I wrote The Ultimate Guide to Fibromyalgia Disability Benefits for people who need to win or maintain disability benefits for fibromyalgia and its related conditions.
This Guide is based on my 25 years experience as a former occupational therapist and now disability lawyer. This Guide is meant to give you an overview of the types of benefits you may qualify for and the challenges you will face.
Because you are reading this Guide, I know you are on the right path. Educating yourself is the single most important thing you can do to improve your chances of success with any disability claim.
If you have questions about this Guide, or any disability claim issue, call our support team toll free at 1-888-732-0470.
Keep on learning and I wish you all the best with your journey,
— David Brannen, disability lawyer & founder, Resolute Legal
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Is fibromyalgia a disability in Canada?
Yes. All disability benefits providers in Canada recognize it as a condition that can qualify a person for benefits. However, a diagnosis on its own won’t qualify you.
Providers pay benefits to claimants who can prove their conditions keep them from working. When reviewing claims for fibromyalgia, providers focus on the seriousness of your symptoms, how they affect your work, what kind of medical treatment you’ve had, and how hard you tried to keep working. You have to have all of this documented in medical records or other paperwork with your claim.
Employment and disability rights for fibromyalgia
Many people worry about losing their jobs because of fibromyalgia. As a general rule, employers can fire anyone as long as they give proper notice and don’t do it for a discriminatory reason.
However, most employers won’t fire employees who need sick leaves. Under Canada’s human rights laws, employers have a duty to help employees with medical conditions that affect their work. Allowing sick leave is a reasonable accommodation that employers should give.
To take a sick leave, you’ll need to give your employer a doctor’s note confirming that you cannot work and need the leave. You’ll need to provide these notes regularly, usually every three to six months, to confirm your continued inability to work.
If you apply for disability and have your claim denied, you can stay on sick leave while you fight the appeal. Most employers won’t question this as long as you continue to provide notes from your doctor.
If your employer attempts to fire you while you’re on sick leave, then you may have legal rights to severance pay or even having the termination overturned, if it was done solely because of your condition. However, these situations are complicated, so you should always get legal advice.
Types of disability benefits for fibromyalgia
If you become unable to work because of fibromyalgia, disability benefits from the government, your employer, or your insurer may apply to your situation.
This list covers the possible options for fibromyalgia in Canada:
- Employment Insurance (EI) sickness benefits
- Short-term disability insurance
- Long-term disability insurance
- CPP disability
- Workers compensation
- Veterans Affairs Canada
- Provincial disability benefits
- Disability tax credit
Let’s go over each so you know whether you qualify, how to apply, and how to appeal if they deny your claim.
Employment Insurance (EI) sickness benefits
EI sickness benefits are a temporary disability benefit paid through the federal government’s employment insurance (EI) program. It pays 55% of your salary for 15 weeks.
To qualify, you must have paid into the EI program recently through deductions from your paycheque. The deductions are automatic, so if you got an official paycheque, you paid into the EI Program.
You apply for EI benefits by filing an online claim with Service Canada, either from home or at any Service Canada office. You also need to have your doctor fill out a form confirming your inability to work for the 15 weeks covered by EI. And finally, your employer will need to issue a Record of Employment (ROE) to confirm your sick leave.
Note: If you qualify for short-term disability, then you can’t claim EI benefits at the same time.
Short-term disability (STD) benefits
Short-term disability (STD) benefits are another temporary disability payment. They pay 50-67% of your regular salary, usually for 15-17 weeks but sometimes longer. You’ll typically receive payments every two weeks.
Employers offer these benefits either through the company or a group insurance policy. In both cases, employers hire an outside agency to run the program on their behalf.
You only qualify if your employer has such a plan. Not all employers offer this option to their employees. If your employer doesn’t, then you may qualify for EI sickness benefits.
As mentioned in the last section, if you qualify here, then you won’t qualify for EI. If you can get STD payments, you have to apply for those instead of EI.
You apply by getting the forms from your employer or the insurer that runs the program. The application will include three forms, one for you, one for your doctor, and one for your employer. It is your responsibility to get all the forms back to the insurer.
