Note: If you have already filed a claim and been denied for disability, or are wondering what to do in the event of a Social Security denial, proceed to the reconsideration and hearing appeal sections below.
Level I: Disability Application - In Pennsylvania, approximately 69 to 70 percent of all disability claims are denied in a typical year. For a majority of claimants, this will make the disability appeal process a necessity.
Fortunately, claimants who have been denied and who appeal their case to the level of an ALJ (administrative law judge) hearing will have a statistical likelihood of winning benefits, assuming their case has been properly prepared for presentation to the judge.
Why are disability claims denied?
When a denial on a disability application happens, it may be the result of a technical issue, such as having too much earned income at the time of filing, or having assets that exceed the allowable limit (note: the assets limit of $2000 only applies to SSI while the Social Security Disability program does not take assets into consideration and has no limit).
However, in most cases, the denial occurs because the claimant's case has failed to meet the medical requirements for disability under the guidelines used by SSA.
The medical requirements of a case have to do with the most basic issue, which is the determination of whether or not a person is disabled.
To arrive at that determination, Social Security uses the following definition of disability: A claimant must have a severe impairment that results in their inability to perform substantial and gainful work activity for a period of not less than one full year.
Meeting the requirements for disability
To satisfy this definition, a person applying for disability in Pennsylvania must prove, through their medical record documentation, that they have a medically determinable mental or physical impairment (in many cases, claimants have both physical and mental impairments) that affects their ability to engage in ADLs, or activities of daily living, and significantly interferes with their ability to perform basic work activities.
Furthermore, a claimant's condition must be severe enough that it rules out their ability to perform their past work (potentially any job they have done in the fifteen year period prior to becoming disabled), and further rules out their ability to use their skills and education to perform some type of other work.
How does the actual disability determination process work?
After a disability application is taken at a local Social Security office in Pennsylvania, it is transferred to the state disability agency. In most states, this agency is known as DDS, or disability determination services. At DDS, the case is assigned to a disability examiner.
The examiner's role is to render a disability determination on the case using both medical and vocational evidence, specifically medical records obtained from the claimant's treatment sources and information obtained from the claimant's work history. With regard to both types of information, the disability examiner will be entirely dependent on the information provided at the time of application.
For this reason, compiling a list of treatment sources prior to the appointment for the disability application interview, with dates of treatment, names of doctors, and addresses of facilities is usually a practical idea. This can minimize the opportunity for important information to be omitted and can allow for more accurate information to be provided.
For example, when the names of medical facilities are incorrectly listed, it can slow down the process of obtaining medical records. In certain instances, it can even make it impossible to obtain records.
By the same token, a claimant may wish to record their work history, complete with job titles and descriptions of jobs and the duties they entailed, prior to going in for the interview (or having the interview conducted over the phone, which is an option for someone filing for disability).
How is the evidence used on a disability case?
The information obtained from the claimant's medical records is used to gauge in what ways, and to what extent, the claimant is functionally limited, either mentally, physically, or both mentally and physically.
Physical limitations such as a reduced ability to stand, sit, walk, carry, reach, or grasp, and mental limitations such as a a reduced ability to remember, concentrate, or assimilate new information are used to render an assessment known as an RFC or residual functional capacity, rating. A person's RFC is a rating what they can still do despite their disabling condition.
When a disability claimant's RFC rating shows that they no longer have the ability to return to their past work, and that they do not possess the ability to perform some type of other work that their skills and education might ordinarily suit them for, they may qualify for disability benefits. This is known as a medical vocational allowance.
Some claims may be approved without regard to a claimant's vocational considerations. This occurs when a claimant has a medical condition that is listed in the Social Security Disability list of impairments, also referred to as the blue book (the blue book began as a desk reference source for disability examiners, judges, and disability attorneys and representatives).
However, not all conditions are listed in the blue book and for those that are the qualifications criteria is very specific and difficult to meet.
Qualifying for disability as a child
For children to qualify for disability, the process of qualifying for disability is esentially the same. Children may be approved on the basis of satisfying the requirements of a listing.
When a listing cannot be met, however, the effect of the child's condition on ADLs (activities of daily living) must be such that it prevent them from engaging in activities that are specific to their age and peers.
For adults to qualify for disability, activities of daily living, of course, must be restricted to the extent that these functional limitations eliminate the ability of the claimant to work and earn a substantial and gainful living.
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WHAT YOU NEED TO KNOW BEFORE YOU APPLY
AVOID MISTAKES W/FREE HELP!
WHAT YOU NEED TO KNOW BEFORE YOU APPLY
The denial rate is quite high at 69% in Pennsylvania, one big reason for this is that many people do not get representation until they have been denied.
Many lawyers are partly to blame for this since it is very common for someone looking for a lawyer at application level for their SSDI or SSI claim to be told to "apply and call back when you are denied". Some lawyers(not all) do this because an attorney's fee is based on past due benefits and if the lawyer wins a case at application they feel the fee does not cover the work involved in handling a case at this level.
This approach should be avoided because it is very important that the case be handled properly from the beginning, not only to assure you have the best chance to win at application, but also to ensure that an application that was not properly done does not come back to haunt you at a later stage in the process. Approval rates are much higher at the initial application level.
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