Social Security Disability Claims
Everyone knows that Social Security benefits are available to retired workers. But did you know that a client might qualify for Social Security payments before reaching retirement age? A client who is disabled and unable to work may be eligible to receive Social Security benefits. There are two separate programs that pay disabled persons—Social Security Disability and Supplemental Security Income (SSI).
To qualify for Social Security Disability benefits, the client must work a minimum number of quarters (three months) and earn at least $500 each quarter. If this minimum is met, the Social Security Administration (SSA) applies a five-part analysis to determine eligibility for benefits. The criteria for receiving SSI benefits are basically the same, except that a person with no work history may qualify to receive SSI benefits. The five-part analysis is as follows.
Is the client working? If so, even part-time, no benefits are payable. As a general rule, a person must be out of work to receive benefits.
Does the client have a severe medical impairment? A severe medical impairment is one that significantly limits a person’s physical or mental abilities to perform basic work activities. The impairment must be one that has lasted a minimum of twelve consecutive months or that will result in death.
Physical limitations include limitations on standing, walking, sitting, pushing, pulling, lifting, bending, carrying, reaching, or handling and the ability to see, hear, and speak. Mental limitations involve attention and concentration and the ability to understand and follow instructions, deal with the public, handle work stresses, etc.
All records, reports, and test results from treating doctors and hospitals must be documented, demonstrating all physical and mental problems.
Does the medical problem meet or equal the listing of impairments maintained by the SSA? The SSA publishes a 70-page document identifying impairments by which it measures the severity of an impairment to determine if the client will receive benefits. This determination is made without consideration of work history, skills, education, or age. This evaluation is based on the medical evidence available. If an impairment does not fit within the listing, the SSA goes on to Step 4.
Does the medical impairment prevent the client from returning to past relevant work? This refers to the job or jobs held within the 15 years prior to the date of application. The SSA will consider the client’s physical and mental limitations along with job requirements of every position held within the past fifteen years. If the SSA concludes that the client cannot perform past relevant work, it must proceed to Step 5.
Does the medical impairment prevent the client from performing other work that exists in the national economy? The SSA is required to consider factors such as age, education, and work experience along with the client’s physical and mental limitations. The SSA also takes into account residual functioning capacity. This involves evaluating ability to sit, stand, walk, lift, carry, bend, push, pull, climb, and do other physical activities. The SSA does not have to establish that the client could actually receive a job offer, nor does it refer the client to a specific job. The SSA is only required to determine if the client is capable of performing other work.
Based on this evaluation, the SSA will determine whether your client can perform a job ranging from sedentary to heavy work. The SSA also takes into account whether skills learned in prior jobs can be transferred to any other job.
Alan is 52 years old, has a 12th grade education, and worked as a truck driver for 20 years in a job classified as medium work (one that routinely requires lifting of up to 50 pounds). Alan suffers from a chronic sprain of the lower back that keeps him from lifting more than 10 pounds and from standing and walking for more than a few minutes at a time. His doctor clears him to perform sedentary work (mostly sitting). Under SSA regulations, Alan would still qualify to receive disability benefits.
Why? Even though Alan can still perform a sit-down job, his age (over 50) is a factor that would make it difficult for him to find and maintain a job. If he were 42 years old, with all other factors identical, his benefits would be denied.
NOTE: With private disability insurance, you are required only to show you are unable to return to your former work.
Applying for Benefits
The first step in applying for benefits is to visit a local SSA office and complete an application. You can locate the address by checking the government section of your telephone directory, calling 800-772-1213, or accessing their website, www.ssa.gov. If you call, be patient. You could be in for a long wait.
When visiting the SSA office, applicants are required to complete a lot of paperwork. They will be asked to describe in detail the physical requirements of each job they have held (standing, walking, lifting, etc.) and their medical history. It is critical that the SSA has a complete list of the applicant’s medical providers. Instruct your clients to keep a record of the names and addresses of the doctors and hospitals where they received treatment. They should bring this with them when visiting the SSA office.
The SSA sends the paperwork to a designated state agency that assigns someone to obtain and review the medical evidence. Within three months, the SSA will send a written decision granting or denying benefits. According to figures provided by the SSA, in fiscal year 1993, roughly 61% of all initial applicants were denied. Ten years later, about 60% of all initial applicants were still being declined.
NOTE: Social Security disability law and the criteria for receiving benefits are separate from and not related to the Americans with Disabilities Act.
Applying for Reconsideration
If the application is denied, the next step is to ask for reconsideration. The local office has the forms. The client must request reconsideration within 60 days after receiving the written notice of denial. Failure to meet this deadline will require the client to start all over again. A majority of the requests for reconsideration are denied.
Requesting a Hearing
If reconsideration is denied, the applicant can request a hearing before an administrative law judge (ALJ). This request must be filed within 60 days after receiving the written notice of reconsideration. The local office has these forms (as do most attorneys who handle disability and SSI cases).
The chance of receiving benefits improves greatly once an ALJ hearing is held. According to SSA figures, ALJs granted benefits in 68% of the claims they heard in fiscal year 1993. Ten years later, almost two-thirds of appellants who were initially denied were ultimately granted benefits. The disparity between the high percentage of initial denials and the high percentage of ultimate success suggests that the system needs to be changed. When it comes to Social Security disability claims, persistence pays off.
At a hearing, applicants have the opportunity to tell the ALJ their story and to present evidence in their favor. ALJs are independent hearing officers with greater knowledge of applicable law and medical terms than the reviewers who decide initial applications and reconsideration.
Disability hearings are informal, fact-finding procedures. You and your client appear before the ALJ to present the evidence. A hearing officer attends and records the hearing and handles the file. Occasionally, medical and vocational experts offer testimony about the case.
Your client’s testimony will cover age, education, vocational training, work record, and physical and/or psychological disability. Before rendering a decision, the ALJ considers this testimony along with the medical records, expert testimony, and your legal arguments. You can expect to receive a written copy of that decision within 90 days of the hearing. If you win, your client should anticipate waiting an additional two to three months before receiving the first check.
Appealing an Unfavorable ALJ Decision
If you have a hearing and the ALJ rejects the claim, you have the right to request review by the Appeals Council 60 sixty days. The Appeals Council is composed of various ALJs who review the evidence and decide whether to uphold or reverse the decision, or to send the case to another ALJ for a new hearing.
If the Appeals Council rejects your appeal, you have the right to file a lawsuit in your local federal district court, where you can ask the court to reverse the SSA, granting benefits or a new hearing. This must be done within 60 days of the Appeals Council’s decision. You may be able to request an extension if you have good cause, but it is best to file within 60 days.
At each stage of the process, clients are entitled to legal representation. Federal regulations limit attorney’s fees to 25% of the benefits obtained for the client. Social Security disability litigation is a specialty unto itself. Procedurally, this area of litigation is very different from car accidents, slip and falls, and other kinds of personal injury litigation.
Persistence and a good deal of patience usually pay when dealing with the SSA.