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Wednesday, February 11, 2015

Names Change, Problems Remain: Myalgic Encephalomyelitis - Chronic Fatigue Syndrome - Systemic Exertion Intolerance Disease

LTD applicants with CFS or ME/CFS can have a hard time being approved for benefits, or to win an appeal of a denial of long-term disability benefits.  The traditional diagnostic
criteria of the C.D.C., link here, are quite subjective.  Also, it can be difficult for a treating physician without experience in this area to exclude all the other diagnoses necessary to establish a diagnosis of CFS.  Due to diagnostic errors by inexperienced doctors, and inherently subjective criteria, insurer have a lot of grounds to deny a claim.   

Some of these issues may be resolved.  Today the Institute of Medicine of the National Academies (“IOM) issued new diagnostic criteria, and recommended that Systemic Exertion Intolerance Disease be the new name for the condition traditionally referred to as Chronic Fatigue Syndrome, and more recently sometimes as myalgic encephalomyelitis/chronic fatigue syndrome (ME or ME/CFS for short).  Here is a link to the IOM page with a number of different reports about the recommended change.  If this is TLDR (too long, didn't read), here  is a link to a New York Times’ discussion of the history of the name of the condition, and why the change was recommended.

The change in diagnostic criteria will make a difference for me as a Connecticut LTD lawyer, in appeals and initial applications. The new criteria establish a diagnostic
algorithm that makes it easier for a doctor to make a proper diagnosis, which will make it less likely that the insurer will deny a claim based on a faulty diagnosis.

But, the most important thing to win a claim for the condition, whether you call it CFS, MECFS or SEID, has not  changed.  You must focus on the impairment, rather than the diagnosis.  See my prior post on this issue.  Your doctor may not be a big help here; doctors are there to diagnose, not conduct a vocational assessment.  So, make sure that in any initial benefits application, or any appeal of a denial, you make sure it is clear:

  • What condition is causing the impairments, 
  • What the impairments resulting from the condition are; and 
  • The specific aspects of the job that you can't do as a result of the impairments. 
Having an experienced ERISA benefits lawyer can help, but whether you are represented or handling the claim on your own, make sure you focus on impairment, not diagnosis.

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