Fibromyalgia Disability Benefits: The Ultimate Guide

I wrote The Ultimate Guide to Fibromyalgia Disability Benefits for people who need to win or maintain disability benefits for fibromyalgia.

This guide is based on my 25 years of experience as a former occupational therapist and now disability lawyer. This article is meant to give you an overview of the types of benefits you may qualify for and the challenges you may face along the way.

Because you are reading this article, I know you are on the right path. Educating yourself is the 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 (888) 732-0470.

Keep on learning, and I wish you all the best with your journey.

— David Brannen, disability lawyer & founder, of Resolute Legal

Contents

This article is part of our guide on medical conditions that qualify for disability benefits.

About Fibromyalgia

Fibromyalgia is a medical condition that causes widespread pain throughout the body. People who suffer from the condition are typically more sensitive to pain, this is referred to as abnormal pain perception processing.

The condition is also associated with other symptoms, such as sleep difficulties, fatigue, memory and concentration issues, mood swings, gastrointestinal problems, and more. The cause of fibromyalgia is unknown. However, in some cases, it can be managed with medication and self-management strategies.

It is estimated that fibromyalgia affects 900,000 Canadians, approximately 3% of the national population. Fibromyalgia is also a leading cause of disability in Canada. A 2014 Statistics Canada study that surveyed people who were permanently unable to work due to a chronic health issue found that fibromyalgia was the second most common condition behind COP. In other words, fibromyalgia accounted for 22.8% of people who were unable to work due to a medical condition.

Is Fibromyalgia a Disability in Canada?

Yes. All disability benefits providers in Canada recognize fibromyalgia as a condition that can qualify a person for benefits.

However, a diagnosis on its own will not qualify you.

Providers pay benefits to people who can prove their condition prevents them from working. When reviewing claims for fibromyalgia, providers focus on the seriousness of your symptoms. They will consider the medical treatment you have had and future treatment plans. They look at how your symptoms affect your work and how hard you try to keep working.

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 do not do it for a discriminatory reason.

However, most employers will not fire employees who take 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.

You need to provide a doctor’s note if you want to go on sick leave. It should confirm that you are unable to work and need the leave. You will need to bring these notes often — every three to six months — to confirm that you still can’t work.

If your application gets denied, you can stay on sick leave while you appeal. Most employers will not give you a hard time — as long as you have a doctor’s note.

If your employer attempts to fire you while you are on sick leave, you may have legal rights to severance pay. You might even be able to get the termination overturned if you are fired because of your condition. However, these situations are complicated. You should always seek out legal advice.

Types of Disability Benefits for Fibromyalgia

If fibromyalgia prevents you from working, you have a few options. You might be eligible for disability benefits from the government, your employer, or your insurer.

This list covers the possible fibromyalgia disability benefits 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 or not. And then, we will explain how to apply and appeal a denial.

Employment Insurance (EI) sickness benefits

People with fibromyalgia may be eligible for EI sickness. It is a temporary disability benefit paid by the federal government’s employment insurance (EI) program. EI covers 55% of your salary for 15 weeks.

To qualify, you must have paid into the EI program recently. You pay through deductions from your paycheque. These are automatic. So, if you got an official paycheque, you paid into the EI program.

You apply for EI benefits online through Service Canada. You can apply from home or at any Service Canada office. Your doctor needs to fill out a form to confirm that you cannot work for the 15 weeks that EI covers. And finally, your employer will need to issue a Record of Employment (ROE) to confirm your sick leave.

Please note: If you qualify for short-term disability, you can’t claim EI benefits simultaneously.

Short-term disability (STD) benefits

Short-term disability (STD) benefits are another temporary disability payment. They pay 50-67% of your regular salary. You can usually get them for 15 to 17 weeks, but sometimes longer.

You 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 you have a plan through your job. Not all employers offer this to their employees. If your employer does not, you might be able to get EI sickness.

As I said before, if you qualify for STD, you will not qualify for EI. If you can get STD payments, you have to apply for those instead of EI.

