Fibromyalgia Claimants are Finally Being Heard: California Court Rules that Prudential May Not Deny Claim Based on Lack of Objective Evidence of Fibromyalgia or Chronic Fatigue Syndrome

Fibromyalgia and Chronic Fatigue Syndrome are illness of unknown etiology characterized by widespread pain, fatigue, sleep disturbance and psychological distress that affect an estimated 5.8 million Americans. Insurance companies are notorious for denying disability claims based on inability to work due to fibromyalgia or CFS since there is no know test to prove one is stricken with the illness. It was once easy for an insurance company to base a denial of benefits on the claimants’ inability to provide objective tests to prove he or she has Fibromyalgia or CFS. Before the courts started stepping in, there was an influx of denials for claimants who were truly disabled due to their illness and could not work, however, could not possibly meet their insurance companies’ requirement of providing objective evidence to support their claims.

Courts Cracking Down on Insurance Companies Basing Denials on Lack of Objective Evidence

Fortunately for claimants, Courts around the country are beginning to crack down on insurance companies that are denying valid claims based on the lack of objective evidence. In a recent case out of California, Eisner v. Prudential U.S. Dist. LEXIS 8554 (N.D.Cal. January 22 2014), the plaintiff worked as the administrator of a surgical center when she stopped work due to chronic pain, fatigue and depression due to fibromyalgia. In denying her claim for LTD benefits, Prudential ignored the opinions of the treating physicians as well as the physicians who performed functional capacity evaluations on the plaintiff, all deeming her totally disabled due to fibromyalgia, claiming that none provided objective evidence of her disability.

The Court held that “the lack of objective physical findings is insufficient to justify denial of disability benefits” quoting another California case, Saloma v. Honda Long Term Disability Plan:

One can understand the frustration of disability plan administrators with claims based on such diseases as CFS and fibromyalgia. Absence of objective proof through x-rays or blood tests or the existence or non-existence of the disease creates risk of false claims. Claimants have an incentive to claim symptoms of a disease they do not have in order to obtain undeserved disability benefits. But the claimants are not the only ones with an incentive to cheat. The plan with a conflict of interest also has financial incentive to cheat. Failing to pay out money owed based on false statement of reasons for denying is cheating, every bit as much as making a false claim… Many medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established until autopsy. In neither case can a disability insurer condition coverage on proof by objective indicators such as blood tests where the condition is recognized yet no such proof is possible.

The hope is that Courts around the country will continue to recognize the validity of these disabling conditions that are characterized by the lack of objective testing and put a stop to the continuous denial of claims based on the lack of objective proof.

Dell & Schaefer did not represent the plaintiff’s in the above claims, but Attorney Alters has been successful in the Middle District of Florida in overturning a claimant’s denial of LTD benefits based on the lack of objective evidence for a Fibromyalgia claim. The claim was remanded back to the insurance company for further review with instructions from the Court to review the claim without the requirement of objective evidence as none exists.

Read more about Fibromyalgia disability claims.

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