If the company denies your claim, you can ask for a second review from someone else in the company, called an internal appeal. You may even be able to ask for a third or fourth internal appeal. After that, you may have to appeal to an outside arbitrator or file with the courts. Your options will depend on your situation.
Long-term disability benefits
Long-term disability (LTD) benefits, as the name implies, pay out for a longer period of time. If you win a claim for LTD, the payments can last for many years. A policy will specify either a number of years (e.g., 2, 5, or 10 years) or a certain age (usually 65).
LTD payments often cover 50-67% of your monthly salary and pay out once a month, rather than every two weeks. Like STD benefits, most LTD benefits come from group plans or private policies.
If your company offers a group medical plan, then check it for LTD benefits. If you’re in a union, your medical plan will likely include LTD.
You can also get them through private insurance policies, if you’re self-employed or underinsured through your company. With private policies, the payment is usually a fixed amount, but sometimes it’s a percentage of your earnings.
You apply for LTD by filling out forms and sending them to the insurer. Once again, you’ll probably have three forms for you, your employer (if applicable), and your doctor. And again, it’s on you to get those forms back in. You won’t get a decision until the insurer gets all the forms.
Just as you can with the STD claim, you can appeal a denial. Your LTD plan may allow two to three internal appeals and then an appeal hearing with an outside arbitrator or a lawsuit.
For more information check out our Ultimate Guide to Long-Term Disability Benefits.
CPP disability benefits
Like LTD, CPP benefits cover permanent disability. If you qualify, the payments can go to age 65. They currently range from $600 to $1,300 per month, and you can get extra payments if you have children. The size of your payment is based on your contributions to the program. The more you contributed, the more you’ll get back.
To qualify, you must have the right amount of CPP pension credits paid into the program. Like with the EI, if you had a job with a paycheque, then you paid into the CPP program. You can also get CPP pension credits by credit splitting with a former spouse or paying into the pension plan of another country. You may also qualify for credits if you left the workforce to raise a child.
You can get LTD and CPP at the same time, but the LTD insurer usually has the right to offset by the amount of your CPP payment. That means that a CPP disability payment of $900 per month could give the LTD insurer the right to reduce its payment to you by $900 per month.
Even with enough pension credits, you still need to prove you have a “serious and prolonged” disability, as defined by CPP rules. A severe disability prevents you from regularly working a paying job. A prolonged disability has little hope for improvement.
You apply for CPP disability by filling out the official form. You also have to get your doctor or nurse practitioner to fill out the medical report form. You then send your application to the designated CPP office for your province.
If Service Canada denies your claim, you can appeal on two levels. You must request the first, a reconsideration appeal, within 90 days of learning of the denial. If denied again, then you must appeal to the Social Security Tribunal within 90 days as well.
Once you appeal to the tribunal, a judge or a three-person panel will decide your claim. You can attend the hearing to give evidence and answer questions from the judge or panel.
Workers compensation benefits
Workers compensation pays short- and long-term benefits to people injured on the job.
Each province has its own compensation program. To qualify, you must have suffered a workplace injury and worked for a covered employer. That’s right, not all employers are covered.
It’s difficult but possible to prove a workplace injury caused or worsened your fibromyalgia. While no one yet knows the exact cause of fibromyalgia, doctors generally agree that a traumatic event can trigger or exacerbate it.
To succeed in this claim, you need a medical doctor to support your belief that the workplace injury triggered the fibromyalgia or made it permanently worse.
Workers compensation payments overlap with EI, CPP, and short- and long-term disability. This can get complicated, so you should seek legal advice for any concerns about payments. Depending on your province, you may keep some (or all) of your CPP disability as well as the workers comp.
If workers compensation denies your claim, then you follow the appeal procedures for your province. These programs also have two levels of appeal, the internal reconsideration and the outside tribunal. In most provinces, this tribunal is called the Workers Compensation Appeals Tribunal (WCAT).
Veterans Affairs Canada
If you’re a member or former member of the Canadian Forces, then you may qualify for short- or long-term disability benefits from Veterans Affairs Canada (VAC).
To qualify, you need to prove that a “service-related injury” caused or worsened your fibromyalgia. You’ll also need a doctor to confirm it.
