Social Security Disability Insurance (SSDI) benefits are designed to help people too ill or who are disabled to pay their medical costs and other expenses. The Social Security Administration (SSA) will consider your application for disability if:
If you have a short-term condition that will not last for 12 months or longer, you will not qualify as disabled. This is true even if you cannot work due to your medical impairment. Applicants must show that their disability prevents them from doing any work, not just the job they held most recently.
Being approved is not an easy task. Applicants undergo a stringent review process that ends in rejection more often than not. In Pennsylvania, the rejection rate is between 63 and 69 percent, close to the national average.
It is essential to understand why your claim was denied. Rejections generally fall into two categories: technical denials and medical denials, which are the most common. Technical denial reasons could include earning too much money, missing a deadline, or incomplete or missing information on the application. Medical denials occur when your disability does not qualify under the SSA’s severity standard or does not meet the 12-month duration requirement.
Often, applicants simply lack sufficient medical proof that their condition impairs their ability to work. Their medical records must meet SSA’s criteria for the condition and demonstrate that they cannot perform required work-related tasks.
The applicant must also complete any treatments or therapies recommended by their treating physicians. Failure to comply with medical treatments and recommendations will significantly increase the chance of claim denial. The SSA needs to determine if your condition is treatable to assess if you could work. If you do not comply with treatments ordered by your doctor, the SSA will be unable to evaluate whether your condition could improve and will deny your claim.
Cooperation is another crucial factor during the application process. If you are not cooperative, miss deadlines, or fail to provide needed information, your claim will probably be denied. This includes keeping scheduled medical appointments and appointments with the SSA.
Other reasons for denial include:
If SSA rejects your claim, they will send you a written notification that explains their decision. If you disagree, there are options.
An SSDI denial is not necessarily final. Some people may think their best option is to file a new claim without the errors or omissions on their previous claim. This is not usually not true. Appealing the denial shows that you provide new evidence and are willing to put forth an effort for approval. If you file a new claim, the SSA may deny it simply because they denied the first application.
A good place to start an SSDI appeal is with a lawyer to help guide you through the process.
The appeals process has several steps that you may or may not have to go through, depending on the outcome at each stage. Your lawyer can guide you through this process and the deadlines.
This first step is filing a request for reconsideration of the original denial. The reconsideration review is conducted through Disability Determination Services (DDS) and performed by an examiner and medical consultant who were not involved in the original decision.
If your claim is denied at the reconsideration level, you will receive a notice of denial that explains why the claim was denied. The next step is requesting a hearing in front of an administrative law judge (ALJ).
Within 60 days of the reconsideration denial, you need to request a hearing with an ALJ. ALJs are lawyers who work with the SSA’s Office of Hearing Operations (OHO). Most of their work involves reviewing decisions to deny initial claims or terminate disability benefits. Claims will be approved at this stage about 50 percent of the time. Your lawyer will collect evidence and build your case to present to the judges.
If you lose your appeal before the ALJs, you can request the Appeals Council reviews your claim. The Appeals Council will randomly select cases for review and has complete discretion to deny, grant, or dismiss a request for review.
For an appeal to go before the Appeals Council, there must have been some abuse of discretion by an ALJ, such as a hearing that was wrongly shortened or an error of law or procedure. Also, if an ALJ’s decision is not supported by substantial evidence, an Appeals Council should review the decision.
As a matter of procedure, the Appeals Council will be looking for a flaw in the ALJ’s decision before granting a review of your case. The odds of success at the Appeals Council level are very slim. Only about one percent of denials are reviewed and overturned. Approximately 10 percent are sent back to the ALJ with instructions to look at the claim again. You should request an Appeals Council review without a knowledgeable lawyer advocating for you.
If the Appeals Council does not overturn the denial and you want to continue fighting to have your claim approved, you can file a lawsuit in U.S. District Court with the help of a lawyer.
A federal judge will hear your disability case without a jury. The judge is supposed to review the case to determine if any legal errors occurred. Some judges will consider questions of fact as well. A federal judge will not reverse an ALJ or Appeal Council decision in most cases. A federal judge may remand, or send back, the disability case, instructing the SSA to reconsider the treating physician’s medical opinion or the claimant’s symptoms. A successful outcome is possible, but bringing a federal lawsuit is time-consuming and expensive.
Once the SSA approves your SSDI application and calculates your monthly benefit, you may be entitled to back pay. The amount depends on the date you applied for benefits and when your disability began.
One of our Philadelphia Social Security Disability lawyers at Galfand Berger LLP can help with the appeals process if your claim has been unjustly denied. Call us at 800-222-USWA (8792) or contact us online to schedule a free consultation. From our offices in Philadelphia, Bethlehem, Lancaster, and Reading, Pennsylvania, we proudly serve clients throughout Pennsylvania and New Jersey, including Allentown and Harrisburg.