Individuals with chronic fatigue syndrome may not be able to work due to their conditions. These individuals may qualify for long term disability (LTD) benefits, but the insurance company must review the claim to see if the individual qualifies under the terms and conditions of the insurance policy.
What is Chronic Fatigue Syndrome (CFS, CFIDS)?
Chronic fatigue syndrome (CFS) is a condition that causes severe and ongoing fatigue that is not improved by rest and does not result from another underlying disease. CFS is also known as chronic fatigue and immune dysfunction syndrome (CFIDS) and myalgic encephalomyelitis (ME). The exact cause of CFS is not known, although some theories include exposure to the Epstein-Barr virus or a disruption in the body’s immune system. Age, gender, exposure to prior illnesses, and stress also may play a role.
In addition to extreme tiredness, CFS symptoms can include the following: sore throat, headache, low-grade fever, painful joints, memory or concentration problems, swollen glands, and generalized muscle weakness.
Disability Evaluation of CFS
Long term disability insurance companies are most likely to refer to the Center for Disease Control (CDC) to evaluate CFS. The CDS defines CFS as persistent fatigue that: has a definite date of onset; has no other mental or physical cause; is not alleviated by rest or sleep; and substantially interferes with work, school, social, or personal activities. The diagnosis also requires that you experience at least four of the following symptoms for at least six months:
- Memory or concentration problems that cause a serious reduction in your activities;
- Frequent sore throats;
- Tender lymph nodes in the neck or under the arm;
- Muscle pain;
- Pain in multiple joints without redness or swelling;
- Headaches of a different quality than before the onset of chronic fatigue;
- Sleep that does not refresh you; and/or
- A general feeling of being unwell that lasts at least 24 hours following a period of exertion.
Your medical records should contain documentation that satisfies the above criteria for a diagnosis of CFS and that shows these symptoms did not begin before the onset of your chronic fatigue.
Long Term Disability and Chronic Fatigue Syndrome
The insurance company will decide your claim based on information you provide during the application and/or appeal process and information from your doctors. Under most LTD policies, an individual is considered disabled if he or she is: (a) unable to perform the material duties of his or her own occupation for the first two years of the policy; and (b) unable to perform the duties of just about any occupation after the first two years of the policy. The definition of disability is specific to each individual policy, so you must review your own LTD policy to determine how the term “disability” or “totally disabled” is defined for you.
Information The Insurance Company Needs From You and/or Your Medical Providers
The insurance company needs information from you and your medical providers to determine the existence, severity, and duration of your impairment(s). You should try to prove the existence of your chronic fatigue syndrome by means of medically acceptable clinical and laboratory findings. Your symptoms alone are not usually sufficient for a finding of disability, although the effects of symptoms may be an important factor in the insurance company’s decision whether you are disabled. If the medical evidence alone shows that are clearly disabled, the insurance company will decide the case on that information.
You should be sure to tell the insurance company everywhere you have treated for your CFS so the insurance company is able to request and obtain your medical records from those providers. In the event one or more of your providers does not produce your medical records to the insurance carrier, you should be sure to obtain and provide those records yourself.
Your doctor’s report should include a thorough medical history, and all pertinent clinical and laboratory findings from your doctor’s examinations. This may include copies of laboratory results, if available. Your providers should also provide the results of any mental status examination, including any psychometric testing.
Comprehensive medical records that chronicle the progression of your Chronic Fatigue Syndrome (CFS), including treatment history and responses, are critical to the success of your claim. Moreover, it would be beneficial if your doctor could provide comparative analysis between your current health condition and functionality, and your state prior to the onset of CFS.
Your doctor should also provide a professional assessment on your residual work-related capacities despite your health condition. The insurance company would greatly value insights from your healthcare provider on your physical and mental capacities, substantiated with underlying reasoning such as clinical findings or observational data. These professional perspectives should illustrate your capacity to sustain work-related activities, typically for a full-time work schedule of 8 hours per day, 5 days a week. Highlighting any functional limitations observed by your doctor during your treatment period would be pivotal.
Work-related capacities include physical functionalities such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, and handling. It also includes mental functionalities such as the ability to comprehend, memorize, and execute simple instructions; exercise appropriate judgment; interact appropriately with supervisors and coworkers, and respond effectively to typical work situations and changes in routine.
What Medical Records Do I Need to Prove CFS?
To help the insurance company evaluate your claim, you need to provide it with your medical records that date back to when the symptoms of your CFS first began. These records should include all lab test results, hospitalizations, doctor visits and reports, and a complete list of medications and their side effects. The following are examples of supportive objective medical evidence important in CFS claims, particularly if they are documented over a half a year or more:
- Swollen or sore lymph nodes on physical examination;
- Sore throat without exudate (fluid);
- Ongoing muscular pain exhibited during repeated examinations;
- The presence of positive tender points;
- Positive test for Epstein-Barr virus;
- Abnormal MRI;
- Abnormal exercise stress test; and
- Abnormal sleep studies.
CFS can be a difficult disease to document clinically. The medical tests and laboratory results do not always reflect the degree of the illness. Therefore, it is important to understand that the insurance company will not approve a disability claim based on the description of symptoms alone, though how symptoms affect your daily life is considered in the decision in your claim.
Hire a Long Term Disability Attorney to Help With Your Claim
Working with an experienced disability attorney will give you the best chance of getting the benefits you deserve for your chronic fatigue syndrome. Even if you have been denied benefits, that does not mean your fight is over. Many people are denied benefits the first time they apply. You have the right to file an appeal and try to get more information that may help your case. Getting expert help is often the difference between being denied and being approved for benefits.
While the process may be intimidating, a skilled disability attorney will be able to guide you through with ease. There are no upfront costs or fees – you do not pay any fees unless your claim is successful. The Ortiz Law Firm has a track record of successfully representing clients in disability cases nationwide. If you would like to consult with an experienced disability lawyer about your chronic fatigue syndrome and its impact on your work capacity, call us at (888) 321-8131. We will evaluate your claim and discuss how we can help you through the appeal process.