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Common Reasons Why SSDI Applications Are Denied The First Time

By   /  October 24, 2016  /  4 Comments

Strengthen your disability benefits claim. Learn the most common reasons why most applicants for Social Security Disability are denied the first time they file.

common-ssd-denial-reasonsThere are medical and non-medical reasons why your application may be denied.

Non-medical reasons for a denial.
You may be disabled, but if your SSD application is incomplete or includes incorrect information, your application will be denied for non-medical reasons without further evaluation or even an explanation.  Here’s what to look for:

  1. To be eligible for SSD, you must meet two different earnings tests:

> A “recent work” test based on your age at the time you became disabled. (This test does not apply to certain blind workers.) Here, summarized, are several general examples:

  • If disability began before age 24, you’ll need to have worked 1.5 years during the previous 3 years.
  • If it began after 24 but before 31, you’ll need to have worked half the time after age 21 until disabled.
  • If it began after 31, you’ll need to have worked 5 of the 10 years just prior to becoming disabled.

> A “duration of work” test to show you worked long enough under Social Security, and therefore paid into the system via payroll deductions (FICA) or self-employment tax. You can consider these payments “premiums,” since—unlike SSI—SSD is actually an insurance program. Like any other insurance, you’re not eligible to receive any benefits unless you’ve paid the required premiums.

Here are a few examples of how much work, under Social Security, you need to meet the test:

If disability began…You generally need…                              

  • Before age 28  –  1.5 years of work
  • Before age 30  –  2 years of work
  • Before age 38  –  4 years of work
  • Before age 42  –  5 years of work
  • Before age 50  –  7 years of work
  • Before age 54  –  8 years of work
  • Before age 58  –  9 years of work
  • Before age 60  –  9.5 years of work
  1. You didn’t provide all the required documents and/or other information. The Application for Social Security Disability and the Adult Disability Report you are required to submit must provide enough information for the SSA and your state’s Disability Determination Services (DDS) to make a sound decision in regard to your eligibility for SSD benefits. The information needed includes the following:
  • Social Security number (SSN)
  • Copy of your birth certificate or baptismal certificate
  • Names, addresses and phone numbers of the doctors, caseworkers, hospitals and clinics that took care of you—in regard to your disability—and the dates of your visits
  • Names and dosage of all the medicines you take
  • Laboratory and test results regarding your disability
  • Medical records from your doctors, therapists, hospitals, clinics and caseworkers you have on hand
  • Summary of where you worked and the kind(s) of work you did
  • Copy of your most recent IRS W-2 Form or, if self-employed, of federal tax return for the past year
  • Form giving the SSA permission to obtain details about your condition

If it’s difficult for you to obtain any of this information, the SSA may be able to help you get it.

  1. Your earnings record shows income (Substantial Gainful Activity) higher than the allowed limit for workers receiving SSD, so the SSA doesn’t consider your disability severe enough to affect earnings.

In 2017, if you’re not blind, the monthly limit is $1,170; if you’re blind, it’s $1,950. However, you may have unlimited earnings during a trial period of up to nine months (not necessarily in a row) and still receive SSD benefits of $840/month, blind or not. The limits are subject to change each year.

  1. There were problems with your Application. You didn’t answer all the questions or answer them fully. Maybe it was impossible to read your writing…or there were other problems relating to the paperwork you submitted.

Perhaps English is not your native language, and you found it difficult to handle the paperwork. If so, a Spanish-language version is available, as are interpreters for over a dozen languages. Just ask the SSA. Or consider having a law firm experienced in SSD and SSI applications and appeals handle the process for you.

Typical Medical Reasons for SSD Denial

You may not be able to work at this time, and your doctor may not be sure when you will be able to return to work, but the SSA has its own criteria for awarding benefits. Medically speaking, you may have been denied for the following reasons.

  1. Your disability is/was temporary or short-term. As noted above, your disabling physical or medical condition must have lasted, or be expected to last, at least 12 months, or be expected to result in death.
  2. Your disability is not considered severe enough to qualify for SSD benefits, because:
  • If you’re able to work and earn more than the specified limit, the SSA assumes that your disability isn’t too severe. (The objective is to help people who are too disabled to earn a sufficient income.)
  • Your state’s Disability Determination Services decided that your condition did not significantly limit your ability to do basic work activities—walking, sitting, remembering, etc.—for at least one year.
  • Your medical condition is not on the SSA’s List of Impairments—conditions considered so severe that they automatically mean you are disabled as defined by law. Nor is your medical condition (or combination of conditions) considered to be as severe as a condition that is on the list.
  • The DDS decided your condition does not prevent you from doing the kind of work you did before.
  • The DDS also decided—based on your age, education, work experience, skills, etc.—that your medical condition does not prevent you from doing some other kinds of work.
  • If you claimed blindness, your condition did not meet the SSA’s definition: your vision can’t be corrected to better than 20/200 in your better eye or your visual field is 20 degrees or less in that eye.
  1. You did not provide sufficient medical evidence describing your impairment and/or its severity. Documentation must come from “acceptable” medical professionals (physicians, psychologists, etc.) Those who treated you or evaluated you in regard to your disability must have credentials. They can greatly reduce or eliminate the need for additional medical evidence to complete your claim.
  2. Additional medical reports are requested, such as: Clinical and/or laboratory findings • Diagnosis of particular physical or medical conditions • Treatment prescribed—with response and prognosis.
  3. Work-related medical reports are requested, regarding what you can still do despite impairment(s): Ability to sit, stand, walk, lift, carry, hear, speak, handle objects, travel, etc.
  • A statement — if 18 or older and claiming mental functional limitations — that describe your capacity to understand, remember and carry out instructions, respond appropriately to supervision, etc. OR…
  • A statement — if applicant is under 18 — describing his or her functional limitations, compared to children that age without impairments, in acquiring and using information, attending to and completing tasks, interacting with others, moving about, manipulating objects, caring for himself/herself, etc.
  1. Further evidence of disability — a special examination or medical test — is needed by the DDS.
  2. Information is requested from others: public and private agencies, schools, parents, care-givers, social workers, employers, or other practitioners (naturopaths, chiropractors, audiologists, etc.).
  3. Additional information or consultative examinations are requested.

