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Fibromyalgia and Qualifying for Disability Benefits

Appealing for benefits is best done under the guidance of an experienced disability lawyer.

Can I get disability benefits if I am suffering from the effects of a Fibromyalgia?

Author: Attorney Greg Reed
Updated: 1/22/2024

Approximately four million adults in the U.S. are affected by fibromyalgia (FM), a condition characterized by extensive musculoskeletal pain and fatigue. Women are more likely to have fibromyalgia and most people are diagnosed during middle age, but the disorder affects people of any age, including children. If you are suffering from the effects of Fibromyalgia you may qualify for disability benefits.

 Fibromyalgia and qualifying for Social Security Disability Insurance

Fibromyalgia is not included in the SSA’s disease list however, this does not mean that you do not qualify for disability benefits. Recently, the SSA changed its rule about fibromyalgia and now gives application evaluators specific guidelines when considering a fibromyalgia sufferer’s SSDI application. Just call 512-454-4000 for a free, no obligation consultation to learn what your options are.

There are three main symptoms of fibromyalgia:

  •    Widespread pain, often described as a dull ache that has lasted at least three months; the pain must occur on both sides of the body and above and below the waist
  •   Fatigue, even after sleeping a long period of time. An affected individual’s sleep may be disrupted by pain and other sleeping disorders such as sleep apnea or restless legs.
  •   Cognitive difficulties that impair an individual’s ability to focus, pay attention, and concentrate.

Fibromyalgia often co-exists with other medical conditions, including:

  •    Chronic fatigue syndrome
  •   Migraine and other headaches
  •   Irritable bowel syndrome
  •   Interstitial cystitis
  •   Postural tachycardia syndrome
  •   TMJ
  •   Depression
  •   Anxiety

These conditions and accompanying symptoms can cause you to miss work, possibly jeopardizing your ability to maintain employment.

Treatment for fibromyalgia involves medication and self-care strategies to reduce symptoms and enhance general health.

There is no cure for fibromyalgia currently, and no single treatment works for all symptoms, but a combination of medications and therapies can have a positive impact on an individual’s well-being. Demonstrating that you are following your doctor’s treatment plan is an important part of qualifying for disability benefits.

Can I qualify for SSDI if I have fibromyalgia?

Social Security considers any “medically determinable” disorder that prevents you from working full-time for at least 12 months a disability.

Fibromyalgia is not listed as a disabling impairment in Social Security’s Blue Book, but the Administration has offered guidance for assessing the condition in a special ruling which has improved applicants’ chances for approval. To qualify for Social Security Disability Income, you must be able to prove that your symptoms and limitations are so severe you cannot work and provide complete medical records supporting a diagnosis of fibromyalgia.

Specifically, you must show:

  •    You experience widespread pain, including pain in the neck, back or chest; AND
  •   Tests and imaging used by your doctor to rule out other diseases such as lupus, hypothyroidism, or multiple sclerosis; AND
  •   Either:

    •   Repeated occurrences of at least six symptoms of fibromyalgia. This includes mental fog, fatigue, poor sleep, IBS, depression or anxiety; OR
    •   At least 11 out of 18 positive tender points on physical examination. The positive tender points must be found on the left and right sides of the body and above and below the waist.

A claims examiner will review your medical records, focusing on your doctors’ notes and look for complaints of pain, fatigue, cognitive difficulties, and memory loss.

The further back your medical record shows evidence of fibromyalgia symptoms and treatment, the better. Social Security will want to see how long you’ve been treated for fibromyalgia, how well you function, what treatments and medications you’ve taken and your response, and how long your doctor expects your functional limitations to last.

You must also show how fibromyalgia prevents you from working at any job.

Ask your doctor to fill out a Residual Functional Capacity form (RFC), an assessment that evaluates your physical and mental capabilities. A person with fibromyalgia is typically limited in the following functions:

  •    How long you can sit, stand, and walk during an 8-hour day
  •   How much weight you can lift
  •   Whether you can crouch, stoop, kneel and bend
  •   How well you can focus and remember instructions
  •   Whether you miss time at work each month

Social Security will use an RFC to determine if you are able to return to your old job or are able to do another job, so it’s important to document all your functional limitations.

