Fibromyalgia is a musculoskeletal disease characterized by widespread pain over the entire body. The pain is accompanied by overwhelming fatigue, sleep, memory, and mood issues. It is believed that fibromyalgia comes from amplified pain signals sent from the brain or spinal cord, even when there is no significant source of pain.
Fibromyalgia often presents after an event such as physical trauma, surgery, significant stress, or an infection. It can also accumulate over time, even without a trigger. Sometimes fibromyalgia accompanies other physical disorders like irritable bowel syndrome or mental health issues like depression and anxiety. This condition still isn’t fully understood by modern medicine.There is no cure, but there are methods of improving the symptoms. Exercise, relaxation, and reducing stress are vital in pain management for fibromyalgia.
Fibromyalgia is fully recognized as a disability within Canada that qualifies for long term disability benefits. However, a diagnosis does not automatically ensure a long-term disability claim approval.
Long term disability claims for fibromyalgia are only approved when the condition entirely prevents the employee from working. To have your disability qualify for benefits, you must demonstrate the severity of your symptoms and why you can no longer work.
The unfortunate truth is that even though it is recognized in Canada as a disability, that still isn’t a guarantee that those who have fibromyalgia will be able to receive disability benefits. Before filing your claim, you must prepare a complete and well-rounded record regarding your claim and how it has affected your employment.
The stress of maintaining employment while managing fibromyalgia symptoms is overwhelming for anyone. Generally, employers can fire or terminate anyone if they give proper notice. However, it is illegal to be let go for a discriminatory reason, such as a medical condition.
Although you cannot be fired, that does not guarantee immediate approval for your long term disability benefits claim. However, sick leave is a reasonable request that employers should accommodate. To be granted sick leave, a doctor’s note stating the need for time off and the length of time is required. A note must be resubmitted every three to six months for an extended absence.
If your employer attempts to fire you while on sick leave, you have legal rights. This may include severance pay or even a reversal of termination. You may submit your long term disability claim while on sick leave, and if you are denied, you can remain on leave while you appeal. Knowing your rights while submitting a claim for long term disability benefits is crucial.
Not all disability insurance plans are the same. Here are the typical benefits included in Canadian disability insurance plans:
Some workers will have a bank of sick time to use in the first days of disability. The intent of this benefit is to allow the worker to have a few days to get back to work. Some workers may have many weeks or even months of accrued time to use.
If you do not believe that you will be able to return to work before your paid sick leave is exhausted, be sure to complete an application for disability insurance benefits right away. You do not need to wait until you have used all your paid sick leave before submitting your application. Also, it is always easier to work on a disability application while you are being paid so don’t wait until your benefits have run out.
Another major reason not to wait to apply for STD Benefits is because of deadlines that may apply. You may miss the deadline to apply for benefits because you are being paid sick leave benefits.
Your alternative to paid sick leave is government provided employment insurance (EI) benefits. Most workers have fewer than 15 weeks of paid sick leave so EI benefits will make up the difference between the expiry of paid sick leave and a STD Benefit. EI Benefits must be applied for through the government. In order to apply, you must obtain a medical report from your doctor and a Record of Employment (ROE) from your employer.
Go to www.servicecanada.gc.ca for information on the EI sickness benefit and to download the application forms. Service Canada will not process your application until both the medical form and the ROE has been submitted, so be sure to book a doctor’s appointment and request your ROE right away.
The first of two main benefits in most disability benefit plans are STD Benefits. The purpose of STD Benefits is to provide you with income while you are unable to work due to illness or disability. The Benefit is designed to cover short absences and not intended to be a long-term solution.
STD Benefits provide a weekly or bi-weekly payment for a number of months. The short pay periods are designed to provide you with uninterrupted income while you are absent from the workplace. Most often, you will be required to use accrued paid sick time before accessing your STD Benefits. While cashing in sick time may be frustrating for some, it is wise to accept this condition because the sick time should provide you with more income than the STD Benefit.
The STD payment typically provides for a percentage of your regular weekly earnings or a specific amount of money. The benefit payment calculation details are specific to the policy and set out in the insurance policy document.
• The worker will be paid 60% of his or her pre- disability weekly earnings, or
• The worker will be paid $500 per week, or
• The worker will be paid their pre-disability weekly earning, up to a maximum of $500 per week.
Most STD Benefits last between three and six months. If the group plan does not have a LTD Benefit, the worker will have no further benefits under the group policy.
LTD Benefits are the second major element of most group disability plans. There are some plans, however, that only include LTD Benefits. If your plan has both STD and LTD Benefits, a disabled worker will ‘roll over’ to the LTD Benefit at the expiry of the STD period if they are eligible to do so.
Eligibility for LTD Benefits is not always a given. Workers often earn their eligibility to the Benefits through working continuously for the employer for a number of months.
Eligible workers will be able to make a claim for LTD Benefits if they have been out of work continuously for a specific period of time. This period of time is typically the length of the STD Benefit. This period of time set out in the policy wording is referred to as a “waiting period” or “elimination period”. LTD Benefits will not be paid prior to the elimination period; however, benefits will be paid for the total period of continuous disability if the claim is approved.
Benefit payments under a LTD Benefit are assessed based on a percentage of your pre-disability income. Typically, the benefit will be between 55% and 75% of your regular earnings, or a set amount of money per month. Other polices will have a net formula.
• The worker will be paid 66.7% of their monthly pre-disability earnings, or
• The worker will be paid $3,000 per month, or
• The worker will be paid 66.7% of his or her monthly pre-disability earning up to a maximum of $3,000 per month.
