Prudential Reverses Fibromyalgia STD & LTD Denial

Friday, September 25th, 2009

I represent a former banker afflicted with fibromyalgia whose short term disability (“STD”) and long term disability (“LTD”) claims had been denied by Prudential Insurance Company of America. Prudential had based its decision to terminate STD benefits and deny LTD benefits on a so-called independent medical examination (“IME”) by a rheumatologist who does not regularly treat fibromyalgia.

The IME admitted the claimant has fibromyalgia; admitted that fibromyalgia is a pain syndrome, admitted that no objective testing exists for fibromyalgia; admitted that the claimant has a global pain syndrome; admitted that the pain is difficult to measure; and admitted that the claimant’s treatment is appropriate. The only difference between the opinions of Dr. Jason Faller, the claimant’s treating rheumatologist, and the IME, was that the IME stated that because the claimant’s pain was difficult to measure, she had no functional limitation. While the IME may have had difficulty measuring the claimant’s pain, Dr. Faller, as the claimant’s long time treating doctor, did not.

Prudential said that the only evidence of functional impairment was the claimant’s self-reported statements, but failed to identify what else could possibly exist other than Dr. Faller’s finding of severe trigger points. The IME had asserted that the claimant’s complaints were inconsistent with range of motion findings, and that absent atrophy, neurological abnormalities and decreased range of motion, the claimant could not be functionally impaired.

In a very abbreviated nutshell, I pointed out that Social Security Disability cases held that “decreased range of motion and/or sensory impairments are not symptoms of fibromyalgia, and the absence of these non-symptoms thus does not reflect on the presence or severity of fibromyalgia.” Prudential implicitly conceded that while no diagnostic test is applicable for fibromyalgia, making it difficult to measure pain in these individuals, the person in the best position to measure the claimant’s pain was Dr. Faller who had examined her many times over many years. Accordingly, Prudential approved both STD and LTD benefits for the claimant

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