You apply for VAC disability through the VAC either online or with a paper form. The VAC will review your service medical records and request more information if necessary.
The VAC follows a familiar pattern for appealing denials: internal reconsideration, then the Veteran’s Review and Appeal Tribunal.
Provincial income support benefits
Each province in Canada pays income support benefits to people who can’t work because of disability. If you qualify, you can receive fixed payments for life.
However, although you can qualify for provincial benefits even if you’ve never worked, they only apply if your total family income falls below a certain amount, and this amount differs from province to province. Family income doesn’t affect the approval process for the other types of disability benefits.
You apply for provincial disability benefits by filing an application with your provincial agency or program. As usual, your doctor will need to provide a report or certificate confirming you are unable to work because of your medical condition.
For denials, you can appeal internally within the agency or program. In some provinces, you can also appeal to an outside tribunal for a final decision. Check with your province for the proper procedures.
Disability tax credit
The disability tax credit is a type of benefit that lowers your taxable income. To qualify you must have a severe and prolonged impairment as defined by the program, but this program has a higher standard than the others.
Qualifying for this credit can get some of your previous taxes refunded, depending on the timeline of your condition. You apply by filling out a T2201form and sending it to Revenue Canada.
If Revenue Canada denies your claim, you can request an internal appeal. If that appeal fails, then you must go to the Tax Court of Canada to appeal again.
How to prove a fibromyalgia disability claim
Because fibromyalgia is largely an invisible illness and doctors can’t verify the seriousness of your symptoms, you will have trouble getting approved for benefits.
No one but you can say how serious your condition is, so disability benefits providers may view your claims with skepticism. After all, you could exaggerate or lie to appear more disabled than you are. Many people with fibromyalgia can manage their symptoms and continue working, so you need to focus on proving that your case is different. Let’s go over how to do that.
Appropriate medical diagnosis
While an official diagnosis is not enough, you still need to have that diagnosis.
It must show a detailed clinical history and the steps taken to rule out other possible conditions. Unfortunately, some doctors will give a fibromyalgia diagnosis without following the right steps. When this happens, the insurance company will dispute the diagnosis or question the treatment.
Because fibromyalgia often occurs with other medical conditions, such as irritable bowel syndrome, depression, or chronic fatigue syndrome, having these other conditions diagnosed can help because it shifts the focus beyond your fibromyalgia.
Objective medical testing
The FM/a blood test can confirm a diagnosis of fibromyalgia. While this test isn’t required, it can save time spent on ruling out other possibilities. However, remember that it cannot confirm the seriousness of your fibromyalgia, only that you have it.
Appropriate treatment
When considering your claim, the disability benefits providers will look to see if you received appropriate treatment. Not getting appropriate treatment is one of the most common reasons for denial.
This requirement covers all other conditions as well. If you also have a mood disorder or depression, you must get the right treatment for each condition, including medications, consultations with psychiatrists, or treatments from psychologists. Multidisciplinary pain clinics now count as appropriate treatment centers also.
Not getting proper treatment can happen for two reasons: either your doctor didn’t follow accepted standards for treatment, or you didn’t. Even if you and your doctor believe that alternative methods may work better, you must at least try the standard treatments to qualify for disability benefits. Otherwise, you leave the door open for someone to say that you could work had you gotten the right treatment.
Mediations and side effects
Serious medications make a serious medical condition more believable, so you must try all the recommended medications, even if you fear the side effects.
Should you have bad reactions to your medications, your medical records must report them in detail. And should your doctor recommend against a standard medication, you need to have it documented that the side effects were worse than the condition. Again, you run the risk of denial if you stray from standard treatments without a compelling reason.
Evidence of work-related limitations
With an invisible illness like fibromyalgia, disability benefits providers place great emphasis on how hard you tried to stay at work.
“You didn’t try” is the most common theme for a denial of benefits and is very difficult to beat.
You must go well beyond saying you can’t do your job. You need to show that you asked for help from your employer to stay at work. Such changes could include fewer hours, easier duties, or changing jobs within the company. If your job was medium or heavy work, then you have to try an easier job with light or sedentary duties.