The exact payment formula will be set out in the policy document. Be sure to refer to your policy to confirm what the applicable payment formula is for your claim.
The LTD Benefit will make payments on a monthly basis for a set number of years (e.g. 5, 10, 20), or until you reach a certain age (e.g. 60, 65, 67). Some plans may have a benefit termination formula where a mixture of the years a claimant received benefits and the claimant’s age is used to calculate an end date. Generally speaking, the latest date where a claimant will be eligible for Benefit payments is called the Maximum Benefit date.
You know this isn’t true in your case; now what? The first step in any long term disability claim is to get a complete medical diagnosis. Insurance companies will want to see that you have gotten an FM/a blood test, which proves the presence of fibromyalgia. They will also want to see any relevant diagnosis. Is your fibromyalgia a result of IBS or some other condition? This is necessary to include in your claim file.
Once diagnosed, the insurance company will also want to see that you follow an appropriate treatment plan. It would help to document your medications, appointments, and changes in prescription. If you’re waiting to see a specialist, take note of what you’ve been doing to manage your fibromyalgia in the meantime. Any absence of treatment within your file will raise a red flag to your insurance provider, so cover all the bases. If you have to stop taking a medication due to side effects or are troubleshooting to find what dosage works for you, note this. Provide any relevant information about your fibromyalgia and any other conditions associated with your claim.
Along with medical records, you must prove that you put in every effort to stay employed before filing for long term disability benefits. Since many people can manage their symptoms and keep working, you must prove how and why you cannot. Insurance companies want to see that you tried working fewer hours and tried lighter roles within the company. Your employer should be flexible in working with you on this.
The best method for being successful with your long term disability benefits claim for fibromyalgia is to present a well-rounded claim with medical evidence backed up by your effort to stay employed. Long term disability claims are meant to be a last resort, and insurance companies will examine your claim thoroughly to see if you’ve done everything you can before they approve you for benefits.
Since fibromyalgia is an invisible illness, insurance companies often seek to minimize the severity of the condition. They will try to undermine your claim and prove it is a minor condition that shouldn’t prevent you from working. Any slight discrepancy or missing document in your medical or employment file will be enough for them to deny your claim.
A doctor’s diagnosis often isn’t enough to convince an insurance company to grant long term benefits. To prevent your claim from being denied, you will need a file full of information and the official diagnosis. All doctor visits, prescriptions, tests, and even stays in the hospital must be documented and presented with your claim.
If your fibromyalgia is linked with another condition, an official diagnosis of that and all relevant documentation of both is necessary. If there is any missing information in your claim, the insurance company will latch on to this as a reason to deny your claim.
If you have been at work while suffering from fibromyalgia, your insurance company will use this as proof that you’re well enough to keep working and deny your claim. Keeping a journal of missed time at work, flare-ups, and other instances will strengthen your claim. If the insurance company doesn’t have it in their records, they will use that to deny your long term disability benefits claim.
Know that you are part of a large group of Canadians who have had their benefits denied by the insurer at some point during the course of a claim. Those who have been issued a denial letter are those who had their application rejected by the insurer. They were deemed eligible to apply for benefits, but not totally disabled and therefore were not approved for benefits. Those who have been issued a termination letter are those who were approved for benefits but were then found not totally disabled. The insurance company generally chooses to terminate benefits at or before the two-year mark from the date of disability.
For those who have been denied, some will be legit mate because the applicant is not in fact disabled. Other applicants are truly disabled but were simply denied by the adjuster because their application was not strong enough to warrant approval. Of course, the insurer would prefer that denied applicants forgo the appeal process and not sue for benefits.
For those who were approved and then cut off sometime afterwards, the insurer is attempting to ensure that the denial is accepted by the insured during the “own occupation” period. This is ideal for the insurer as it may prevent appeals or legal claims. Thus, it allows the adjuster to close the file well before the Change of Definition date occurs.
You cannot change the fact that the insurance company denied your claim. However, you do have complete control over what you do in response to the denial or termination of benefits.
The options available to the applicant will depend on what is permitted by their policy or plan. In most cases, the applicant can advance their claim to an internal appeal mechanism or commence a lawsuit. If a plan is through a non-profit disability benefit trust fund, it is likely that only an internal appeal mechanism will be available to them. For these workers, they have been denied the right to have a neutral court decide whether or not they are entitled to benefits.
What the disabled person does after receiving a denial letter or termination letter is critical. First, be sure that you keep a copy of the letter. Photocopy and safely store a copy of the letter before making any marks on the letter. Any competent disability lawyer will want to see a clean copy of the letter to review at an initial meeting.
The denial letter is also important as it offers a window into the insurance company’s decision-making process on your file. The letter should (but does not always) spell out what information was reviewed and what findings were made with respect to the information in your file. The insurer should explain why your application was denied, or why you are no longer entitled to benefits. For new claims, the denial will typically mention that while your injuries cause you to suffer some restriction, you do not meet the test for total disability. For cases where a benefit termination letter is sent, the insurer will often mention that activities (often from surveillance evidence or information from phone calls) are inconsistent with reported restrictions and limitations. The explanation provided in other circumstances will parrot select wording from the medical expert chosen by the disability insurer. Once you have sorted out why you were denied, you can then determine what you can do to attempt to overturn the unfavourable decision.
Warning! There is a lot of misinformation about insurance policies and the rights that come with them. Do not rely on the word of a union representative, co-worker, or supervisor to explain your rights and ideal strategy when facing an insurance benefits claim. This is especially so where there is no right to sue. While they may have the best intentions, they may not have the best advice. Contact an experienced disability lawyer to avoid a major claims mistake.