ongoing, slow-moving medical quandary

It’s believed that up to five million people in the U.S. alone suffer from some degree of fibromyalgia. And even this substantial number may be an undercount considering the difficulty in diagnosing the condition. As of this writing, no test isolates fibromyalgia from other conditions such as rheumatoid arthritis or lupus. Arriving at a fibromyalgia diagnosis is a matter of detailed and careful clinical evaluation which rules out everything else.

Some policies improperly classify fibromyalgia as a mental health disorder. In these instances, disability is somewhat easier to obtain, but these benefits usually expire after 12-24 months. After that, the claimant has the long-term disability mountain of proof to climb.

Having said all that, people have successfully won long-term disability benefits for their fibromyalgia. Even if you have received a claim denial, you may still have legal recourse. Do not accept “no” for answer. Fibromyalgia is a legitimate cause of severe disability, despite the hostility which the insurance industry tends to display when confronted with such a claim. That the industry sees the condition from this perspective is conveniently self serving and should not be accepted without serious push back.