Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) is a serious medical condition that is characterized by severe fatigue, post-exertional malaise, sleep disturbances, and a range of other debilitating symptoms that can severely limit a person's ability to work and participate in normal activities1. Unfortunately, those living with ME/CFS often have the difficult reality of proving the disabling effects of a condition that may not be noticeable to others in order to receive long-term disability (LTD) benefits.
Because a lot of the symptoms of ME/CFS are subjective, there is a greater risk of denial for these claims compared to those that can be demonstrated through objective clinical testing. However, while obtaining LTD benefits for ME/CFS can be challenging, it is still possible. It is important to understand some common issues that arise with these claims in preparing to file a claim for long-term disability benefits.
Understanding Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
ME/CFS is a chronic disease that causes extreme fatigue that lasts for at least 6 months and does not improve with rest.1
Symptoms and their severity can vary depending on the person and on the day, and are frequently triggered by physical activity or emotional stress. Some of the symptoms include:
- Severe fatigue
- Difficulty sleeping
- Extreme exhaustion after physical exercise or mental activity
1
https://www.mayoclinic.org/diseases-conditions/chronic-fatigue-syndrome/symptoms-causes/syc-20360490
- Difficulty with thinking, attention, concentration, and memory
- Headaches
- Joint pain
- Mood swings
- Tingling or numbness in feet, hands, or face
- Vision problems
- Dizziness and fainting
Why ME/CFS Disability Claims Can Be Difficult
Unlike many medical conditions, there is not a single definitive diagnostic test to establish if someone has ME/CFS. Instead, ME/CFS is diagnosed by ruling out other health conditions with similar symptoms. This can be done by completing a physical and mental examination, a blood and urine sample, and by going over symptoms and medical history with your doctor.3
However, getting a diagnosis is only half the battle. Proving you are unable to perform the material duties of your occupation or any occupation, which is determined by your policy, is also required. Insurance companies will often focus on the limited number of objective findings and require extensive documentation proving you are unable to work, and still your claim may be denied. Additionally, you could be denied due to limited treatment records, evidence that you are able to engage in some activities of daily living, and a non-treating physician’s opinion that your functional limitations are not as severe as they are claimed to be.
Proving Disability due to ME/CFS
Although getting an ME/CFS diagnosis can be helpful in proving your LTD claim, it is equally important to focus on your functional capabilities. Therefore, it is crucial that your insurer agrees that your functional limitations preclude you from working. To prove
2
https://www.mayoclinic.org/diseases-conditions/chronic-fatigue-syndrome/symptoms-causes/syc-20360490; https://www.cdc.gov/me-cfs/about/index.html
3
https://my.clevelandclinic.org/health/diseases/17720-myalgic-encephalomyelitis-chronic-fatigue-syndrome-me-cfs; https://www.cdc.gov/me-cfs/hcp/diagnosis-testing/evaluation-of-me-cfs.html
this, insurance companies will often demand objective medical evidence. Unfortunately, ME/CFS causes more subjectively measured symptoms. However, objective evidence can still be required by your insurer even for symptoms that are subjectively measured, like pain. (See “More Than a Diagnosis: The Objective Evidence Gap That Sinks LTD Claims.”)
Important evidence that can strengthen a claim may include:
- Detailed and consistent treatment records
- Physician statements explaining work-related limitations
- Documentation of post-exertional malaise and recovery periods
- Neuropsychological testing when cognitive impairment is present
- Functional capacity evaluations (FCEs)
- Statements from family members, coworkers, or supervisors regarding observed limitations
- Symptom journals that demonstrate the frequency / severity of impairments
Need Help With A Long-Term Disability Claim for ME/CFS
For individuals who are no longer able to work due to ME/CFS, LTD benefits can provide critical financial stability and help ensure continued access to necessary medical care and treatment. Whether you are preparing to file an LTD claim for ME/CFS or appealing a denied claim, understanding how these cases are evaluated can make a significant difference in the outcome. While the disability process can feel stressful and overwhelming, an attorney can help by guiding you through the process and helping you gather important evidence to support your claim. Please contact us today to learn how we can help.