Insurance Companies are Wrongfully Denying Disability Insurance Benefits Due to "Lack of Objective Medical Evidence..."

Disability insurance is supposed to replace your lost income if you are unable to work.  If your disability insurance is part of an employee welfare benefits plan with your employer, then a relatively unknown federal law called the Employee Retirement Income Security Act of 1974 (ERISA) governs your rights to disability insurance and the process that the insurance company has to use in order to determine whether to accept or deny your application for disability insurance benefits.

Insurance companies have been increasingly denying disability insurance benefits for people with chronic pain conditions like fibromyalgia.  "Fibromyalgia is a form of rheumatic disease with no known cause or cure.  The principal symptoms which are entirely subjective are pain and tenderness in muscles, joints and ligaments, but the disease is frequently accompanied by fatigue, sleep disturbances, anxiety, dizziness, irritable bowels and tension headaches."  Walker v. Am. Home Shield Long Term Disability Plan, 180 F.3d 1065, 1067 (9th Cir. 1999).  

Because complaints of pain and fatigue are hard to document on objective medical tests like MRIs, X-rays, or blood work, disability insurance companies are frequently denying disability benefits to their customers with diagnoses of fibromyalgia and other disorders that are hard to document and verify through objective medical tests.

The Sixth Circuit (the federal appeals court for Ohio, Kentucky, Michigan, and Tennessee) has recognized the difficulty of diagnosing fibromyalgia.  "Unlike most diseases that can be confirmed or diagnosed by objective medical tests, fibrositis can only be diagnosed by elimination of other medical conditions which may manifest fibrositis-like symptoms of musculoskeletal pain, stiffness, and fatigue."  Preston v. Sec'y of Health & Humas Servs., 854 F.2d 815, 817-19 (6th Cir. 1988).

What most often ends up happening is that a person will experience chronic pain symptoms over a period of time, and their primary care physician will send the patient out to see specialists to try to confirm or rule out various different diseases or disorders.  Fibromyalgia is sometimes the diagnosis after the rheumatologist has ruled out other possible diagnoses.  

Most of the treatment notes documented by primary care physicians and rheumatologists will simply document the patient's own complaints of pain and frequency of pain.  Then the disability insurance company requests medical documentation from the patient's primary care physician and rheumatologist and they will end up getting documentation that does little more than transcribe the patient's complaints of pain.  Then the insurance company uses these medical records against their own customers by denying the disability insurance claim with the explanation that there is no "objective" evidence of a disability, but only subjective medical documentation.

There are certain things that a person can do who has been denied disability insurance for fibromyalgia or other chronic pain conditions.  First, it is most helpful to consult with an ERISA attorney experienced in disability benefit denials for chronic pain conditions.  Most disability insurance plans allow either one or two chances to appeal the disability denial with the insurance company itself.  This is an absolutely critical time to talk to a disability attorney before you appeal with the insurance company.  If you have to file a lawsuit with an ERISA case, then you have to shore up your case at the administrative appeal stage in order to give yourself the best shot at winning at the district court stage.  

Attorney Evan T. Engler is a partner at the central Ohio law firm of Harris & Engler.  Evan T. Engler helps individuals with their ERISA governed disability and life insurance denials for cases located within the 6th Circuit (Ohio, Michigan, Kentucky, and Tennessee).  The 6th Circuit has been developing a few standards that tends to help individuals battling for their disability insurance benefits for chronic pain conditions like fibromyalgia.  You need to talk to an attorney experienced in disability insurance denials in order to give yourself the best show at getting your benefits.
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