Summary to Submit With Medical Literature and Your Documents
(Adjust and use sections that fit your circumstances- for insurance and disability denials)
SUMMARY
It is challenging for patients with late-stage, chronic Lyme and associated tick borne diseases to remain hopeful while experiencing disabling illnesses that impact every aspect of functioning, that are poorly understood, that are not effectively managed by the healthcare system, and that are not adequately covered by the insurance system.
Medical reports generated over the past twenty years, as well as the scientific evidence and medical documentation included in and attached to this report, indicates overwhelmingly that the Claimant has suffered immensely from her illnesses and sustained significant damage from relapsing, long-term chronic Lyme and tick borne diseases. Claimant requires ongoing medical intervention and treatment from a variety of specialists to sustain even a minimal quality of life.
Baseless assertions by INSURER setting forth mere unsubstantiated conclusions do not suffice to establish the basis for denial of this claim. As documented in this report, current scientific and medical literature from reputable sources is at odds with the evaluation of Claimant’s activities by INSURER with regards to the diagnosis, symptoms, and treatment of chronic multiple tick borne diseases and Claimants additional diagnoses.
Lyme disease is widely known to be highly variable in the occurrence and severity of its symptoms. One defining aspect of Lyme is that with rest and appropriate treatment, many people feel relatively well or better on some days, but symptoms flare with exertion or activity and relapses are common. Some people will have only a few hours a week when they are able to function at a reasonable level, if that many. It is during that time they attempt to catch up on shopping or do limited activities outside the home with somewhat less difficulty. Any good measure of the disability status needs to take these variables into account.
Professionals reporting on individuals with chronic Lyme and tick borne illnesses (or anyone with these symptom presentations) should be aware of the number of shared challenges facing individuals with these maladies. The specific tick borne illnesses exhibit enormous fluctuations in symptom severity and level of impairment between and within individuals as is noted in the scientific literature attached. The enormous variation in symptom severity that can allow patients to be relatively functional for brief intervals, yet be severely impaired at another time is very difficult for most to comprehend. Physicians reporting on behalf on insurers should consider and provide accurate information relating to this topic when forming opinions that deny sick patients of necessary, life-sustaining medical care and income.
Objective Evidence
Although the standard commercial blood tests on the market reportedly miss up to 75% of those affected by Lyme disease, Claimant has X (#) of serology results and additional tests confirming the diagnoses from a number of labs. As proven in this document, the multitude of signs and symptoms of Lyme and tick borne coinfections are fully recognized by all medical and governmental agencies and they report Lyme disease is diagnosable by trained physicians in a clinical setting, with or without confirmatory tests. Like other illnesses, the symptoms of Lyme and tick borne coinfections form a presentation that, when combined with the characteristic physical examination, detailed history and objective evidence, is conclusive.
CURRENT SITUATION:
Currently Claimant is undergoing intensive IV antimicrobial therapy for a relapse of her Lyme and chronic infections (supported by objective evidence, symptoms and clinical picture). She has a picc line inserted that requires daily care and maintenance, which is performed at a near-by facility when she is taken there for her daily infusions.
During the past X months Claimant has been to over 70 doctor, hospital and therapy appointments related to her deteriorating condition. Over 90% of the time Claimant requires transportation to and from scheduled appointments, causing an additional burden for herself and family members.
Claimant continues to require and receive assistance with grocery shopping, cooking, house cleaning, mail, paying bills, repairs, transportation and errands. She has a few good days interspersed with many bad days, but never a time when she can predict in advance the extent of her needs or her ability to accomplish even the most simplest of tasks.
While cognitive problems allow Claimant such luxuries as an occasional trip out to attend doctor and therapy appointments or to visit her family and friends, they make it very difficult for Claimant to function in a workplace setting. She clearly remains unable to work in any occupation, which understandably adds to the depressive nature of her illnesses.
Claimant remains totally disabled under the federal Social Security Administration’s definition and is receiving minimal benefits due to her inability to be gainfully employed in any occupation.
Insurer’s Decision to Terminate Benefits
Insurer failed to provide any credible medical evidence indicating Claimant’s circumstances are other than what has been reported and documented over the years by her treating physicians. There is no evidence whatsoever indicating the Claimants situation has improved substantially, allowing her to resume any type of gainful employment.
Patients suffering from late-stage chronic Lyme and tick borne diseases face the hardship of knowing there is no universal cure or a procedure available to reverse permanent damage. The treatment goal for patients in this situation is to improve and reduce their symptoms if possible in order to allow them to sustain a minimal functioning level.
Anyone of the conditions outlined in the patients medical records can cause significant disability, but the combination of multiple chronic illnesses makes it especially unrealistic and unreasonable for Claimant to perform even sedentary work on a regular and sustained basis. Claimant is markedly impaired by weakness and fatigue after minimal every day activity; post-exertional malaise that may prostrate her for days; weakness with prolonged sitting or standing; sleep disruption that leads to excessive somnolence despite therapy; and significant confusion and neurocognitive dysfunction including problems with memory, attention, reaction time, processing speed, comprehension and calculation. She is unable to maintain a set work schedule due to the unpredictable flares, treatment protocols and required therapy appointments, and the fluctuating and severe nature of her illnesses.
Claimants cognitive profile is entirely consistent with that observed in the majority of patients with chronic Lyme and tick borne diseases. Most patients are yearning to remain productive members of society and often try “extra hard” to accomplish cognitive tasks, previously easily completed, but now complex and challenging. This effort often leads to significant post-exertional fatigue, a major issue for many Lyme patients, rendering the patient housebound for days afterward.
The courts have addressed this issue in cases such as Irwin v. Shalala, 840 F. Supp. 751 (D. Or. 1993), where the Federal Court stated:
A disability claimant need not vegetate in a dark room in order to be deemed eligible for benefits nor should an otherwise eligible claimant be penalized for attempting to maintain some sort of normalcy in her life and a modicum of independence. The critical issue in a disability case is the claimant’s capacity for work activity on a regular and continuous, ongoing basis.
After a thorough review of Claimants treating physicians medical records, combined with an understanding and personal experience assisting thousands of Lyme and multiple tick borne disease infected patients, my opinion is her medical records and the scientific evidence clearly establish that Claimant does indeed continue to suffer from these illnesses to an extent that her medical condition renders her incapable of performing the requirements of any job for any employer for which she is qualified or may reasonably become qualified by training, education or experience.
The INSURERS attempt to paint Claimant as having fully recovered after nearly two decades of chronic disease progression and subsequent damage is seriously flawed. To report Claimant’s impairment as psychogenic in origin is not only insulting and self-serving, it is a major error - one based on inexperience or ignorance, and one that results in using an inappropriate label that lacks any scientific basis or credibility.
We hope in the future that the INSURER and its hired consultants, especially when evaluating cases that are so obviously outside their area of expertise, will perform at least rudimentary research on the illnesses, signs and symptoms described in the patients charts before rendering an opinion. Claimants are entitled to such minimal effort from their insurers.
In summary, Claimant is markedly impaired by ongoing symptoms and years of permanent damage caused by chronic bacterial, protozoan, and viral infections (Lyme disease, Babesiosis, Bartonella, Ehrlichiosis, Mycoplasma, Epstein Barr virus), hypothyroidism, metal toxicity, central vestibular dysfunction, multiple cognitive deficits, a sleep disorder, vertigo and balance issues, deregulation of innate immune responses, decreased proprioception, muscle and joint pain, headaches, menstrual irregularities, chronic fatigue-like syndrome, fibromyalgia-like syndrome, fevers, allergies, hypoglycemia, low blood pressure, and sensory hyperarousal.