Fibromyalgia is a chronic condition that causes widespread pain, fatigue, and cognitive difficulties (including a condition which is sometimes called “brain fog” or “fibro fog”). It can seriously affect your ability to work and maintain a normal routine.
While total and permanent disability (TPD) and income protection insurance can provide financial support, these claims can be challenging because fibromyalgia symptoms are often variable, subjective, and hard to measure. Below, we explain:
- what evidence is needed;
- which doctors can best support your claim; and
- the main reasons insurers reject fibromyalgia-related disability claims.
What medical evidence is required to support a TPD claim for fibromyalgia?
To qualify for a TPD benefit, you must show that your fibromyalgia prevents you from returning to work in your usual occupation, or in any occupation suited to your education, training, and experience (depending on your policy).
Because fibromyalgia does not always show up on standard tests and most doctors agree that there is no cure, medical evidence should focus on confirming the diagnosis and detailing the symptoms of the illness and the impact on your work capacity. That is, what you can and cannot do on a day-to-day basis in a work context.
Strong supporting medical evidence includes:
- Reports from your treating GP and rheumatologist confirming your diagnosis and describing your ongoing pain, fatigue, and cognitive symptoms;
- Specialist medical reports addressing how your condition limits your work capacity - for example:
- Difficulty sitting or standing for long periods;
- Difficulty walking, lifting, etc.;
- Concentration problems;
- Inability to maintain consistent hours.
- Detailed treatment history showing that you have tried appropriate medications, physiotherapy, or pain management without sufficient improvement and that the relevant testing has been conducted;
- Consistency between your medical reports and your own statements about your daily functioning and employment history.
To be successful, the insurer will want evidence that your condition is long-term and unlikely to improve, rather than temporary or fluctuating. Getting the right specialist reports early can make a significant difference to the outcome; however, many doctors will want to see sustained treatment before they will provide the necessary certifications.
Because fibromyalgia symptoms can fluctuate, insurers often argue that you can perform “light duties” or part-time work. Your medical evidence should clearly explain why your condition prevents sustained or predictable employment, even if you have some “good days”.
Importantly, performing light or part-time duties can have an impact on your claim because the relevant definitions that apply are different if you are working lesser hours when you make your claim.
TPD claims - further reading
- TPD and Income Protection Insurance for People with a Chronic Illness
- Your guide to making a successful TPD claim
- The importance of your doctors for a successful TPD claim
What medical evidence is required to support an income protection claim for fibromyalgia?
Income protection benefits are usually paid when you are temporarily unable to work because of illness or injury. The work-incapacity usually need only be in your own occupation, but all policies are a bit different. If you’re unsure about eligibility to claim on your income protection insurance, contact us for some free advice.
In fibromyalgia claims, the main challenge can be confirming the diagnosis and demonstrating that your symptoms are severe enough to prevent you from performing the important duties of your occupation, not just that you are unwell.
Key medical evidence includes:
- Certificates and reports from your treating doctor describing your capacity for work, including how pain and fatigue affect your ability to meet normal work demands;
- Objective assessments (such as assessments that focus on functional capacity) that show reduced stamina, concentration, or mobility;
- Regular medical reviews confirming ongoing treatment and lack of improvement over time.
Also, as with TPD claims, working lesser duties due to fibromyalgia can impact your income protection claim because:
- of changing definitions depending on work hours; and
- your benefit payments are usually calculated based on your income in the 12 months before you cease all work, so you may get lower benefits if you are earning less in this 12-month period.
Income protection claims - further reading
- What is income protection and how do income protection claims work?
- Income protection waiting periods
- How much will my monthly income protection benefit be?
Which doctors are best to support disability insurance claims for fibromyalgia?
Fibromyalgia is best diagnosed and managed by rheumatologists, but support from your GP, pain specialist, and psychologist or psychiatrist is often also crucial.
Each doctor plays an important role:
- Rheumatologist - confirms the diagnosis and rules out other conditions. Their opinion carries significant weight in disability insurance claims.
- GP - provides continuity of care and can describe the long-term pattern of symptoms, treatment history, and their effect on work capacity.
- Pain specialist - can document how pain limits daily functioning and work tolerance.
- Psychologist or psychiatrist - may support your claim where chronic pain is associated with depression, anxiety, or cognitive issues. They may also assist with secondary psychiatric conditions that arise due to your fibromyalgia symptoms and limitations.
What are the main reasons that fibromyalgia disability insurance claims are rejected?
Because fibromyalgia is a condition without clear diagnostic tests, insurers often question the validity or severity of the symptoms. Below are the most common reasons claims are rejected and how to avoid them.
Lack of doctor support
One of the biggest challenges is obtaining clear and confident medical support. Some doctors are hesitant to describe fibromyalgia as permanently disabling, especially early in the treatment process.
Incorrect date of disablement
Insurers often dispute the date you became disabled, particularly when your work hours gradually reduced before you stopped completely.
For TPD claims, your disablement date determines whether you were insured at the time and which policy applies. For income protection, it affects your waiting period and benefit calculation.
Because fibromyalgia symptoms can worsen gradually, it’s vital that:
- your doctor records a clear date when you first became unable to work due to the condition;
- you see a doctor before or around the time you stop working, not months later;
- your medical certificates and employment records align with your version of events.
Even small discrepancies can lead to disputes or reduced entitlements.
Lack of certainty about work capacity in the future
Another reason insurers reject claims is because they believe your condition may improve with treatment.
Fibromyalgia can fluctuate, and insurers sometimes argue that your condition is not “permanent” or that you could return to work in the future.
Disputed claims - further reading
- What to do if your superannuation TPD claim is rejected
- What to do if your income protection claim is rejected?
- Three options to appeal a rejected insurance claim
Get help from a disability insurance lawyer
TPD and income protection claims due to fibromyalgia can be challenging because the condition is complex, invisible, and often misunderstood. The key to success is clear, consistent medical evidence from the right specialists, recorded at the right time.
If you’re facing difficulties with a fibromyalgia-related claim, Berrill & Watson’s superannuation and insurance team can help you prepare, lodge, and manage your claim. We offer free initial advice, no upfront fees and run cases on a ‘no win, no fee’ basis.
Contacting Berrill & Watson
📞 Melbourne: 03 9448 8048
📞 Brisbane: 07 3013 4300
📞 Anywhere else in Australia: 03 9448 8048
How we charge
We are Australia's best-value superannuation/insurance law firm. Other law firms charge nearly double (& sometimes more than double) what we charge. So, if you get a quote from them, or have a cost agreement, ask us what we will charge you.