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 - More than 60 percent of all disability claims in Texas are denied in any given year. This is in line with most states: The average rate of denial at the disability application level tends to hover around 70 percent.
Due to a variety of factors, the majority of claimants will not meet the qualifications for disability benefits until one or more appeals have been filed. And in most cases, winning disability benefits will require pursuing a claim to the second appeal level, the request for hearing before an administrative law judge.
Qualifying for disability
Qualifying for disability can be difficult. The Social Security Administration uses a unique definition of disability. It is not enough to have a percentage loss-of-function, or to lose the ability to return to a former job. An individual must have a severe medically determinable impairment (which may be mental, physical, or both) which must last for one full year or longer.
However, if the condition has not lasted a full year by the time the application for disability is filed, this is not necessarily an issue as a disability claims examiner can review the medical evidence and make a projection as to whether the individual's state of disability will last a year or longer.
In addition to the duration requirement, the condition must be severe enough that it impacts normal daily activities and interferes with the ability to perform basic work activities.
Each Social Security Disability and SSI Disability claim decision is both medical and vocational in nature, meaning that the limitations posed by the claimant's condition, or conditions, are considered in the context of how it affects their ability to work.
Applying for disability
Filing for disability in Texas will involve initiating a claim with the Social Security Administration online, or by contacting a local Social Security office.
Contacting a local office offers distinct advantages over the online process. While the online process is touted as saving time, an SSI application cannot actually be filed online.
This means that an individual whose claim will involve SSI--either entirely or as part of a concurrent Social Security Disability and SSI application--will still have to be contacted by a Social Security Claims representative. Translation: the online process may not save any time at all.
Additionally, the act of contacting a local Social Security office offers the advantage of being able to ask questions and receive answers about a) the process of filing for disability and b) the requirements for qualifying for disability benefits. This, by itself, can avoid confusion and eliminate mistakes.
However the claim is initiated, each disability claim in Texas will eventually involve a claimant having to undergo a disability application interview with a CR, or claims representative, at a local Social Security office. The interview can be conducted in person.
For individuals who have mobility or transportation issues, however, the interview can be conducted over the phone. This may also be requested for claimants who simply prefer a phone interview.
Who makes the decision on the disability claim
After the claim has been taken, it will be transferred to a case processing specialist known as a disability examiner. This is at a separate state-level disability agency known as DDS, or disability determination services. The examiner at the Texas DDS will be responsible obtaining the medical evidence that is needed to make a decision on the case.
However, the examiner can only gather records from the sources indicated by the claimant on their disability report form at the time of filing for disability. For this reason, claimants should be sure to include all pertinent information regarding their medical treatment history, including their dates of treatment, the names of their treating physicians, and the names and addresses of all hospitals and clinics.
The correct name for a medical facility is especially important since Social Security will use this information to send out letters requesting medical records. If a claimant supplies an incorrect name, the disability examiner may fail to obtain the needed records which can pose a significant disadvantage to the case.
At the very least, it may cause a significant delay in receiving a decision on a Social Security case. The wait for medical records, in fact, constitutes the longest portion of the time needed to process a disability application.
What is the actual process of evaluating a claim?
The process is as follows:
1. The claimant's medical records are gathered, read, and evaluated. If it becomes apparent from the analysis of the records that they have a condition that satisfies a listing in the Social Security Disability list of impairments, they may be approved on this basis.
2. If the claimant does not have a listing-level impairment, the information from their medical records will be used to determine what their current mental limitations and/or physical limitations are. This is their RFC, or residual functional capacity. The RFC rating is then compared to the demands of the jobs that were performed in the 15 year time period prior to becoming disabled.
Note: This is why it is extremely important for a claimant to supply a complete and detailed work history during the interview for the disability application -- in fact, this is why it is generally a good idea to write down both the work history, as well as the medical history, prior to the application appointment at the Social Security office so no important details will be omitted.
3. If the claimant's limitations do not rule out the ability to return to their past work, meaning they can return to one of their former jobs, they will be denied on this basis.
If their limitations are great enough to rule out their past work, the case will move on to the final step, which is to determine whether or not they have the education and skills needed to perform some type of other work (which they have never done), given consideration of their age and functional limitations.
4. Individuals whose condition is severe enough to make it impossible to do their past work, as well as other work that relies on their education and job skills, will meet the requirements for disability.
In other words, they will be found to be disabled and will qualify to receive disability benefits on an ongoing monthly basis, in addition to receiving whatever back pay they may be eligible for.
As stated, the majority of claims are denied at the disability application level. Most claims, of course, are denied on the basis that the claimant can do some type of other work.
How long does it take for a disability decision?
Claims for disability are usually decided within 90-120 days. There are exceptions to this, of course. Claimants who are scheduled for consultative medical examinations by Social Security and do not keep their appointment will add unnecessary delay to their case.
Also, claimants who have had recent heart or eye surgery, or who have suffered a stroke will usually have their case deferred for three months so that Social Security can evaluate the residual effects.
Since the large majority of claims in Texas are denied by Social Security, claimants should be ready to file an appeal upon denial. The first appeal is the request for reconsideration.
What You Need To Know Before You Apply
The denial rate in Texas is quite high at 67%, 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 level, 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. Studies have shown approval rates are much higher at the initial application level.
Will I Get Approved? Find Out if You Qualify
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