Getting long-term disability benefits for fibromyalgia can be particularly frustrating. Besides widespread pain and physical limitations, victims of FM must overcome credibility problems that go hand-in-hand with “invisible diseases.” But it can be done! Here’s what you need to know.
Fibromyalgia is a complex disorder that causes persisting, body-wide pain, often accompanied by numbness and tingling in the extremities, and muscle and joint stiffness. Pain fluctuates in intensity and may not always be present. Symptoms include fatigue, sleep problems, waking unrefreshed, headaches, memory problems (“fibro fog”), depression, anxiety disorder, and irritable bowel syndrome.
If you live with fibromyalgia, the multitude of symptoms caused by this condition may disrupt your life so much you can no longer work. If so, it’s important to know:
- You may qualify for Social Security disability benefits for fibromyalgia.
- You may also be able to claim long-term disability benefits if you have disability insurance coverage through your employer or a private insurance policy.
- For disabled veterans, the VA follows a fibromyalgia rating scale ranging from 10% to 40%. For Gulf War veterans, fibromyalgia is a presumptive condition. Additionally, VA now accepts “pain alone” as a basis of disability. These rules may improve a veteran’s chance of obtaining disability benefits for fibromyalgia.
But it can be very hard to prove that your fibromyalgia is disabling.
The symptoms of FM are notoriously difficult to diagnose. Symptoms resemble those of other diseases, and proper diagnostic testing for fibromyalgia is not always done. Self-reported, “invisible” conditions are sometimes viewed with suspicion and doubt by insurance companies and federal disability programs.
We know FM is very real. At Marc Whitehead & Associates, we represent individuals who can’t work due to fibromyalgia, helping them apply for and win their rightful disability benefits. If your claim has recently been denied, our attorneys can help you appeal the denial and pursue the benefits you deserve.
In all cases, you need to know how each disability program or insurance company views and determines claims based on fibromyalgia. And although obstacles may abound, they simply mean you need a strategy that will craft the most competent claim for your situation.
Social Security Disability Benefits for Fibromyalgia
The Social Security Administration (SSA) does not include fibromyalgia in its published Listing of Impairments. Even so, you may still qualify for Social Security Disability Insurance (SSDI). Social Security will evaluate your medical conditions to see if they “meet or equal” one of the listings. Even beyond that, you may qualify for disability benefits based on vocational standards.
Winning Social Security disability benefits for fibromyalgia requires specific medical and vocational evidence.
SSA will want to know whether you (1) have a medically determinable impairment, and (2) your condition so limits your functional abilities that it keeps you from working – or as SSA calls it, performing any “substantial gainful activity.”
What evidence does the SSA need to find that fibromyalgia is disabling?
- Objective, diagnostic medical evidence. In cases of fibromyalgia disability, SSA wants to establish the presence of a medically determinable impairment of fibromyalgia. SSA will consider either of the following two sets of criteria for diagnosing FM:
- 1990 American College of Rheumatology (ACR) Criteria for the Classification of Fibromyalgia.
Criteria include (1) history of widespread pain throughout your body for at least three months, (2) the “18 tender points” test, and (3) evidence that other disorders that could cause the symptoms or signs are excluded.
– or –
- 2010 American College of Rheumatology (ACR) Preliminary Diagnostic Criteria.
Criteria include (1) history of widespread pain throughout your body for at least three months, (2) repeated manifestations of six or more FM symptoms, signs, or co-occurring conditions, and (3) evidence that other disorders that could cause the symptoms or signs are excluded.
- 1990 American College of Rheumatology (ACR) Criteria for the Classification of Fibromyalgia.
- Diagnosis from a specialist. Because the symptoms are often self-reported, you’ll need a thorough medical history and treatment from a specialist such as a rheumatologist, who can be a pivotal factor in your case.
- Longitudinal records. This becomes extremely important because the symptoms of fibromyalgia can wax and wane. Longitudinal records are medical histories that prove you’ve endured ongoing evaluations and treatment from acceptable medical sources. To claim disability based on FM, longitudinal records—such as from a rheumatologist with expertise in fibromyalgia—are very helpful in substantiating both the existence and severity of your impairment. SSA generally will want to see evidence from the 12 months prior to the date of your disability application.
- Supporting medical evidence. Getting disability benefits for fibromyalgia involves developing your case further with supporting medical evidence. For example, we help our clients keep a fibromyalgia journal to document pain and other symptoms suffered. Or, we may advise having a psychological assessment of the severity of the FM and how it affects your ability to function on a day-to-day basis and long term.
Relevant non-medical evidence. Supporting statements from family, friends, employers, clergy, and others help document the impact of fibromyalgia on your daily activities and reinforce the credibility of your allegations of pain and suffering.
SSA follows a 5-step sequential evaluation process:
Social Security then reviews your case file using the following process:
Step 1: Are you engaged in substantial, gainful employment currently? If the answer is Yes, SSA will say you are not disabled. If No, proceed to Step 2.
Step 2: Do you have a severe impairment? If SSA finds that your pain (or other fibromyalgia symptoms) limits you more than “minimally” in your ability to do work activities, SSA will find that your impairment is severe. You go to Step 3.
Step 3: Does your impairment meet or equal the medical criteria of any of the SSA Listings? Because fibromyalgia is not a listed impairment, it cannot meet a listing. SSA is going to look at whether your fibromyalgia medically equals any listing, or if it equals a listing in combination with at least one other impairment.
