Disability Claims Solutions


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FibromyalgiaFibromyalgia and Chronic Fatigue Claims have long been a source of denial by most American insurers. When I was a claims hander those diagnosed with FMS were treated with morphine pumps and yet today patients are expected to “get up on a treadmill” and exercise that connective tissue to remain on the job.

How times change. While extremely disabling FMS claims were paid for short periods of time, eventually insurers got around to either subjecting FMS to the 24 month Mental and Nervous provision or “self-reported”/subjective criteria, again limiting benefits to shorter payment periods. In fact, FMS and CFS have never been off the chopping block in terms of paying total disability benefits.

Today, the treatment of FMS is very different, but not in ways one might think, given new treatment modalities and industry experience. The change to DMS-5 is partly to blame by including a new section of “somaticized” impairments that are presumed to result from exaggeration of symptoms through depression and various components of, “it’s all in your head.”

Of course insurers are going to take advantage of such a prestigious resource such as the Diagnostic and Statistical Manual of Psychological Disorders (DMS-5) to back-up schemes that all sufferers of FMS and CFS are imagining, or over exaggerating symptoms defined as a mental disease. And there you have it.

BUT, not surprisingly the real culprits are rheumatologists and other treating physicians who outright refuse, or reluctantly document FMS as a viable totally impairing diagnosis. Physicians don’t mind taking FMS patients’ money, but they won’t document total disability without sitting on the fence procrastinating by saying…..”may be this….may be that.” Physicians just aren’t going to make themselves look like fools within the medical community by supporting FMS claims.

As most of my readers know FMS is a physical connective tissue disease diagnosed by a history of clinical treatment and observation. There are no tests for FMS that can objectively prove what patients say they have.

According to the insurance industry, the appropriate and regular treatment of FMS is at a minimum, monthly visits with a rheumatologist and bi-monthly therapy sessions. It is assumed that patients cannot get better unless both aspects of FMS are treated – physically and mentally. It was ALWAYS presumed that there was a mental component to FMS and CFS.

The current problem is that insurers are pulling out the “objective evidence” card, (there is no “objective evidence standard” in disability contracts or Plans), but recognizes the mental and nervous component of the disease by paying claims for 24 months – maybe, assuming there is a fully supportive physician documenting the severity of the disease.

Treating physicians and even insureds themselves do not help the issue. Insureds, after having researched on the Internet, continue to use catch-stone phrases such as “brain fog”, and “I hurt all over.” “Brain fog” is an old cliché from way back that is not specific and doesn’t do anyone any good to support disability claims.

How about, “I have difficulty processing information quickly and am often confused when asked to respond to certain things?” “Brain fog” is basically a non-descriptive stereotype that gets no one anywhere. More specificity is needed when describing modern day “brain fog.”

FMS suffers don’t “hurt all over” because there are only up to 18 identifiable “trigger points” that can’t test positive. Although it may feel as though you do “hurt all over”, again, it’s not a great description of what is actually going on. Again, how about, “The back of both shoulder blades, just below my neck, the thoracic region, thighs and behind my knees also hurt?”

Finally, FMS patients should never say, “I have good days and bad days.” EVERYONE has “good days and bad days” and clearly the description doesn’t apply to only FMS patients. The description has just become another stereotype that claims handlers ignore and laugh at. How about, “My pain levels are between 5-6 on the pain scale at least 3-4 times per week.” This is so much better than, “I have my good days and bad days.”

In reality, FMS, and to some extent CFS, have gone by the wayside in terms of supportable, credible impairments for total disability. Claims may be paid short-term, but unless FMS can be proved to be severe, claims are either denied as “subjective”, or limited to 24 months of benefits.

Also, it may be difficult to find a physician who is willing to support a disability claim much less permanent disability.