It is not uncommon for disability claims to be denied at one point or another during the Social Security Administration’s disability determination process. The final award rate has varied significantly for applicants seeking disability benefits depending on the type of impairment, whether the legal representation was involved, and even the claimant’s location. From 2004 to 2014, approximately 61 percent of all Social Security Disability (SSD) claims were ultimately denied. On average, about 77 percent of applicants are denied at the initial claims level.
By familiarizing themselves with the common reasons SSD claims are denied and the steps that can be taken when a denial is received, applicants can increase their chances of achieving a final disability award.
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The SSA Denies Disability Claims for a Variety of Reasons
Social Security has provided benefits to disabled Americans since 1956. Under the program, applicants must meet specific requirements to qualify to receive SSD benefits. Unfortunately, many claimants are denied SSD benefits even though they are impaired and unable to work. The SSA might deny a disability claim for a variety of reasons.
Insufficient Medical Evidence to Support the Claim
One of the most significant factors the SSA uses to approve or deny a disability claim is medical evidence. When there is insufficient medical evidence to prove a disability, benefits are generally denied. To avoid this, disabled victims should be sure to obtain medical evaluations and treatments for their conditions from approved medical professionals. When there is not enough medical evidence to support a claimant’s position, the SSA may request that the applicant attend a consultative examination (CE) to obtain sufficient medical information.
Failure to Identify Severity of Impairment
Many times, disabled victims downplay their medical conditions. In doing so, they often fail to accurately portray the extent of the impact their impairments have on their ability to perform substantial gainful activity (SGA). The Social Security disability claims process requires a great deal of information regarding work history, medical conditions, medical treatment, and physical and mental limitations. When these details are not accurate, denials often occur.
Earning More than the SGA Limit
Disabled workers are allowed to work in limited amounts while applying for and collecting SSDI benefits, but when their hours worked or earnings exceed the SGA limits, their benefits may be denied or discontinued. For 2017, the SGA limit for non-blind people is $1,170. Calculating the SGA for people who are self-employed is different, however, and may be best performed by a Social Security disability attorney.
Failure to Follow Prescribed Treatment
When disabled victims fail to follow their doctor’s orders for therapy, medication or other treatments they are often denied benefits. The SSA does recognize some legitimate excuses for not following prescribed treatments, however. A disability attorney can explain the acceptable medical and nonmedical excuses that SSA typically accepts.
Failing to Follow Through with a Claim
Many people who are denied SSDI benefits during the initial phases of disability determination fail to follow through with the next steps in pursuing their claims. Some individuals simply start over with the entire claims process, some wait too long to appeal, and others give up completely. For those who seek legal representation from a Social Security Disability lawyer and continue to pursue their claims in a timely manner, a large percentage is ultimately approved.
The Appeals Process When SSD Claims Are Denied
Understanding and preparing for the appeals process when a disability claim is denied is crucial. There are four levels of appeal: reconsideration, ALJ hearing, SSA Appeals Council review and federal court review. Many people must go through at least the first two levels before receiving a favorable decision.
- Reconsideration: During reconsideration, a new claims examiner reviews the existing claim and makes a new decision. When requesting reconsideration, applicants can submit any new medical evidence that may impact the claims examiner’s decision. However, applicants can do little else to prepare for reconsideration. Many claims are denied at this level because the primary facts in the case have typically not changed.
- ALJ Hearing: During the next level of appeal, an administrative law judge holds a formal hearing to further evaluate the case. After questioning the claimant and a vocational expert, the judge makes a new determination based on his or her findings. The hearing is independent from the previous decision the claims examiner made, therefore applicants may benefit from spending more time preparing for this stage of appeal.
Fortunately, there is typically plenty of time for a claimant and a social security disability lawyer to prepare for an ALJ Hearing. Although the hearing level has the highest rate of success in the approval process for disability claims, it is also generally the most lengthy of all phases. Nationally, the average wait time for a hearing is about 18 months. In Illinois, claimants often wait approximately 16 months in Chicago and longer in other areas of the state. Since about 45 percent of cases are approved at the ALJ hearing level in Illinois, however, it is typically worth the wait.
A disability attorney is more likely to be familiar with the vocational and medical guidelines used by the SSA and therefore can often prepare a case, cross-examine expert witnesses and ultimately present the facts in the most effective manner at the hearing level.
