Over 70% of initial disability claims are denied.
For a process intended to be non-adversarial it can seem the claimant is up against a system designed to scare people off or prevent them from filing in the first place. Considering all my cases past and present I cannot easily sum up all the reasons for so many claims denials. But in retrospect and in dealing with current cases I have identified some common issues claimants face in the process. I will not deny at times it would seem that the Social Security Administration (SSA) has a policy of denying as many initial claims as possible. I cannot deny that my experience dealing with some SSA representatives a person can be made to feel the system is rigged against her. Overall though, this is not the case. While there is no way to completely avoid less-than-fair case outcomes there are ways a claimant can minimize problems in the process. Following are some reasons a case gets denied and how these issues can be helped.
The unrepresented or poorly represented claimant.
Claimants that are represented by a qualified representative have an increased change of getting their claims approved. It is important the claimant choose the right person and/or firm to represent him and I will address this in more detail in a later blog. If a claimant chooses to go the process alone, he must be proactive and willing to do a lot of legwork on his own.
A qualified disability advocate is anyone (attorney or non-attorney) that has knowledge of the administrative law process; especially that of Social Security Disability. The best advocate is someone who has a legal education and/or specific training and passion for representing claimants of disability. A qualified disability advocate can charge a fee for services and receive direct payment for those fees. Such an advocate must either be an attorney or have met specific criteria set forth by SSA. A lousy advocate, even if technically qualified can actually hinder the outcome of the claim. A lousy advocate can be both an attorney or a non attorney. When a claimant is not represented or poorly represented the disability process can go unchecked:
- Important forms are not completed and/or received by SSA. This could be due to SSA not having the most updated address for the claimant. Or perhaps the claimant is unable to complete the forms on her own due to being in the hospital, illiterate, or otherwise unable to complete the forms on her own.
- The claimant does not attend medical exams arranged by SSA.
- Medical records are not obtained by SSA. This can be due to having the wrong doctor or treatment date information on file.
- The claims adjudicator and claimant do not have contact to discuss the development of the claim file.
Like most workers in today’s world, SSA claims adjudicators have heavy case loads and limited resources to get work done. This has not prevented most claims adjudicators I have encountered from being compassionate and detail oriented professionals that will do what it takes to get the job done right. This is not the case with everyone in a decision-making position regarding claims at SSA. If a claimant is unrepresented or represented by an absent advocate it can result in the claims adjudicator making less effort to dot all i’s and cross all t’s. A good advocate will make sure the claimant completes and returns forms and that SSA receives the forms. A good advocate will also make sure that the claims file is well-developed and that medical information is correct and assist in getting medical records on file if necessary. The advocate will communicate with SSA and the client to ensure the integrity of the process and prevent or address issues, promptly. Being well represented a claimant stands a better chance of getting approved.
The ‘weak case’.
Some of those 70% of case denials are a result of cases that should be denied. This may sound a bit harsh but there are many claimants that file a claim for disability who are not disabled and should not be found disabled per the SSDI/SSI rules.If you have read my earlier blogs or others similar to mine you are already aware that SSA looks at whether a person can perform ANY substantial work on a sustained basis. SSA does not have to be concerned with where a person lives and the state of the job market. SSA does not have to be concerned with the fact that a person may no longer be able to earn the kind of money he used to before he developed serious health problems. SSA does not have to be concerned with the fact a person cannot drive herself to work.
SSA has an outdated method of determining what work is available in the national economy. For the most part common sense can be applied and often is when considering if a person can perform substantial work of any kind and if a substantial number of such jobs exist in the US. SSA considers a person’s past jobs and skills that could transfer into other types of work if he can no longer do the work he used to.
A case can be weak due to no medical evidence to support the allegations. If there is insufficient evidence in the file then SSA is supposed to arrange at least one medical exam to address the claimant’s conditions and how they affect her ability to work. These exams are often very short and sometimes not sufficient to fully evaluate the claimant’s impairments and how they affect her ability to work. There are problems with some of the physicians that examine SSA claimants. Many operate with the highest standards in medical practice and honest reporting to SSA. There are some that do not. I have seen reports that could only be pure fiction citing no serious medical problems when the average layperson could see the claimant suffers from severe physical impairments. This may be that the physician did not have the right methods or specialty to observe the claimant properly. Unfortunately there is always the physician who will state in a report what she thinks SSA wants to hear by falsely downplaying symptoms and exaggerating physical or mental capabilities. These bad reports are used by some adjudicators and judges to deny claims even in the face of other supporting evidence. This is not right but it happens and is a good reason for an appeal.
A difficult jurisdiction.
There are far too many speculations on why in one region of the country a claimant has a better chance of getting approved than in others. There is more speculation as to why one judge would approve a case and another would not. We want the judges to have broad discretion because disability cases are very sensitive and personal to the claimant. The problem lies in where there is a major discrepancy in the approval rate of one judge to another or one region to another. For example, compare two judges in the same hearing office. One approves 40% of his cases while the other approves only 20%. A good advocate will approach a case with these facts in mind, but these issues unfortunately add to the high number of denials.
Claimant ineligible to receive benefits despite having severe medical impairments.
A person may not have earned enough work credits with SSA to receive SSDI benefits or he may be past the date where his eligibility for SSDI expired. If the same person is not eligible for SSI then despite his having a strong medical claim, SSA cannot provide him with any benefit program that he would be eligible for.
Current state of affairs.
According to my colleagues with experience in disability going back to the 80s and 90s; it was much easier to get a claim approved years ago, than it is today. One reason is the current economic downturn. Before the latest bust, employers could afford a large workforce that included challenged workers. When cuts had to be made these workers were among the first to go. Unfortunately many of these workers were older, aged 50 or more and experience extreme difficulty finding other work they can perform with their physical limitations and employers willing to work around them. This has resulted in a higher number of people applying for disability benefits.
Some large disability firms have a policy of taking in as many cases as possible despite the merits of the individual cases. These cases are piled onto a system that is already backlogged frustrating the process and hindering it for those whose cases do have merit. Many of those cases will be denied as they should be.
Humans being humans.
No one person is perfect and this includes SSA employees. Mistakes can be made such as not processing documents properly or not considering medical evidence properly per the very complex rules set forth by SSA. There is always the person who has a bad day. There are adjudicators, claims managers, and judges that unfairly deny a deserving client her benefits. All of these situations contribute to that unsightly 70% of denied claims.
In no way is this an exhaustive list of the reasons disability cases are denied. These are the situations I and many of my colleagues in the practice experience as a general rule and can be overcome most of the time.
Feel free to comment or message me with your thoughts or questions!
Up next: Having Appropriate Treatment for Your Medical Conditions is Crucial for Your Case!
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