About 500,000 Canadians have chronic fatigue syndrome, generally referred to as myalgic encephalomyelitis (CFS, ME, or ME/CFS for short). Some individuals who have chronic exhaustion nonetheless work. Others, though, may file a claim for long-term disability insurance if the symptoms are too severe. Sadly, a lot of ME/CFS disability applications are rejected. This article will cover how to file for long-term disability benefits, improve your claim’s approval odds, and what to do if your claim is denied.
What Is Myalgic Encephalomyelitis/Chronic Fatigue Syndrome?
- Chronic fatigue causes excessive exhaustion, which makes it difficult to do daily tasks. Physical and mental tiredness are also possible symptoms. Common signs of ME/CFS include:
- Malaise or feeling unwell after physical or mental effort can cause chronic or recurring weariness that interferes with daily tasks and is not eased by rest.
aches and pains
- Cognitive deficits from lack of sleep are frequently called “brain fog.”
Tender lymph nodes, digestive issues, an unusual heartbeat, and light or sound sensitivity are just a few examples of neurological and immunological reactions that may be present. Since 1969, the World Health Organization has classified ME/CFS as a neurological condition.
However, despite what some doubters (and insurance adjusters) may think, myalgic encephalomyelitis is not “all in your brain.” Chronic tiredness is occasionally linked to melancholy and anxiety.
Fibromyalgia and chronic fatigue syndrome are often mistaken. Even though some symptoms may be similar, they are different medical disorders. While pain is the prominent symptom of fibromyalgia, exhaustion and malaise are the main symptoms of ME/CFS after engaging in physical or mental activity.
What triggers the syndrome of chronic fatigue?
Although the exact origin of ME/CFS is unknown, research suggests that various variables, including environmental, viral, microbial, social, physiological, and psychological, may be at play. The symptoms of chronic fatigue syndrome might appear up to 75% of the time following a viral infection. For instance, the Epstein-Bar virus is one of the most prevalent human viruses. Numerous investigations in people with ME/CFS have revealed that the virus alters the cellular immune response. In particular, for people with long-COVID, research is presently being done to determine whether the COVID-19 virus may potentially be connected to chronic tiredness.
Chronic Fatigue Syndrome diagnosis
It might not be easy to receive a myalgic encephalomyelitis diagnosis. There are no trustworthy diagnostic procedures accessible right now. In addition, numerous symptoms are similar to other illnesses, including autoimmune diseases, endocrine problems, and other neurological disorders. In Canada, ME/CFS is often only diagnosed when all other potential explanations of the symptoms are ruled out. The Centers for Disease Control in the USA require one of two secondary symptoms and three of the primary ME/CFS features to make a diagnosis.
The capacity to perform tasks that you previously could first be significantly reduced and this decline must persist even after rest or sleep.
Second, after engaging in physical or mental activity, ME/CFS symptoms deteriorate. Post-exertional malaise, or PEM, is a common name for this.
Some sleep disorder is the third need. Sleep often does not promote healing to the same extent as it does for the ordinary individual, and there may also be difficulties falling or staying asleep.
The last need for a ME/CFS is either: cognitive impairments, such as troubles with thinking clearly or processing thoughts, memory problems, or executive functioning deficits, or symptoms that increase while sitting or standing upright, also known as orthostatic intolerance.
Chronic fatigue syndrome treatment
Unfortunately, there is no cure for chronic fatigue syndrome, making treatment extremely difficult.
Treatment often focuses on symptom management through activity level pacing, medication, psychotherapy (mainly when sadness and anxiety are problems), targeted exercise regimens, and alternative treatments.
Impact of ME/CFS on Employment
Some persons with chronic fatigue syndrome continue to work with or without adjustments. Employers must provide reasonable accommodations for their employees’ medical restrictions and limits in Ontario unless doing so would cause undue hardship. Among other things, this can entail taking more pauses, using aids, or working from home.
Some ME/CFS patients are entirely unable to work. Short-term or long-term disability insurance could offer financial assistance in various situations.
Making a Disability Insurance Application
Many Canadians have access to short-term and long-term disability insurance through their place of employment. Others, frequently professionals and independent contractors, have invested in an individual policy to cover their income in the case of a sickness or accident that stops them from working.
