The diagnosis of fibromyalgia is made purely on clinical findings based on the history obtained from the patient and the doctor’s physical examination. There are no objective tests that specifically point the doctor to the diagnosis of fibromyalgia. However, there are several tests that can be done to exclude other possible diagnoses.
The National Health Institute explains that, in patients with chronic widespread body pain, the diagnosis of fibromyalgia can be made by identifying point tenderness areas (typically, but not always, patients will have at least 11 of the 18 classic fibromyalgia tender points), by finding no accompanying tissue swelling or inflammation, and by excluding other medical conditions that can mimic fibromyalgia.
Fibromyalgia patients have widespread body pain which often seems to arise in the muscles. Although many fibromyalgia patients are aware of pain while they are resting, it is most noticeable when they use their muscles. Their discomfort can be so severe it may significantly limit their ability to lead a full life. Patients can find themselves unable to work in their chosen professions and may have difficulty performing their everyday tasks. Most fibromyalgia patients learn quickly there are certain things they do on a daily basis that seem to make their pain problems worse. These actions usually involve the repetitive use of muscles or prolonged tensing of a muscle, such as muscles on the upper back while looking at a computer screen.
Courts Address Problems Producing Objective Evidence in Fibromyalgia Cases
A common reason for the denial of disability benefits when a claimant is diagnosed with fibromyalgia or chronic fatigue syndrome is the failure to provide objective medical evidence of these disorders. Some policies specifically require objective proof of illness. This policy language becomes problematic when disabling conditions such as chronic fatigue syndrome and fibromyalgia cannot be proven by blood tests, x-rays or CT scans.
The First and Second Circuit Courts have addressed this very issue, recognizing that the causes of Fibromyalgia are unknown, that there is no cure and, of greatest importance, its symptoms are entirely subjective. In the case of Cook v. Liberty Life Assurance Company, the court held that "since there are no specific laboratory findings that are widely accepted as being associated with CFS, and given the nature of Cook’s disease, it was not reasonable for Liberty to expect her to provide convincing ‘clinical objective’ evidence that she was suffering from CFS."
Courts do recognize, however, that there are physical limitations imposed by the symptoms of theses illness that do lend themselves to objective analysis. As a result, Fibromyalgia can be diagnosed, more or less objectively, by the 18-points test that can be performed by a rheumatologist or primary care physician.
Failure to Undergo 18 Point Tender Point Test Can Result in a Disability Denial
It is very important to treat with a physician that is experienced in the diagnosis and treatment of fibromyalgia, such as a rheumatologist or your primary care physician if he or she has experience with this disease. A primary care physician may suspect that you have fibromyalgia, but may not be familiar with the signs and symptoms and the way in which to confirm the diagnosis.
Hartford Insurance Disability Denial Upheld By Court of Appeals
On January 24, 2013, the Second Circuit Court of Appeals addressed this very issue in the case of Ianniello v. Hartford Life and Accident Insurance Company. In this case, the Plaintiff, Virginia Ianniello, was suffering from chronic fatigue and fibromyalgia and, as a result, could not perform the material duties of her occupation. Hartford denied her claim on the basis that she failed to undergo the tender points test. The Plaintiff argued that it was unreasonable for Hartford to require her to undergo such testing since her policy does not require it and she was not asked specifically to provide it. Furthermore, she argued that no objective test for fibromyalgia has been generally recognized by the medical community. The Court held that "although the terms of the policy did not require objective evidence of disability, it was not unreasonable for a plan administrator to require tender points testing so long as the claimant was notified." The records showed that the Plaintiff was well aware of the use of the tender points as a diagnostic criterion for fibromyalgia, and had the opportunity to obtain and present such testing results to Hartford. Because the Plaintiff bore the burden of showing that she was disabled, Hartford’s demand for objective evidence was neither arbitrary nor capricious.
Ms. Ianneillo’s failure to undergo a tender points examination cost her the long-term disability benefits she would have been entitled to collect had she provided such evidence. This is why it is extremely important for you and your treating physicians to understand the terms and conditions spelled out in your policy and to pay attention to the reasons for the initial denial. It is also important to ensure that you treat with the proper physician who specializes in the very disease or illness that prevents you from working. This case was not handled by our law firm, but with proper guidance prior to any claim denial, this seems like a claim denial that could have easily been avoided.
If your claim for short or long term disability benefits has been denied, please contact Attorneys Dell & Schaefer for a free consultation.