  •    Review your medical records yourself and make sure they include a diagnosis of fibromyalgia and any other medical conditions you are being treated for. Make sure your doctor has included comprehensive notes, knows you are applying for disability, and is willing to support your claim.
  •   Get a referral from a specialist. Social Security will take your claim of fibromyalgia more seriously if you have a diagnosis from a doctor who treats bone or tissue conditions or disorders involving pain and fatigue. Avoid a diagnosis of fibromyalgia by a mental health professional as it will carry less weight with Social Security. Instead, any diagnosis of depression or anxiety should be separate.
  •    Keep a journal of your symptoms and side effects so that Social Security can see your symptoms are real and have a pattern. It will be helpful if you can state how often you experience pain, fatigue, sleep disturbances, memory problems, or digestive issues and how many days you have to avoid certain activities.
  •   Provide statements from your family, friends and co-workers regarding your fibromyalgia symptoms and limitations.

Once Social Security determines the limitations caused by your condition, they will employ a vocational expert to assess whether a person with these limitations is employable.

“Once Social Security determines the limitations caused by your condition, they will employ a vocational expert to assess whether a person with these limitations is employable. Most vocational experts will find a person to be unemployable if their condition or the treatment rendered for the condition causes the person to regularly be absent two or more days a month or be “off-task” 15% or more of the workday.” – Lloyd Bemis Disability Attorney

If you are 55 or older or have another medical condition you may get approval.

Social Security follows a set of rules to determine when the agency expects an applicant to learn a new job.

Applicants who are 55 or older often fall under a grid rule, which means they are not expected to learn a new job. For example, if you are 55 years old and can’t go back to your old job and lack the skills to learn a new job, Social Security will likely grant you disability benefits.

You may also be eligible for Social Security Disability benefits if you have another medical condition, such as high blood pressure.

One disorder alone may not meet the requirements of an impairment as stated in Social Security’s Blue Book, but if you have more than one medical condition, Social Security must consider how those combined health issues limit your ability to hold a job and perform necessary daily tasks.

Social Security also has basic financial requirements.

Additionally, you must satisfy some basic financial requirements before you are eligible for Social Security disability benefits.

You must: 1) have a disability that has lasted, or is expected to last 12 months; and 2) you must have worked in a job where you paid Social Security taxes long enough and recently enough; and 3) you must not earn more than Substantial Gainful Activity (SGA), which is $1,550 per month in 2024 for nonblind applicants and $2,590 per month for blind applicants.

What if I don’t qualify for SSDI?

If you don’t qualify for SSDI, you may be eligible for disability benefits through another Social Security program, such as Supplemental Security Income (SSI), or from a long-term disability insurance plan through your employer or a privately purchased policy.

SSI is a program that pays monthly benefits to people with limited income and resources who are disabled, blind, or age 65 or older. Instead of work credits, SSI is based on income and is financed by general funds of the U.S. Treasury.

I have long-term disability insurance – should I file a claim?

Yes, you should file a claim as soon as you become disabled.

Long-term disability insurance (LTD) coverage protects your income if you are unable to work due to illness or injury and is purchased as part of a group employment plan or privately through an insurance company. Policies pay between 50-60% of your salary and benefits continue until you return to work or for the number of years stated in the policy. Do not quit your job before you file a claim – LTD coverage is good only as long as you are employed. Be sure to check your policy’s definition of “disabled” as each policy will state the definition of “disabled” which is in use, and be aware that long-term disability insurance companies can require a claimant to also apply for SSDI.

How do I file for Social Security Disability benefits?

You can apply for Social Security Disability benefits online, over the phone, or in person at your local Social Security Administration office.

If your initial application is denied, don’t be discouraged; this is not uncommon and you will have the opportunity to appeal. There are four steps to the Social Security appeal process:

  1.   File a Request for Reconsideration with the Social Security Administration to completely review the case.
  2.   If you don’t agree with SSA’s response to your Request for Reconsideration, you can request a hearing before an Administrative Law Judge (ALJ). ALJs are attorneys who work for the Social Security Administration; they review SSDI cases and either uphold or overturn decisions to deny SSDI benefits. If you are not represented by an attorney at this point, now is the time to obtain legal counsel. This is a critical point in the process and will raise your chance for success.
  3.   If an ALJ does not grant your claim, you can request that the Appeals Council review your case.
  4.   Federal Court review. The final step in the appeal process is filing suit in U.S. District Court.

