Insurance Issues and Fibromyalgia

When you are diagnosed with fibromyalgia, you can possibly turn to an insurance company, Social Security or Workman’s Compensation for financial help. Many employers offer group health insurance plans that pay for a portion of medical expenses. Each state also requires that companies carry Workmen’s Compensation insurance should you be able to prove a work related injury or illness. Social Security does not pay medical expenses, only disability, though the implementation of the new Affordable Care Act beginning 2014 requires all citizens to be covered by health insurance.

Dealing with Insurance Companies

The very first thing you need to always remember is that insurance companies are not in business out of a desire to help people. They are, in spite of commercials indicating otherwise, in business to make a profit. That’s why they have refused in the past to cover people with pre-existing conditions. This is what one researcher refers to as the “business ‘ethic’ of cost-containment and profitability.” [1] The result is that you have to prepare a solid case to support your medical claims when it comes to fibromyalgia. You should also get organized and be able to supply the specific information and documentation needed to meet the insurance company’s requirements.

Be aware that not all medications and treatment are covered by your insurance provider. Your doctor may recommend a specific drug that is experimental or not proven to help fibromyalgia patients. Your medical provider and insurance policy may refuse to compensate you for it making it your responsibility. Coverage refusals may also extend to include various alternative or complementary treatments.

Before you submit a claim or even talk to your insurer, make sure you have read your policy thoroughly. It’s amazing how many people assume they have insurance coverage for specific procedures and treatments when they don’t. Know exactly what you are eligible for under the policy terms and learn the options and rights included. If necessary, consult a lawyer if too many justifiable expenses are denied on your claims.

If you do not have access to private or employer health insurance, many of the states have established the first insurance exchanges in accordance with the requirements of the Affordable Health Care Act. In addition, if you income qualify, you may also apply for Medicaid.

Assessing your needs through Workmen’s Compensation

Another possible route some individuals have chosen involves Workmen’s Compensation. If you believe your fibromyalgia is directly linked to your work environment, it’s possible to file a Workmen’s Compensation claim. Any such claim can only cover a job-related injury or illness. If approved, it will cover medical expenses and lost income. Medical research to date, unfortunately, does not support a link between fibromyalgia and work factors like stress or chemical exposure.[2]  However, that could change as more research studies are completed. As of right now, there’s a good chance your workmen’s compensation claim will be denied.

There are several roadblocks someone with fibromyalgia will have to get through before successfully being approved for workmen’s compensation payments. Fibromyalgia sufferers are faced with:

  • The difficulty in directly relating fibromyalgia to a work related accident or illness
  • The difficulty of fitting fibromyalgia into the category of “occupational disease”
  • The high number of individuals with similar symptoms not related to fibromyalgia who attempt to use the symptoms to get paid time off from work through workman’s compensation

In determining the validity of your case, workmen’s compensation will go over your past medical records in fine detail. If you have gone to the doctor as long as 10 years ago, with a complaint similar to what you are now experiencing that you claim is work related, your claim will be denied. Workmen’s compensation will call your condition pre-existing or a recurrent problem that was not caused by your work environment.

The result of such careful and sometimes biased scrutiny of your health issue results in a high rate of denials. This is a documented result. It has been noted that those who have stated fibromyalgia as their injury or illness and have applied for workmen’s compensation since 2000 are more denied than accepted.[3] Similar problems are also waiting any one with fibromyalgia who decides to apply for Social Security Benefits.

How Secure is Social Security?

Social Security Insurance disability claims are often made by those seeking a replacement for lost income resulting from having fibromyalgia and being unable to work. Social Security does not offer medical expense coverage, but does offer disability coverage. However, although you may have paid into the system with regularity, you will probably face problems getting approval for disability. According to some research, denial is not only common for individuals with fibromyalgia, but is particularly applicable to women suffering from this syndrome.[4]

Receiving Social Security benefits depends on you proving that fibromyalgia fits into the specific clinically determinable definition of disability. Even if you believe your illness fits the description, you will need to supply all the clinical records required.[5] The disability claims process is complex and difficult which is why so many people decide to hire an attorney to get help maneuvering the system. An examination by other than your own physician may also be requested to determine if there is agreement on a clinically described condition.

Refusal rate for most forms of Social Security Insurance or Social Security Disability Insurance are high. If you are denied, you can request a review. The process is as follows:

  • Ask for reconsideration by the Disability Determination Service (DDS) that initially refused your claim
  • Seek justice from an Administrative Law Judge (ALJ)
  • Go to the Social Security Administration Appeals Court, which is your final recourse

For the review or appeal process, you might want to consult a skilled attorney. You can talk to someone in a fibromyalgia support group, lobby group or national association to see what approach may be most effective and who to hire in your region.

Denials

Insurance denials are a fact of life, unfortunately. You must take them in stride and prepare to defend yourself. Whether it is the insurance claim for medical care or a request for workmen’s compensation or Social Security, be aware of the potential for being turned down and don’t get discouraged.

When denied, examine your papers, documents and/or policy once again in preparation to make an appeal.  Add further documentation when necessary that specifically addresses the reason for the denial. Resubmit your claim or petition for a reconsideration.

It may be, at this point, a good idea to consult the services of a lawyer familiar with fibromyalgia, and insurance or workmen’s compensation claims. It may also be beneficial to talk to an association or group that supports fibromyalgia sufferers who can provide some insight into what path you should take to improve your chances of being approved for insurance.

Conclusion

Suffering from fibromyalgia is painful enough physically without having to deal with the mental anguish of being denied insurance help with paying for the medical expenses. Unfortunately, insurance denials are a fact of life. Often, it is those who persist that eventually get approval. Be prepared to fight for your benefits and to consult a lawyer when necessary.

References 

[1] Schatman, ME (2011). “The Role of the Health Insurance Industry in Perpetuating Suboptimal Pain Management.” Pain Medicine, 12(3): 415–426.

[2] Marek, CC (2004). The First Year: Fibromyalgia. New York: Marlowe and Co.

[3] Everest, J (2009). “Fibromyalgia and Workers’ Compensation: Controversy, Problems, and Injustice.” Alabama Law Review, 60(4): 1031-1034.

[4] Purvis, DE (2011). Clinical Evidence as Gendered: Fibromyalgia Social Security Disability Claims. Texas Journal of Women and Law, 20 (Fall).

[5] Mitchell, D (2011). The Complete Guide To Healing Fibromyalgia. New York: St. Martin Press.

This article was originally published on July 11, 2012 and last revision and update of it was 9/7/2015