You can start the application process for STD by asking for the required forms from your employer or the insurance company. The application includes three forms: one for you, one for your doctor, and one for your employer. It’s up to you to get all the forms back to the insurer.

If your application gets denied, you can ask for a review. This is called an internal appeal. During the appeal, your claim gets reviewed by someone else in the company. You usually have three or four of these appeals. After that, you may have to appeal to an outside judge or file with the courts. Your options will depend on your situation.

Long-term disability benefits

As you may guess, long-term disability (LTD) benefits pay for a longer period of time. If you win a claim for LTD, the payments can last for many years. A policy will specify that the benefits last a number of years — 2, 5, or 10, for example. Or, they last until you reach a certain age — usually 65.

LTD payments often cover 50-67% of your monthly salary. You receive payments 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, you should check to see if it includes LTD benefits. If you’re in a union, your medical plan will likely have coverage for LTD.

You can also get LTD through private insurance policies if you are self-employed or underinsured. 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. There should be one for you, your employer, and your doctor. And again, it’s your job to submit them. You won’t get a decision until the insurer receives all the forms.

You can appeal a denial, just like an STD claim. Your LTD plan may allow to do two to three internal appeals. After, you would need to do an appeal hearing with an outside judge (external appeal).

CPP disability benefits

CPP benefits cover permanent disability. If you qualify, then you can get paid until age 65. The payment ranges for 2022 are $524.64 to $1,457.45 per month. The amount you receive is based on how much you paid into the program. The more you contribute, the more you’ll get back. Similar to EI, if you had a job with a paycheque, you paid into CPP.

To qualify for CPP disability, you must have the right amount of credits. You can get credits by credit splitting with a former spouse or paying into another country’s pension plan. Or, you can qualify for credits if you leave work to raise a child.

You can get LTD and CPP at the same time. However, the LTD insurer usually has the right to offset your payments by the same amount. For example, if you get $900 from CPP disability, your insurer can reduce its payment by $900 for the same month.

Even with enough credits, you still need to prove that your disability is “severe and prolonged.” 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 forms. Your doctor or nurse practitioner will have to fill out the medical report. Then, you send your application to a designated Service Canada office for your province.

If Service Canada denies your claim, you can appeal on two levels. The first is a reconsideration appeal. You must request this appeal within 90 days of denial. If denied again, then you appeal to the Social Security Tribunal. The deadline is 90 days as well.

At the tribunal, a judge or a three-person panel will decide your claim. You can attend the hearing to give evidence and answer questions.

Worker’s Compensation for fibromyalgia

Worker’s compensation pays short- and long-term benefits to people injured on the job.

Each province has its own compensation program. To qualify, you must suffer a workplace injury or illness and work 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 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 or illness 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 worker’s compensation.

If workers’ compensation denies your claim, you need to follow your province’s appeal procedures. 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, you may qualify for short- or long-term disability benefits from Veterans Affairs Canada (VAC).

To qualify, you must prove that a “service-related injury” caused or worsened your fibromyalgia. You’ll also need a doctor to confirm it.

You can apply for VAC disability 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 unable to work because of a disability. If you qualify, you can receive fixed payments for life.

You can qualify for provincial benefits even if you have never worked. However, they only apply if your total family income falls below a certain amount. That amount differs from province to province, however. Family income does not affect the approval process for other types of disability benefits either.

You apply for provincial disability benefits by applying through your provincial agency or program. As usual, your doctor will need to provide a report or certificate that confirms you can’t work because of your condition.

You can appeal internally within the agency or program if you get denied. 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. But, this program has a higher standard than others.

Qualifying for this credit can get some of your previous taxes refunded. It depends on the timeline of your condition. You apply by filling out a T2201 form 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 an invisible illness, doctors can’t verify the seriousness of your symptoms. You will likely have trouble getting approved for benefits.

No one but you can understand how serious your condition is. So, insurance companies may view your claim 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 prove your case is different. Let’s go over how to do that.

Appropriate medical diagnosis

While an official diagnosis alone is not enough, you still need to have that diagnosis.

