Tag Archives: subjective symptom condition limitation provisions

Can A New Blood Test Objectively Prove Fibromyalgia?

As we’ve discussed in more detail in a previous post, fibromyalgia is a syndrome characterized by chronic, wide-spread muscle pain as well as fatigue, difficulty sleeping, depression or anxiety, muscle knots, cramping, or weakness, painful trigger points, and headaches.  Fibromyalgia can be difficult to diagnose, given the relative or subjective nature of most symptoms.  Symptoms can also mimic those of rheumatoid arthritis and other diseases, so often a diagnosis is established after other causes of symptoms are ruled out.  Doctors will examine a patient’s history, conduct a physical examination, as well as evaluate X-rays and blood work.  Doctors will also test patients for 18 tender points.  The American College of Rheumatology guidelines suggest that those with fibromyalgia have pain in at least 11 of these tender points.[1]

Although the majority of fibromyalgia cases are diagnosed chiefly by ruling out other conditions, many patients may now have access to a blood test that may diagnose the disease.  In 2012 a privately held biomedical company, EpicGenetics, released the FM/a® Test, which is an FDA-compliant blood test designed to diagnosis fibromyalgia.  The test identifies the presence of certain white blood cell abnormalities.[2] The use and accessibility of the test has been growing,  as Medicare and an increasing number of private insurance providers have begun covering the costs,[3] and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) has also recently agreed to cover the cost of testing.[4]

The blood test works by analyzing protein molecules in the blood called chemokines and cytokines.  Founder and CEO of EpicGenetics, Bruce Gillis, MD, explains that those with fibromyalgia have a lower count of these protein molecules in their blood, leading to weaker immune systems.[5]  A diagnosis of fibromyalgia the traditional way can take, on average, more than two years.[6]  Many believe that FM/a® offers an objective and concrete diagnosis that allows sufferers to more quickly find adequate resources and treatment.

However, others argue that the test does not offer the diagnosis it promises.  Some argue that fibromyalgia is not a discrete medical condition but rather a “symptom cluster” or that the biomarkers the test identifies are also found in people with different illnesses, such rheumatoid arthritis.[7] As of this writing, major medical resource databases such as MedLine Plus, the CDC, and the Mayo Clinic continue to state that there is no lab test or definitive way to diagnose fibromyalgia.

As we’ve previously discussed, disability insurance policy holders can often face challenges with they go to file a claim based on disabilities, such as fibromyalgia, that are considered “subjective conditions.”  A test promising objective proof may remove some of these challenges. However, it remains to be seen how insurance companies and the medical community as a whole will agree on what constitutes objective proof of fibromyalgia, whether via this test or other medical advances down the road.

 

[1] 18 Points Used to Diagnose Fibromyalgia, Health, http://www.health.com/health/gallery/0,,20345635,00.html#where-does-it-hurt–1
[2] Businesswire, EpicGenetics with the Assistance of Leading Medical Centers, Expands Clinical Study of FM/a® Test to Diagnose Fibromyalgia, Identify Genetic Markers Unique to the Disorder and Explore Direct Treatment Approaches, Yahoo! Finance, Apr. 19, 2017, https://finance.yahoo.com/news/epicgenetics-assistance-leading-medical-centers-120000519.html
[3] Pat Anson, Fibromyalgia Blood Test Gets Insurance, Pain News Network, May 27, 2015, https://www.painnewsnetwork.org/stories/2015/5/27/fibromyalgia-blood-test-gets-insurance-coverage
[4] Emily Riemer, Mass General researcher investigating possible fibromyalgia vaccine, WCVB5, July 27, 2017, 6:05 p.m., http://www.wcvb.com/article/mass-general-researcher-investigating-possible-fibromyalgia-vaccine/10364683
[5] Anson, id.
[6] Getting a Diagnosis, Fibrocenter, http://www.fibrocenter.com/pain
[7] Anson, id.

Subjective Conditions Limitation Provisions

In previous posts we’ve talked about mental health limitation provisions.  In this post, we are going to discuss a similar type of provision:  subjective symptom limitation provisions.

What are Subjective Symptom Conditions?

Insurance companies typically invoke these types of provisions when a claimant describes a disability or condition based upon self-reported symptoms, without producing objective medical evidence to back up the reported symptoms.  This can occur in situations where there is no standard accepted medical test to confirm a diagnosis, or when tests do not return any confirming or conclusive results, or when a claimant has not properly developed his or her medical records and/or simply neglected to have objective testing done.

We most often see these types of limitations in ERISA policies, but they are becoming more and more common in individual policies.  An example from an actual policy defines subjective symptoms as follows:

Some examples of conditions an insurance company might contend are encompassed by this provision include:

  • Fibromyalgia
  • Chronic Fatigue Syndrome
  • Sleep Apnea
  • Paresthesia/Dysesthesia
  • Carpal Tunnel Syndrome
  • Myofascial Pain Syndrome
  • Lyme Disease
  • Orthopedic Conditions
  • Temporal Lobe Phenomenon
  • Vertigo
  • Migraine
  • Tinnitus
  • Irritable Bowel Syndrome
  • Osteopathic and Rheumatoid Arthritis
  • Generalized Pain
  • Epstein-Barr Syndrome
  • Valley Fever

Insurers also use these limitation provisions to argue that other conditions should be limited, even when there is some objective evidence.  For example, a dentist suffering from a musculoskeletal condition might report to his or her doctor that he or she is experiencing neck pain, or lower back pain. The doctor might order an MRI, which might show that the dentist has some issues in his or her cervical or lumbar spine, but even with the MRI imaging, it can sometimes be difficult to pinpoint the precise cause of the symptoms that are being reported.  Insurers know this and target these types of claims because, under a broad reading of the policy provision, they involve subjective reports of pain and the  physical source of the pain cannot always be conclusively verified using tests.

Why is this provision important to know about?

These limitations typically cap benefits that will be paid out, generally at 12 to 24 months.  After this mark has been reached, no additional benefits will be issued even if your symptoms continue and you cannot return to work.  In other words, a policy you thought would last for the maximum benefit period can end up being good for as little as a year.

Insurance companies want to avoid paying out claims and often construct policies in a manner that allows them to restrict or deny coverage. This can include hiding limitations at the end of a policy or in a vaguely worded provision.  It is not enough to simply look at a policy’s schedule page, because a limitation provision may actually be much broader limitation than you might think when you read “mental/nervous limitation” in your policy summary.  Subjective condition limitation provisions are often combined with mental health and substance abuse limitation provisions, so it is easy for a policy holder to skip over this sort of provision when scanning through his or her policy, assuming that it only applies to mental health disorders or alcohol/addiction issues.

The Takeaway

When invoking these limitations, the insurance company is not denying that a claimant has an illness or even that it prevents a policyholder from working.  Rather, the insurance company is seeking to take advantage of the limits of medical science and/or lack of agreement in the medical community regarding finding and establishing guidelines regarding conditions like the examples listed above. They then use the subjective condition provision to cast doubt on a claim and complicate the claim procedure.  Often, they will use multiple in-house physicians to contradict a claimant’s own physician and medical records.

Fighting an insurance company’s decision to classify a condition as subject to this provision can be a costly and long process, and can turn into an expensive war of attrition that can often end in litigation. For these reasons, these types of claims must be handled with care from the start and require the assistance of a supportive doctor to properly document and treat the condition.

When purchasing a policy, it is important to watch out for subjective symptom condition limitation provisions.  Always be sure to read your policy or potential policy carefully so that you understand the scope of the your protection.