Chronic Fatigue Syndrome and Long Term Disability Claims

chronic fatigue syndrome and long term disabilityChronic Fatigue Syndrome and Long Term Disability Claims

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 no 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 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

Individuals with CFS may not be able to perform work activities on a full time basis and must apply for Long Term Disability (LTD) benefits. The insurance company must then decide whether the claimant is disabled under the LTD insurance policy.

The insurance company will base its decision on information obtained from your medical providers and upon any information you provide during the application and/or appeal process. The following will help you understand the kind of information your long term disability insurance company needs to evaluate your LTD claim based on CFS.

Definition Of Disability

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.

Proof of CFS

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.

What The Insurance Company Needs From You and/or Your Medical Providers

The insurance company needs information from you and your medical providers that will help it to determine the existence, severity, and duration of your impairment(s).

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.

Longitudinal clinical records and detailed historical notes discussing the course of your CFS disorder, including your course of treatment and response, are very useful for the insurance company since it is interested in the impact of the illness over a period of time. Additionally, any information your doctor is able to provide contrasting your medical condition and functional capabilities since the onset of CFS with that of your prior status would be helpful.

Your doctor should also include a statement of his or her opinion about what work-related activities you can still do despite your impairment. Your medical provider should tell the insurance company his or her opinions about both physical and mental functions and, to the extent possible, the reasons for the opinions (such as the clinical findings and/or the physician’s observations). These opinions should reflect your abilities to perform work-related activities on a sustained basis, i.e., 8 hours/day and 5 days/week. The doctor’s descriptions of any functional limitations he or she noted throughout the time he or she treated you are very important.

Examples of work-related functions include:

Physical work-related functions such as walking, standing, sitting, lifting, pushing, pulling, reaching, carrying, and handling.

Mental work-related functions such as the ability to understand, remember, and carry out simple instructions, the ability to use appropriate judgment, and the ability to respond appropriately to supervision, co-workers, and usual work situations, including changes in a routine work setting.

The insurance company will usually pay a reasonable amount for medical evidence requested from physicians/psychologists, hospitals, and other providers of medical services.

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.

Evaluating Disability For Persons With CFS

The insurance company’s adjudicator is the insurance adjuster assigned to your claim. The adjuster may have your file reviewed by a physician, psychologist, or other medical disability examiner (such as a nurse practitioner) to give an opinion as to your level of impairment. The adjuster may also send you for a compulsory medical examination or functional capacity evaluation. In evaluating disability for persons with CFS, the insurance adjuster should consider all of the available evidence, including the clinical course from the onset of the illness, and should consider the impact of the illness on each affected body system.

If the insurance adjuster believes there is not enough information to make a decision, he or she may call or write you to find out if you have the needed information. If you do not, they may ask you or, in some circumstances, an independent medical source, to provide the information.

Although your physician may reach a diagnosis of CFS on the basis of your symptomatology (after ruling out other disorders), your disabling impairment should still be documented by medically acceptable clinical and laboratory findings. Statements merely recounting your symptoms or providing only a diagnosis will not usually be sufficient to be approved for long term disability insurance benefits. The insurance company should have reports documenting your objective clinical and laboratory findings. Thus, it is essential that your doctor(s) submit all objective findings available concerning your condition, even if they relate to another disorder or establish that you have a different condition.

How the Insurance Company Assesses Your RFC

In light of your documented symptoms, the insurance company may develop an RFC for you that states, for example, that due to persistent fatigue you need to take frequent breaks throughout the day to rest as needed. Because most employers would not accommodate this limitation, it would be difficult for you to obtain and maintain most jobs.

If you suffer from documented muscle pain and weakness, your RFC may include limitations on certain work-related physical activities as well. For example, the RFC may state that you cannot lift or carry objects that weigh more than 10-15 pounds. This limitation would prevent you from doing jobs that required physical exertion, such as factory work, warehouse work, and most janitorial positions.

Mental illnesses such as anxiety and depression are also associated with CFS. If you are seeing a therapist or psychologist for treatment of a mental illness, you should report this to the long term disability insurance company and provide it with the treatment notes from your provider. The adjuster assigned to your claim will use the records to prepare a mental RFC that addresses your ability to perform the mental tasks required for work. For example, if you suffer from severe anxiety or depression, you may have difficulty maintaining attention or concentration on your work or even showing up for work on a regular basis. Anxiety and depression can also interfere with your ability to interact with coworkers. The insurance company will consider the severity of these symptoms when determining their limiting effect on your ability to work.

Chronic Fatigue Syndrome can also cause significant difficulties with memory, focus, and understanding and processing information. If you suffer from these symptoms, a mental RFC might state that you have significant difficulty following basic instructions or are unable to complete tasks in an acceptable amount of time. According to most vocational experts, limitations that cause a 20% reduction (or more) in your productivity would prevent any employment at all.

If you are receiving mental health treatment, you should ask your treating physician (your psychiatrist or psychologist), to fill out an RFC form that details his or her opinions of your work-related limitations. Keep in mind that the insurance company they will assign them weight only they are supported by objective medical evidence.