Is fibromyalgia a critical illness?

Does critical illness cover fibromyalgia?

Fibromyalgia is not usually a named condition on standard critical illness lists. A diagnosis alone therefore does not normally trigger the main payment. That describes the insurance contract, rather than the seriousness of someone's symptoms or the effect on their life.

There can be a separate question under total permanent disability, often shortened to TPD. This is a benefit for a permanent loss of ability that meets the policy's test, which may concern work or specified everyday tasks. It is not included in every policy, and its presence does not establish that a particular claim qualifies.

Income protection is another type of insurance, providing regular payments when illness or injury meets a policy's test for inability to work. It can be relevant to fibromyalgia under existing cover, subject to exclusions and the other terms. Taking out new insurance after symptoms begin is a different question from claiming under insurance already held.

If you are checking existing cover, the distinction between medical language and an insurance definition, meaning the written test for payment, matters. The guide to what counts as a critical illness explains that difference.

Why a long term condition is not automatically a covered illness

The NHS describes fibromyalgia as a long term condition causing widespread pain. Symptoms can include fatigue, sleep problems and difficulty concentrating or remembering things, sometimes called fibro fog. They can change, improving or worsening over time.

The NHS also says there is currently no cure, although treatments can relieve symptoms. That does not by itself answer a disability claim. A lasting diagnosis and a permanent inability to perform the policy's required activities are different things.

Critical illness insurance pays for specified events under written conditions. The Association of British Insurers' guide contains minimum definitions for the core illnesses and certain optional benefits. It does not contain a named fibromyalgia definition.

Nor is the ABI guide a complete list of everything an insurer may cover. The full policy wording remains necessary, particularly for disability benefits and any personal exclusions, which are circumstances the insurance does not cover. The guide's absence of a fibromyalgia definition cannot settle every existing contract.

The NHS page in Sources provides medical information. Insurance descriptions here concern the tests for a payment, rather than diagnosis or treatment.

A fibromyalgia critical illness claim starts with the benefit

Consider a fictional example. Ruth is a dental nurse in York who bought a personal critical illness policy before developing symptoms. After a fibromyalgia diagnosis and an extended absence, she looks for the condition in her policy documents.

Not finding its name is only the first check. Her policy schedule, the document recording her particular cover, might show that TPD was selected. The full conditions would then explain its definition, its age limit and any exclusions applicable to that benefit.

Suppose Ruth's schedule shows an own occupation test. This concerns her trade or type of work, rather than simply her particular post with one employer. The claim would need evidence about the significant duties of dental nursing and the permanence required by that wording.

If TPD is absent, Ruth cannot assume the general description of critical illness creates that benefit. If it is included, being off work is still not the same as meeting its full definition. A fit note confirms information about fitness for work, but it does not by itself establish permanent disability under an insurance contract.

This is why an enquiry about an existing policy needs its actual documents. The guide to making a critical illness claim explains the wider process.

What does total permanent disability actually test?

Under an own occupation definition, the central question concerns lasting inability to perform the significant duties of the insured person's occupation. A suited occupation definition also considers other work matching their skills, education or experience. These are different tests, even where two policies both use the heading TPD.

Other definitions use specified work tasks or everyday activities. These can include walking, lifting, washing or dressing, with exact thresholds in the wording. Difficulty managing a demanding shift does not automatically establish inability to perform the required number of those tasks.

The ABI model wordings require specialists reasonably to expect disability to last throughout life with no prospect of improvement. Policies can also exclude disability where specialists cannot give a clear prognosis, meaning an assessment of its likely future course. A policy's reference to permanence can therefore demand more than absence lasting until its expiry date.

For Ruth, a report saying she cannot currently work would answer a narrower question. The insurer would also need evidence addressing the relevant duties or tasks and the required outlook. There is no automatic conversion from a long period on sick leave to TPD.

Some older policies use different definitions. The Financial Ombudsman Service considers the particular wording and medical evidence when examining disputes, rather than treating every disability benefit as identical.

Why exclusions can matter before disability is assessed

An exclusion can prevent a payment even where the policy includes a disability benefit. Personal policies may have individual restrictions recorded when the application was assessed. Employer schemes may also have rules about symptoms or conditions present before someone joined.

One published Ombudsman decision, DRN-3004697, concerned a member of an employer's critical illness scheme who had fibromyalgia before joining. She later claimed under disability benefits. The insurer relied on the scheme's exclusions for associated conditions, meaning conditions or symptoms connected in the way its terms specified.

