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The evolution of denying fibromyalgia and chronic fatigue syndrome claims in group long term disability policies

As a disability claimant it is important to be aware of any limited benefit periods which may unfairly limit your benefits to two years. Once considered “fringe” conditions not commonly understood by many- especially Group Long Term Disability insurance companies, Fibromyalgia and Chronic Fatigue Syndrome (CFS) have become more prevalent, spurning widespread acknowledgment and recognition of these debilitating conditions. The medical communities acceptance of Fibromyalgia and CFS as disabling conditions have resulted in Long Term Disability insurance companies looking for ways to combat paying claims for these conditions.

Disability insurance companies attempt to limit payments for Fibromyalgia and CFS by including 2 year Limited Benefit Period provisions in their disability policies. The 2 year limited benefit period limitations are usually titled: Self Reported Symptoms Conditions, Neuromusculoskeletal and Soft Tissue Order Condition Limitations, or Other Limited Conditions. These “catch-all” provisions are the insurance company’s way of limiting their exposure in paying claims for such conditions as Fibromyalgia, CFS and other medical conditions that cause chronic pain and cannot be verified by objective medical testing. The language in these provisions can be overcome if you have the appropriate medical documentation.

Today, in reviewing information from an insured denied by SUN LIFE Insurance Company, I came across what is perhaps the most restrictive Fibromyalgia and CFS language I have yet to see in a Group Disability Insurance Policy. The Sun life Disability Policy, which is governed by ERISA, states, in part:

For Chronic Fatigue Syndrome:

Limitations

No LTD benefit will be payable for any Total or Partial Disability during any of the following periods:

7. any period of Total or Partial Disability due to Chronic Fatigue Illness, unless the Employee is under the continuing care of a Physician providing appropriate treatment and regular examination and testing in accordance with the disabling condition unless the Employee has reached his maximum point of recovery and is still Totally or PartiallyDisabled.

Benefits will be payable for the first 24 months after the Employee completes his Elimination Period.

The Policy defines Chronic Fatigue Illness as:

Chronic Fatigue Illness means an Illness that is characterized by a debilitating fatigue in the absence of known medical or psychological conditions, which includes but is not limited to:

  1. Chronic Fatigue Syndrome as supported by Center for Disease Control Guidelines
  2. Chronic Fatigue Immunodeficiency Syndrome as supported by Center for Disease Control Guidelines
  3. Post Viral Syndrome
  4. Limbic Encephalopathy
  5. Epstein-Barr virus infection
  6. Herpes virus type 6 infection
  7. Myalgic Encephalomyelitis

Chronic Fatigue Illness does not include a disorder identified as a(n):

  1. Neoplastic disorder
  2. Neurologic disorder
  3. Endocrine disorder
  4. Hematologic disorder
  5. Rheumatologic disorder
  6. Depression

For Musculoskeletal and Connective Tissue Disorders
(Soft Tissue Disorders)

Limitations

8. any period of Total or Partial Disability due to Musculoskeletal and Connective Tissue Illness, unless the Employee is under the continuing care of a Physician providing appropriate treatment and regular examination and testing in accordance with the disabling: condition unless the Employee has reached his maximum point of recovery and is still Totally or Partially Disabled.

Benefits will be payable for the first 24 months after the Employee completes his Elimination Period.

The Policy defines Musculoskeletal and Connective Tissue Disorder as:

Musculoskeletal and Connective Tissue Illness means a disease or disorder of the neck and back and sprains and strains of joints and adjacent tissues, including but not limited to:

  1. cervical, thoracic and lumbosacral back and its surrounding soft tissue
  2. Carpal Tunnel or repetitive motion syndrome
  3. Fibromyalgia
  4. Temporomandibular joint or craniomandibular joint disorder
  5. Myofascial pain
  6. Scoliosis that does not require surgery

Musculoskeletal and Connective Tissue Illness does not include:

  1. Herniated, ruptured or bulging discs with neurological abnormalities that are documented by electromyogram, and computerized tomography or magnetic resonance imaging
  2. Scoliosis that requires surgery
  3. Tumors, malignancies, or vascular malformation
  4. Radiculopathies that are documented by electromyogram
  5. Spondylolisthesis, grade II or higher
  6. Myelopathies and myelitis
  7. Demyelinating diseases
  8. Traumatic spinal cord necrosis
  9. Osteopathies
  10. Rheumatoid or psoriatic arthritis
  11. Lupus

As you can see, there are still exceptions to these limitations, but this is a clear indication that Group Long Term Disability carriers are taking proactive steps to limit such conditions as Fibromyalgia and Chronic Fatigue Syndrome. Disability insurance companies are trying to limit all disability claims to those medical conditions that can only be verified by objective medical testing such as an MRI, X-ray, EMG, NCS, or other diagnostic testing. Proper medical testing and documentation is vital to fighting denials from insurance carriers, as many of the above conditions can have overlapping symptoms.



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