If SSA finds that your FM satisfies the criteria of another listing at Step 3, you will be considered disabled. If not, your claim is still alive and proceeds to Steps Four and Five.
At this point, SSA will do a Residual Functional Capacity (RFC) Assessment. RFC is based on all relevant evidence in your case record. SSA looks at the effects of all your medically determinable impairments, including those that are “not severe.”
Longitudinal records may be especially important to winning disability benefits for fibromyalgia at Steps 4 and 5 of the evaluation process. Your fibromyalgia symptoms may come and go, and you will need continuing documentation showing, over time, how you have both good days and bad days that cumulatively support a finding of disabled.
Step 4: SSA looks at your RFC assessment to determine whether you are able to do any past relevant work, and if you cannot.
Step 5: SSA considers your RFC and age, education, and work experience to see you can adjust to any other work. If you cannot pass both the requirements of Steps 4 and 5, SSA will find you to be “disabled” and disability benefits for fibromyalgia will be granted.
Tips on what SSA looks for in Steps Four and Five of the Evaluation Process:
- Extensive pain, exhaustion, and other symptoms of fibromyalgia often result in exertional limitations that may keep you from being able to do many kinds of unskilled work.
- Pain, fatigue, and other symptoms may burden you with non-exertional physical or cognitive limitations, or cause you to need environmental restrictions in possible workplaces.
- SSDI adjudicators are supposed to factor in the potential for exertional or non-exertional limitations (such as postural limitations, or environmental restrictions) that undermine your remaining ability to perform many jobs, which thus reduces your occupational base.
Don’t file your initial claim or appeal a denied claim blindly. When you need help with your initial application, our Social Security disability attorneys can help you build a compelling case for benefits. If your claim was denied, an experienced attorney becomes even more essential to your success.
Were Long Term Disability Benefits for Fibromyalgia Denied by your Insurance Company?
Insurers often deny disability claims based on fibromyalgia and other chronic pain diagnoses. Most insurers will look for weakness in a claim that gives them a way to avoid paying benefits. Unfortunately, the subjective nature of this disease creates further incentives to deny.
To meet the insurance company’s threshold of evidence for FM, it is essential to prepare your LTD claim with the same level and strength of medical and vocational evidence used to win Social Security disability benefits for fibromyalgia. If denial occurs, you will have a well-developed case that will hold up in court.
We are prepared for every attempt by the disability carrier to invalidate your claim.
One aspect of dealing with insurance companies is to be prepared for any tactics a disability carrier may use to deny benefits and to hold the company accountable for wrongful denials.
For instance, the disability company may try to claim:
- You were misdiagnosed
- There is no objective basis for the restrictions and limitations assigned by your doctor
- You can still work in a sedentary capacity
- You aren’t being properly treated
- Insurers often use biased independent medical examination (IME) doctors to review and deny fibromyalgia claims
For every “reason” the carrier uses to deny a valid claim, our disability insurance lawyers work to reverse the denial with multiple arguments in your favor to help you win the disability benefits for fibromyalgia you deserve.
Claiming Veterans Disability Benefits for Fibromyalgia
If you have been denied VA disability compensation for fibromyalgia, or you are not satisfied with the disability pay you were awarded, you may want to work with an accredited veteran’s claims attorney. Marc Whitehead & Associates can help you develop your claim with the information needed for VA approval.
The VA’s Schedule for Rating Disabilities evaluates fibromyalgia under The Musculoskeletal System: Diagnostic code 5025 Fibromyalgia (fibrositis, primary fibromyalgia syndrome), as follows:
VA fibromyalgia ratings: from 10% to 40% disabling
“With widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesia, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms.”
|Symptoms are constant, or nearly so, and resistant to therapy:||40% rating|
|Symptoms are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time:||20% rating|
|Symptoms require continuous medication for control:||10% rating|
Fibromyalgia is a Presumptive Condition for Gulf War Veterans:
If you served in the Gulf War and have been diagnosed with fibromyalgia, you do not need to show a nexus between fibromyalgia and military service.
The VA presumes that health conditions are related to Gulf War service if the veteran has experienced them for six or more months. This includes fibromyalgia. The illness must have also appeared during active duty in the Southwest Asia theater of military operations by December 21, 2021, and be at least 10% disabling.
Eligible theaters of operation include:
- Saudi Arabia
- The United Arab Emirates
- The Gulf of Oman
- The Persian Gulf
- Neutral zone between Iraq and Saudi Arabia
- The Gulf of Aden
- The Arabian Sea
- The Red Sea
Veterans’ disability benefits for fibromyalgia based on “pain alone”
For purposes of VA disability compensation, pain alone can serve as a functional impairment, no matter the underlying cause.
In the 2018 US Court of Appeals case Saunders v. Wilkie, the court held that a veteran’s pain is a functional impairment that affects a veteran’s earning capacity, regardless of the disease causing the pain or lack of any formal diagnosis. To establish the presence of a disability such as fibromyalgia, a veteran will need to show that his or her pain reaches the level of functional impairment of earning capacity.
We know how frustrating the VA claims process is. If your ability to earn a living is impaired as a result of your military service, we will fight for your benefits with all our might.
Make Sure You Get the Disability Benefits for Fibromyalgia You Are Due
The key to winning disability benefits for fibromyalgia is in how you develop and present your claim. Our disability attorneys have an extensive understanding of the restrictions and limitations that people who suffer from fibromyalgia endure. We will help you take action swiftly, as timing can be critical to your case.