The Ombudsman upheld the insurer's position under those particular terms. For the TPD benefit, the listed associated conditions included chronic pain and fatigue, and that exclusion did not expire after the scheme's usual two year period. It applied before a decision about whether the disability definition was met.

That decision is not a rule that every fibromyalgia claim fails, and its group scheme terms cannot be transferred to another contract. It shows why the disability definition and the exclusions both need reading. A convincing report about inability to work does not, on its own, answer an exclusion dispute.

If you have cover through employment, the relevant documents are the scheme rules and your membership information. A general staff benefits description may not contain all the restrictions.

Can income protection pay for fibromyalgia?

Under existing income protection, fibromyalgia can be considered as a cause of inability to work if the policy covers it. A claim depends on the definition of incapacity, meaning the required loss of ability to work, as well as exclusions and evidence. It does not normally depend on fibromyalgia appearing on a named critical illness list.

Income protection usually has a deferred period, the agreed wait before benefit payments can start. Payment can continue while the claim qualifies, subject to the policy's limits. Some policies limit each claim to a shorter payment period than the overall years of cover.

Unlike TPD, income protection does not generally require proof of lifelong disability. However, an own occupation policy and one testing ability to do other work can assess the same absence differently. The comparison of critical illness cover and income protection explains the broader distinction.

Imagine Ruth already has an income protection policy as well. The question under that contract could be whether she meets its work test after the deferred period, even while her future recovery remains uncertain. A separate TPD claim might still require evidence of permanent loss of ability.

That example assumes existing cover without a relevant exclusion. It does not establish that new income protection would cover symptoms or a diagnosis that already exists.

What evidence helps explain symptoms that change?

A diagnosis letter names the condition, but a claim may also need evidence of its practical effects. For Ruth, that could concern preparing equipment, assisting during procedures and maintaining concentration through the working day. The relevant details depend on the duties or tasks her contract tests.

Evidence can include medical reports, a job description, absence records and information about adjustments already tried. A factual account can describe how long activities are manageable, how symptoms vary and what help is needed. The insurer can explain which reports it requires and who will obtain them.

The Ombudsman's income protection guidance says it assesses medical and other evidence against the policy's disability definition. It also recognises that a brief activity, such as visiting a supermarket, does not necessarily demonstrate ability to perform a job. A disagreement about evidence needs that context as well as the wording.

If an insurer declines a claim, its written reason can identify which issue remains disputed. The problem may concern an exclusion, the work test or evidence of permanence. Complaints can first be raised with the insurer and then, where eligible, with the Financial Ombudsman Service.

Applying for cover after a fibromyalgia diagnosis

If you are considering new cover, an application and a claim answer different questions. Underwriting is the insurer's assessment of an application and the terms it is prepared to offer. Common questions concern medical history, treatment, symptoms and their effect on work or daily activities.

An offer of critical illness cover does not mean fibromyalgia becomes a covered diagnosis. Equally, accepting an application for income protection does not establish that every existing symptom is included. The accepted terms and any exclusions explain the scope of the actual cover.

The guide to pre-existing conditions covers that separate application issue. A protection specialist can check an individual's situation, the benefits available and the restrictions attached to any offer.

For an existing claim enquiry, the useful starting material is more specific. It is the schedule, the disability wording, any exclusion letters and the insurer's explanation of what evidence it needs. Those documents identify the question that a diagnosis alone cannot answer.

Questions people ask

Sources

We checked this guide against these sources. It is general information, not advice.

• Fibromyalgia overview, NHSSupports the limited description of symptoms, their variability and the distinction between lasting illness and symptom improvement.
• Guide to Minimum Standards for Critical Illness Cover, ABIThe September 2022 guide with April 2023 clarifications contains disability model wordings and no named fibromyalgia definition.
• Critical illness complaint guidance, Financial Ombudsman ServiceExplains occupation and activity tests and assessment of permanence.
• Decision DRN-3004697, Financial Ombudsman ServiceA published decision illustrates how a group scheme's associated condition exclusions affected disability claims.
• What is income protection insurance, MoneyHelperExplains regular payments, waiting periods, application questions and policy limits.
• Income protection complaint guidance, Financial Ombudsman ServiceSupports assessment of job duties, medical evidence and the limits of brief observations of activity.
• Critical illness cover complaints for consumers, Financial Ombudsman ServiceExplains the complaint route and review of policy terms and medical evidence.