Will You Receive Disability Benefits If You have an “Open and Shut” Case?

Most people who file for Social Security disability benefits are in for a fight, even if it seems to them that they have an “open and shut” case. It’s important for those filing for SSD/SSI to realize that there is no medical condition in and of itself that qualifies one for disability (though there are certain conditions that may qualify for expedited processing).

Disability decisions are based on two things:
1) The existence of a severe, ongoing mental or physical impairment, and
2) an inability to earn living as a result of this impairment (which, for the social security administration, equates to the inability to work and earn at least the monthly SGA, or substantial gainful activity, amount that is in effect for the current year).

Proving the existence of a severe medical impairment can be difficult, particularly if the claimant hasn’t recently sought medical treatment for the condition, a situation that can easily come to pass, of course, if the individual no longer has health insurance.

The general rule of thumb is that if the claimant hasn’t seen a physician in the 90 days prior to the evaluation of the disability claim, a disability examiner will schedule the individual for a consultative medical exam (CE).

CEs are performed by doctors who are in private practice (not Social Security employees) and who are paid by Social Security to perform medical examinations and mental examinations and mental testing. CEs can be very brief (physical CEs probably last an average of only 20 minutes), and are intended to provide only a snapshot of the claimant’s current state of health.

There are really no substitutes for solid medical records from a treating physician documenting the date of onset (when symptoms began), how the impairment has developed over time, a prognosis, and, especially, some indications of how the claimant’s condition has reduced their functional ability to engage in normal activities of daily living. However, when this information does not exist for whatever reason, a claimant will likely be required to go to a consultative exam.

Are the results of a CE a good substitute for records from a treating physician, particularly a medical source statement from a treating physician that succinctly explains that the claimant’s remaining functional capacity does not allow a return to work activity? Of course not. And as a disability examiner, I found few examples of cases that were approved solely on the strength of a consultative examination report.

Medical record documentation from a physician who has an established history with a claimant and who continues to provide medical or mental treatment will always be the bedrock on which social security disability and SSI disability cases are decided.

Yet, just the same, even those who have copious medical records in support of their disability claim, and even physician statements, sometimes get turned down for disability. About 70 percent of all disability applications filed each year are denied, and first appeals are even less likely to succeed. Does this mean that the majority of people who file for benefits are not really impaired in some way? Hardly.

Statistics also show that most people who request a second appeal, a hearing before an administrative law judge (ALJ), go on to win benefits. This fact alone strongly throws doubt on the ability of the federal disability system to make accurate decisions at the initial claim and reconsideration appeal levels that occur right before the disability hearing level.

Of course, it can take years to work through the entire disability process from initial application, to reconsideration appeal, to the disability hearing.

Some would argue that’s the idea: wear people down over time so that they just give up and go away. However, those who stay the course and go through with the disability hearing win their cases more often than not, and these individuals are usually rewarded with considerable back pay in addition to monthly benefits. However, by that time the financial and emotional toll is considerable.

The lesson in all this? If you are disabled and unable to work, do not assume that your case will be “open and shut.” When it comes to winning SSD/SSI, there’s no such thing. Instead, begin documenting your medical treatment as soon as you begin to experience difficulty working.

And, if your application for disability is denied (and most are) do not give up. The chances of being approved for disability go up at each level of appeal, particularly at the administrative law judge hearing level.

Tim Moore is a former disability examiner and the creator of Social Security Disability Secrets. He currently writes at My Disability Blog

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Tips for When Your Spouse is Chronically Ill

My husband has Psoriatic Arthritis. This invisible illness is quite a challenge for us. Here are some ideas that may help you if your spouse has a chronic invisible illness.

1. Make sure you have a support system. For me, this is my family and a few close friends. You may want to utilize a Sunday School teacher, a counselor, or a support group for caregivers. Check out Rest Ministries Hope Keepers.

2. Take care of yourself. Exercise, eat right, have a hobby. The healthier you are spiritually, mentally, and physically, the better you will be able to help your spouse.

3. Educate yourself. Read everything the doctors gives you. Do research on the internet. Read up on your health insurance. Get to know your pharmacist and ask them questions about your spouse’s meds. Knowledge is power.

4. Remember it is okay to be sad. It is perfectly alright to feel upset about your situation sometimes. We are to weep with those who weep.

5. With chronic illness, you and your spouse may need to get professional counseling to help you cope. Check out the Minirth Clinic or New Life Live for recommendations for Christian counselors.

6. Figure out what you CAN do. Maybe you and your spouse will never be able to go dancing again, but you could go to a concert. Maybe you’re like us, and you can’t go to the movies, but you can watch Netflix! Get a movie size candy from the grocery store and a bottle of Diet Coke. Make it fun.

7. Research alternative medicine, such as chiropractic care, massage therapy, diet and supplements. Even if there isn’t a cure for your spouse’s invisible illness, perhaps they can get some temporary relief from Epsom salts in a hot bath.

8. Talk to your spouse. Ask them what they’re thinking. Find out what their concerns are. Ask them how you can help. And a few weeks later, ask again. I’m always surprised at how my husband can change his mind about things from month to month.

9. Get life insurance. Who would care for your spouse if something were to happen to you?

10. Maybe your spouse can’t do everything they used to. But maybe they don’t mind if you still engage in those activities. Your spouse might love to take a nap while you’re wakeboarding.

National Invisible Chronic Illness Awareness week is a wonderful way to educate family and friends about the struggles people with invisible chronic illnesses face.

A Young Wife has been married for three years. She and her husband have a dog named Henry that they spoil rotten. A Young Wife is a housewife that loves Diet Coke and dessert. Eighteen months ago, her husband was diagnosed with Psoriatic Arthritis. This debilitating invisible chronic illness is quite a struggle for them. Visit her blog here!

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