Social Security Ruling May Help Fibromyalgia Patients with Disability Insurance Claims

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Fibromyalgia remains an enigmatic condition, as its symptoms are entirely self-reported and there is no objective testing that can confirm the presence of the disease. See MD Guidelines. This often makes it extremely difficult for claimants with fibromyalgia to get their disability carriers to pay their claims.

Fortunately, the Social Security Administration came out with a ruling this summer that provides guidance in determining whether a claimant is functionally impaired due to fibromyalgia. See SSA Ruling of July 25, 2012. Instead of the objective testing–such as x-rays and lab reports–which can substantiate other diagnoses, the SSA will here focus on the quality of the evidence documented by a claimant’s treating physicians. The SSA has provided that proofs may come in the form of medical records, so long as the physician conducts a physical exam and documents symptoms of fibromyalgia as prescribed by the American College of Rheumatology including pain, tender points, and the absence of any other objectively diagnosable disorder. The SSA will then look to see whether the pattern of the symptoms the physicians document is consistent with a diagnosis of fibromyalgia.

The SSA’s emphasis on the importance of treating physician’s opinions and documentation in fibromyalgia disability cases buttresses the holdings of many federal courts in ERISA cases who have maintained that an insistence on objective symptoms and the rejection of consistently documented subjective symptoms is an inappropriate basis on which to deny a fibromyalgia claim. See Brown v. Continental Casualty Co., 348 F. Supp. 2d 358, 369-70(E.D. Pa. 2004) (even if an ERISA administrator may sometimes impose a requirement for “objective” medical evidence that does not appear explicitly in a plan’s terms, it would be unreasonable to do so here . . . Such a requirement would effectively preclude any fibromyalgia patient from qualifying as totally disabled on the basis of the disease . . . Such a requirement would merit reversal here even if CNA’s administrative decisions were entitled to deference); Duperry v. Life Ins. Co. of North America, 2009 U.S. Dist. LEXIS 83532, *40-1 (E.D.N.C. Aug. 10 2009), aff’d at 632 F. 3d 860 (4th Cir. 2011) (finding the administrator’s denial arbitrary and capricious where it relied on the report of a physician who “recognize[d] plaintiff’s diagnoses of rheumatoid arthritis and fibromyalgia…[but went] on in each report to summarily state that pain associated with plaintiff’s fibromyalgia is not disabling”).

We at Bonny G. Rafel frequently handle cases involving fibromyalgia, rheumatoid arthritis, and other conditions characterized largely by self-reported symptoms. We understand the difficulties in substantiating these disorders to the insurance companies, and will work with you to ensure the best possible chance for success with your disability.

– By Sara E. Kaplan, Esq.

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