You must have a detailed clinical history. It should show the steps taken to rule out other possible conditions. Unfortunately, some doctors will diagnose fibromyalgia without following the proper steps. When this happens, the insurance company will dispute the diagnosis or question the treatment.

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 is not required, it can save the time you spend ruling out other possibilities. However, remember that it can’t show the seriousness of your condition. It only confirms 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 a denial.

This requirement covers all other conditions as well. For example, if you also have a mood disorder or depression, along with fibromyalgia, you must get treatment for each condition. This can include medications, consultations with psychiatrists, or psychological treatments. Multidisciplinary pain clinics now count as appropriate treatment centres as well.

Not getting proper treatment can happen for two reasons: either your doctor didn’t follow accepted standards for treatment, or you refused treatment. Even if you and your doctor believe that alternative methods may work better, you must try the standard treatments to qualify for disability benefits. Otherwise, you leave the door open for someone to say that you could work if you had the right treatment.

Medications and side effects

Serious medications make serious medical conditions more believable. So, you must try all the recommended medications even if you fear the side effects.

If you have a bad reaction to your medications, your medical records must report that in detail. And, if your doctor recommends against a medication, you must have it documented that the side effects are worse than the condition. Again, you run the risk of getting denied if you stray from standard treatments without a good reason.

With an invisible illness like fibromyalgia, disability benefits providers place great emphasis on how hard you try to stay at work.

“You didn’t try” is the most common reason for a denial. It is a difficult one to beat.

You need to go beyond saying you can’t do your job. You need to show that you asked for help from your employer to stay at work. This could include asking for fewer hours, easier duties, or changing jobs within the company. If your job was medium or heavy work, you should try an easier job with light or sedentary duties before going off on disability.

You need evidence to show how hard you tried to stay at work.

This evidence can include the following:

Medical records discussing your work attempts
Employment records showing the places you tried to work and all accommodations made
A written statement from you that details your work efforts
Signed written statements from your employer or co-workers describing how they observed your struggle to work

If you have strong evidence showing you tried to stay in the workforce, 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 little chance of gaining 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 evidence 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

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

Making sure what you say matches the medical records
Taking responsibility for errors or problems with your claim (not blaming others)
Being cooperative and respectful of everyone in the claim
Accepting expert advice and opinions
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 Benefits

The following are the most common reasons an insurance company will deny disability benefits for fibromyalgia.

Insufficient objective evidence of disability

Although insurers often cite “insufficient objective evidence of disability” to deny claims, this reason doesn’t work with fibromyalgia. Modern medicine has yet to find objective evidence of disability for fibromyalgia.

If you receive this as a reason, you should address it in your appeal letter. Fortunately, objective evidence is not a requirement under plans and programs.

Your letter should then focus on how your doctor followed best practices for diagnosis and treatment. Mention how you stuck to the recommended treatment. And emphasize all the things you’ve done to keep working. These aspects can make up for the lack of objective evidence.

Incorrect treatment

If you got the right treatment, then you would not be disabled, right? This reason for denial shifts the blame to you or your doctor. It supposes either your doctor offered the wrong treatment or you refused the right treatment. This is the most common reason for the denial of disability benefits for fibromyalgia.

The insurer may argue that your symptoms come from misdiagnosed and untreated depression rather than fibromyalgia. By that logic, of course, your treatment would not work for you.

Some insurers may say that you have not received treatment for multidisciplinary pain. Therefore, they argue that your disability is not permanent. Make sure you have ways to shut down this argument.

Insufficient work effort

Another common reason for denial is you can’t do your job, but maybe you could do an easier one. This reason often arises when your job requires medium to heavy duties, and you didn’t try a job with light or sedentary duties.

The best way to fight this 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 accommodations that made your work qualify as light duty.

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 only been diagnosed 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 a fibromyalgia diagnosis and treatment. Cooperate with all treatment recommendations and do your best to keep working.

If you can show you tried everything, you have a much better chance of success. Remember, your credibility counts more than you might think in getting approved for disability benefits.

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