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.
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