If you are suffering from the effects of Fibromyalgia and have been denied disability don’t give up, almost 70% are denied initially! Just call 512-454-4000 for a free, no obligation consultation to learn what your options are. Have some questions? just give us a call, we love to help folks just like you!

Do I need a disability attorney for SSDI?

If you have a fibromyalgia and cannot work, you may be eligible for Social Security Disability benefits, but applying for SSDI is a long process that can take several months to years.

Your chances for approval will increase significantly if you have legal representation. At each potential stage of the process, from the initial application stage, the reconsideration stage and the ALJ hearing stage, an attorney can assist you in completing the detailed forms and questionnaires required by Social Security, collecting and submitting relevant medical evidence, and preparing questionnaires for your doctors. At the ALJ hearing phase an attorney will not only assure that the evidence is complete, but can prepare you for questioning by the ALJ, prepare an argument on your behalf and question any doctors or vocational experts selected by the ALJ to testify at the hearing. At the Appeals Council and federal court level, a lawyer can present legal arguments to show your case was wrongfully denied. Fees charged by disability attorneys are regulated by federal law and are usually 25% of disability backpay you are owed. There are no out-of-pocket costs, and if you don’t win your case, you won’t be charged anything.

Do I need a disability attorney for a long-term disability insurance claim?

Whether you have a long-term disability insurance policy purchased through a private insurance broker or a group policy purchased with your employer, filing a claim for long-term insurance is a complex process.

The wording in LTD policies can be confusing and the laws and regulations which affect the two types of LTD insurance differ in their procedures for filing claims and appeals. An experienced LTD attorney with thorough knowledge of ERISA laws and regulations will avoid mistakes and increase your chance of success. An attorney will act on your behalf, completing your application and filing your claim in a timely manner. They can also negotiate a settlement or file an appeal for you. If it becomes necessary to file suit, an LTD attorney can prepare your case against an insurer. Most LTD attorneys handle cases on a contingency basis and charge approximately 25%-40% of a claimant’s past due benefits. You do not pay an attorney’s fee unless the attorney wins your case.

Bemis, Roach & Reed Fibromyalgia Case Example

A college professor suffering from fibromyalgia in north Texas contacted Bemis, Roach & Reed to assist in challenging the denial of long term disability (LTD) benefits through Fort Dearborn Life Insurance Company.

At the time we were contacted, the client had already initiated an appeal of the Fort Dearborn denial by requesting a review from the Employee Retirement System of Texas (ERS). The claim was set for hearing before an administrative law judge (ALJ) with the State Office of Administrative Hearings in Austin, Texas. The disease had progressed to the point that work was no longer possible due to constant pain and fatigue. Fort Dearborn denied the claim when it was filed.
Bemis, Roach & Reed accepted the representation and began to litigate the case.

We arranged for our client to attend a functional capacity evaluation (FCE). The FCE supported our contention that our client could no longer work as a college professor. We also developed medical testimony from the client’s treating physicians. The case resolved to the satisfaction of all parties by confidential settlement prior to the ALJ hearing.

A Floresville client had been found totally disabled by the Social Security Administration (SSA).

The SSA found that she had a medically determinable impairment, fibromyalgia, which met the criteria set out in Social Security’s Guidelines.

She was presumptively disabled due to fibromyalgia under Social Security’s standards, but Liberty Mutual denied her. Mr. Roach challenged the denial and got her a settlement.

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"Words can not truly express the gratitude that I feel toward Mr. Lonnie Roach and his professional team. I give them an A+++. Very compassionate and prompt. Their priorities are first and foremost helping you succeed at your case. When you feel helpless, feeling like someone is on your side can mean the world to you. Thank you for working for the people."
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Author: Attorney Greg Reed has been practicing law for 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion Gold rated by Martindale Hubbell. Through his extensive litigation Mr. Reed obtained board certification from the Texas Board of Legal Specialization. Greg is admitted to practice in the United States District Court - all Texas Districts and the United States Court of Appeals-Fifth Circuit. Mr. Reed is a member of the Travis County Bar Association, Texas Trial Lawyers Association, past Director of the Capital Area Trial Lawyers Association, and an Associate member of the American Board of Trial Advocates. Mr. Reed and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.

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