You need to give evidence to show how hard you tried to stay at work. This evidence can include:
- Medical records discussing your work attempts
- Employment records showing the places you tried to work and the accommodations made for you, including sick days or leaves
- A written statement from you detailing your work efforts
- Signed written statements from your employer or co-workers describing how they observed your struggle to work
If you give strong evidence showing you tried your best to stay in the workforce, then you have a good chance of winning benefits. On the other hand, if you have little evidence of your efforts to stay at work or evidence that you made no effort, then you have no chance at approval.
Credibility
Medical and employment documents will give you some of the best support for your claim, but the decision-makers need to believe you too. In legal settings, credibility refers to a person’s trustworthiness or believability.
A decision-maker who finds you trustworthy may rule in your favour, even if you have weak documentation for your claim. And a decision-maker who doesn’t trust you won’t give you the benefit of the doubt in uncertain areas, even with good evidence. Credibility gives you an invisible edge that many people overlook.
Credibility killers include:
- Contradicting medical records or earlier statements
- Making excuses or blaming others for problems
- Criticizing other parties in the claim (even if they deserve it)
- Filing complaints against professionals you see as negative, biased, or unprofessional
- Using aggressive, sarcastic, or confrontational tones in your claim or testimony
- Blocking or stalling reasonable requests for information
- Fighting with doctors over your diagnosis instead of focusing on the disability
- Acting like a medical expert
Credibility boosters include:
- Making sure what you say matches the medical records
- Taking responsibility for bad facts or problems with your claim
- Being cooperative and respectful of everyone in the claim
- Accepting expert advice and opinion
- Not blaming other individuals or groups
- Making good faith efforts to try all reasonable advice, even if you disagree with it
- Obvious efforts to keep working
Common reasons for denial of fibromyalgia disability claims
Insufficient objective evidence of disability
Although insurers often cite “insufficient objective evidence of disability” to deny claims, this reason doesn’t work with fibromyalgia because modern medicine has yet to find objective evidence of disability with fibromyalgia.
If you receive this as a reason, address it in your appeal letter. Fortunately, objective evidence is not a requirement under most disability insurance policies and programs.
Your letter should then focus on how your doctor followed best practices for diagnosis and treatment as well as how you adhered to the recommended treatment faithfully. You should also emphasize all the things you’ve done to keep working.
Incorrect treatment
If you got the right treatment, then you wouldn’t be disabled, right? This reason for denial shifts the blame to you or your doctor – either your doctor offered the wrong treatment or you refused the right treatment.
The insurer may argue that your symptoms come from misdiagnosed and untreated depression rather than fibromyalgia, so your treatment can’t work for you.
Some insurers may say that you haven’t received treatment for multidisciplinary pain and therefore your disability is not permanent. Make sure you have ways to shut down this argument.
Insufficient work effort
You can’t do your job, but you could do an easier job, couldn’t you? This reason often arises when the job you did had medium to heavy duties, and you didn’t try a job with light or sedentary duties.
The best way to fight this reason is to try easier jobs. Until you do, the disability benefits providers will always doubt you. You might also show that while your job had medium duties on paper, you got enough disability accommodations from your employer to qualify your work as light duties.
Final thoughts
Fibromyalgia can result in severe disability. Many people with fibromyalgia gradually lose the ability to work over several years, so even if you’ve been diagnosed only recently, don’t wait. Get started on confirming your eligibility for all of these programs, just in case.
Each program has its own rules you must follow. If your claim gets denied, don’t give up. It happens a lot for fibromyalgia claims, and you can appeal.
Winning disability benefits for fibromyalgia is difficult, but not impossible. You’ll face challenges because you can’t prove beyond the shadow of a doubt how serious your condition is. To maximize your chances of success, make sure your doctor follows all best practices for fibromyalgia diagnosis and treatment. Cooperate with all treatment recommendations and do your best to keep working.
If you can show you tried everything and done all you can do, then you have a much better chance of success. Remember, your credibility counts more than you might think in being approved for disability benefits.
Still feeling unsure about your fibromyalgia disability claim? Sometimes a quick call with us can help you move forward with confidence. Call us at 1-888-732-0470 or click on the help icon to start a conversation with our support team.