- Appeals Council Review: During this stage of the appeals process, the Appeals Council can either refuse to review a claim, refer the case back to the judge who initially handled the case for review, or award SSD benefits. In most cases, unless a claimant’s condition has worsened, the judge made a gross error in his or her previous decision, or additional evidence can be provided that was not considered at the ALJ hearing, the chances of approval for benefits are slim. In fact, many people file an entirely new disability claim while waiting for the decision.
- Federal District Court Review: If all other paths are unsuccessful, disabled claimants can pursue their benefits in federal court. This is a civil action that is typically initiated by the applicant’s Social Security disability attorney, and is the final step in the appeals process. Although awards are unlikely at this level of appeal, some disabled victims have benefitted from pursuing their claims in federal court.
If, after completing the appeals process, a claimant is still denied benefits, he or she may be able to start a new disability claim and begin the process over again.
Preparing for the ALJ Hearing
Although the Reconsideration and the Appeals Council Review levels of the appeals process require little preparation on the part of the claimant and his or her disability attorney, and a Federal District Court Review is fairly uncommon, the more common ALJ Hearing is more complicated and often requires significant preparation. Factors Social Security disability lawyers and their clients often consider include:
Before the hearing, applicants should review the medical documentation in the SSA’s case file. Doing this offers several benefits:
- Applicants can check for missing or inaccurate information that may have negatively affected the initial claim decision. Applicants can then secure relevant documentation to remedy any issues.
- Applicants can see when the collected medical records leave off. After a claim is denied, the SSA usually stops gathering medical evidence. Given the typical delay between claim denial and the hearing, several months of records may be missing. This can be problematic since an administrative law judge cannot make a decision without current medical information.
- Applicants can request missing or updated medical records and submit them to the Office of Disability Adjudication and Review. Applicants may also want to keep a personal copy to help prepare for the hearing.
Applicants should also seek out secondary documentation to support objective medical evidence. Statements from medical professionals and personal sources can help establish the severity and impacts of the disabling condition.
Any statements from physicians should be detailed and descriptive. A doctor may write a letter or use a Residual Functional Capacity (RFC) form to describe the applicant’s functional limitations. The RFC form specifically asks for information about the applicant’s ability to do necessary work-related activities. These include sitting, standing, lifting weight and carefully handling objects.
Personal sources, such as co-workers, relatives or personal acquaintances, can also provide supporting statements. These statements carry less weight than medical evidence or a professional medical opinion. However, the SSA recognizes that personal sources may offer unique insights into an applicant’s daily symptoms and limitations. As a Chicago injury attorney can attest, this documentation can add valuable support to a claim.
Besides gathering medical evidence and supporting statements, applicants should be prepared for the hearing itself. During the hearing, an administrative law judge asks detailed questions about the disabling condition. Applicants should be ready to provide descriptive answers, since vague answers may undermine credibility.
Applicants should be able to describe the location, intensity, and frequency of symptoms, along with any precipitating factors. They should be prepared to talk about the specific functional impacts the disabling condition causes including activities they can no longer perform independently or activities that require special accommodations.
Claimants should be as accurate as possible when describing their conditions. Understatement or over-exaggeration can substantially hurt a claim. Considering likely questions and answers before the hearing is the best way for applicants to be ready with credible answers.
An applicant’s ability to work gainfully is another crucial focus during the disability hearing. The administrative law judge closely reviews the applicant’s work history to determine whether he or she is able to resume past work. Previous work also serves as an indication of the applicant’s work-related skills.
Applicants should be ready to discuss prior jobs in detail. Aside from the job title and duties, applicants must describe relevant training, typical hours and use of special equipment. Unique duties, such as supervising others or interacting with the public, are also considered relevant. If any past jobs and related duties are represented inaccurately during the hearing, applicants should correct the misunderstanding.
An administrative law judge can only consider “past relevant work” when making a disability determination. Any work the applicant performed over 15 years ago is not relevant. Part-time or short duration work is typically not given weight. A failed work attempt or a job that ended before the applicant mastered it is not material either. Applicants should inform the judge if they believe work has been classified as past relevant work in error.
Based on work history and the claimant’s current abilities, a vocational expert testifies whether the applicant could reasonably pursue new work. The testimony of the vocational expert typically holds a lot of weight in a judge’s decision.
Many disability applicants benefit from working with an attorney when appealing denied claims. A Chicago disability attorney can provide advice on properly documenting the claim and preparing for the hearing. An attorney can also assist during the hearing by correcting errors that might otherwise lead to an unfavorable decision.