Filing a disability claim for ME/CFS is simple in principle. Your primary care physician provides a form detailing the diagnosis, prognosis, and severity of symptoms; you submit a state with some basic information about yourself and your medical conditions; and, in the case of group insurance, your employer also offers a form. After reviewing the data you’ve supplied, an insurance adjuster calls you for a phone interview. If everything is in order, the claim will likely be accepted, and you will begin getting compensation.
But in reality, making a chronic fatigue syndrome disability claim may be complex, and many claims are rejected.
Application for Disability Insurance: Obstacles caused by ME/CFS
Preliminary diagnosis is frequently the first issue. Even though your level of function should be the basis for any disability claims, the absence of a diagnosis will worry the insurance provider. It may take months or years before an official diagnosis of ME/CFS is made because the disorder is usually diagnosed by ruling out all other potential causes of the symptoms. You cannot wait for a diagnosis to receive financial assistance if you cannot work.
Second, you must prove that despite having a diagnosis, the functional restrictions of chronic fatigue syndrome hinder you from carrying out the crucial duties of your job. Finally, these symptoms vary from person to person, and even when they are the same person, their intensity frequently changes daily due to the nature of ME/CFS. Therefore, claims based on hazy or erratic symptoms are more likely to be rejected.
Lastly, unlike a bone fracture or cancer, ME/CFS is not an “objective” disease or damage. It doesn’t make it any less incapacitating, but it does make it more difficult to substantiate your inability to work. Keep in mind that insurance adjusters do not approve all claims. With less verifiable data, it is simpler for them to refute the assertions.
How To Get Chronic Fatigue Disability Benefits Approved
You may undertake the following three things to improve the likelihood that your ME/CFS claim will be accepted:
- cite your medical credentials
- Be frank, honest, and accurate.
First, be clear about your limitations and constraints. Try to quantify wherever possible when completing documents and interacting with the insurance provider. For instance, it is far more accurate to say, “I cannot sit in one position for more than 30 minutes, walk for more than 15 minutes, or read for more than 10 minutes before I need to rest for an hour.” Linking your restrictions to your job responsibilities would be even better. As an illustration, consider the following: “As part of my employment, I must stand at a machine from 7 a.m. until 3 p.m., with two 15-minute breaks and a 30-minute lunch. I can’t stay up straight for more than 30 minutes. I cannot stand or walk for more than 1.5 hours daily, even with breaks. Or, if you work in an office, say, “My job is fast-paced yet sedentary. I must read, type, analyze data, answer calls, and maintain several calendars. I lose focus and start making mistakes after 15 minutes. I find it impossible to concentrate after 30 minutes. When I’m not at work, I have trouble following the storylines of TV series, and I can’t read for more than 15 minutes without forgetting what I just read.
Second, offer as much legitimate medical proof as you can. Your doctor(s) will be asked to fill out paperwork and give medical records by your insurance company. Ensure the insurer is aware of every medical professional you see for treatment (including your family doctor, rheumatologist, psychiatrist, group therapist, chiropractor, etc.) and every medicine you take. Your insurance provider will carefully review the medical records and compare them to what you say when determining whether to provide disability insurance benefits for chronic fatigue syndrome.
This brings us to our third point: communicate honestly, openly, and openly with your healthcare professionals and the insurance. Claim denials may result from inconsistencies. This is crucial for invisible illnesses like ME/CFS and in which your level of function and impairments cannot be correctly assessed with an objective test.
Remember that insurance firms occasionally carry out surveillance and other types of inquiries. This could include paying a private eye to follow you for a few days. Be cautious of your online behaviour since even if the insurance company does not conduct surveillance, the adjuster will at least look you up on Google, Linkedin, Facebook, Instagram, and other social media.
After the waiting time, benefits will begin if authorized. However, you must continue obtaining regular, reasonable, and customary care for your medical condition throughout the waiting period and while on the claim.
You will get a letter outlining the decision and information on appealing if STD or LTD benefits are refused, either after the first application or after receiving benefit payments.
Your Rights Upon Denial of Disability Insurance Claim
The STD or LTD claim’s denial is not the end. You have the following rights:
- the right to a free consultation with a long-term disability attorney
- the ability to contest an insurance provider’s decision
- the ability to pursue additional legal action
Most long-term disability attorneys don’t bill their clients for the initial appointment. Instead, the attorney can thoroughly explain your alternatives, which often include appealing or taking legal action. Long-term disability attorneys usually do not collect fees unless they win a case if one is filed.