If the evidence provided by your own medical sources is inadequate to determine if you meet the SSA’s strict definition of disabled, further proof may be sought by re-contacting the treating source for more information or clarification, or by arranging for a consultative examination (CE).

The treating source is the preferred source for a CE—if qualified, equipped, and willing to perform the examination for the authorized fee. Even if only a supplemental test is required, the treating source is ordinarily the preferred source for this service. However, SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:

  • The treating source prefers not to perform the examination.
  • The treating source does not have the equipment to provide the specific data needed.
  • There are conflicts or inconsistencies in the file that can’t be resolved by going back to the treating source.
  • You prefer another source and have good reason for doing so.

OR

  • The SSA knows from experience that the treating source may not be productive.

What a Consultative Examination report shows:
A complete CE report involves all the elements of a standard examination in the applicable medical specialty. It typically includes the following:

  • The claimant’s major or chief complaint(s).
  • A detailed description, as per the examiner’s specialty, of the history of the major complaint(s).
  • A description, and disposition, of pertinent “positive” and “negative” detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing.
  • Results of laboratory and other tests (e.g., x-rays) performed according to the requirements stated in the SSA’s Listing of Impairments.
  • A diagnosis and prognosis regarding the claimant’s impairment(s).
  • A statement regarding what kind of activities the claimant can still do, despite his or her impairment(s), unless the claim is based on statutory blindness.

> If the claimant is age 18 or over, it should describe—in the consultant’s opinion— the claimant’s ability, despite the impairment(s), to do work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.

> If the claimant is under 18, it should describe—in the consultant’s opinion—the   child’s functional limitations compared to children of the same age who do not have impairments in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about, manipulating objects, caring for himself/herself, and health and physical well-being.

  • A statement, in adult cases of mental impairment(s) or mental functional limitations, that also describes—in the consultant’s opinion—the claimant’s capacity to understand, carry out and remember instructions, and to respond appropriately to supervision, co-workers, and work pressures in a work setting.
  • The consultant’s explanation, comments and conclusions regarding the claimant’s major complaint(s) and any other abnormalities found via the history and examination, or reported from the laboratory tests.

What symptom-related evidence shows:
The SSA investigates all evidence presented that pertains to the effects of symptoms—such as pain, shortness of breath, or fatigue—on a claimant’s ability to function. This include information provided by the treating sources and other sources regarding:

  • The claimant’s daily activities.
  • The location, duration, frequency, and intensity of the pain or other symptoms.
  • Factors that precipitate or aggravate the symptoms.
  • The type, dosage, effectiveness, and side effects of any medication taken.
  • Treatments, other than medications, for the relief of pain or other symptoms.
  • Any other measures the claimant has used to relieve pain or other symptoms.
  • Other factors re: the claimant’s functional limitations due to pain or other symptoms.

Once the existence of your impairment is fully established, the evidence assessing its severity is considered.  The SSA may review your records in later years to see if you continue to meet their disability criteria.

Common Reasons Why SSDI Applications Are Denied The First Time
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  • Published: 2 months ago on October 24, 2016
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  • Last Modified: December 5, 2016 @ 8:10 pm
  • Filed Under: Claims Process

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  • greg

    dds came to a decision Dec 1st 2016. I am 58 years old with a work history of heavy construction. I also have extensive medical records that are ongoing. on my 5th spinal epidural and on heavy pain meds. One of my doctors is sure spinal surgery is in my future. DDS lady said it could be a couple of weeks if sent to quality control. then it would go to my local field office and they would send the decision letter.
    Sure wish my attorney would have told me to get my own RFC.
    Q. How long should the letter take.
    Q how can I replace this attorney.
    Q will ssdi give me a copy of my records if I ask for them.

    • Kay Derochie

      Dear Greg,

      If the claim is randomly selected for a quality assurance review, it will likely take two to four weeks for the medical decision to be finalized. I suggest that you hold off on replacing your attorney because you might be approved and there would be no need. If you are denied, check your written agreement with your attorney; it should tell you how to terminate the contract. If it is not clear, ask Social Security for the necessary action to follow. Then officially appoint a new attorney when you appeal. If you are denied, you can get a copy of your full claim file by asking Social Security for a copy. That will allow you to see the exact reasons for the denial and the evidence on which the decision was based so that you can tailor your appeal to those reasons.

      Sincerely,
      Kay

  • LISA JUNTUNEN

    I WAS ALREADY DENIED BY THE ORAR JUDGE IN LIVONIA MY ATTORNEY
    SENT IT TO WEST VIRGINA TO A HIGHER COURT LAST MARCH HOW
    LONG DO THESE DECISIONS TAKE I WAS TOLD ABOUT 6, MONTHS AND
    STILL NO WORD

    • Kay Derochie

      Dear Lisa,

      An Appeals Council Review can take as much as two years.

      Sincerely,
      Kay