I Have Never Filed
I HAVE NEVER FILED
About the Process
As we shared with you on our home page, many Americans don’t really understand the Social Security Disability (SSD) and Supplemental Security Income (SSI) application and appeals process. These pages will provide you in the simplest terms possible, a semi-detailed overview of what you need to do and what happens when you file a claim for SSD or SSI.
YOU CAN’T BE WORKING
We at the Social Security Law Group (SSLG) receive calls every week from people who tell us they’re disabled, want to file a claim for disability benefits, but they’re still working. The first thing you have to understand is that if you’re working full-time, irrespective of your medical condition, you can’t be approved for SSD or SSI. In many cases, our prospective clients are working part-time and if their earnings exceed the statutory limit, or what the Social Security Administration calls “Substantial Gainful Activity (SGA),” they will be denied. The monthly SGA amount for non-blind individuals in 2020 is $1,260, while it is $2,110 for individuals that are considered blind.
Our would-be clients who are working part-time often believe that if they stay below the SGA earnings limit they’ll be fine. This is NOT always accurate. While the regulations allow you to deduct what the agency dubs “Impairment Related Work Expenses” (IRWE) from your pay, in some cases people are intentionally staying below that statutory limit by choice – not truly as a result of their medical condition. If the evaluators at SSA believe that you are deliberately staying below the SGA earnings amount, and determine that you could work more if you wanted to, tried harder, or had additional job opportunities, then they are authorized to consider you not totally disabled.
So first and foremost, you can’t be working and file a claim for Social Security Disability.
YOU MUST HAVE A SERIOUS (SEVERE) MEDICAL IMPAIRMENT
The next thing you have to consider is what is the disabling condition, or diagnosis, that is keeping you from working? The Agency has a definition for this. They call it a “severe medically determinable impairment.” That’s a lot of bureaucratic gibberish. The official SSA definition makes it look easy:
An impairment or combination of impairments that significantly limits the individual’s physical or mental abilities and, as a result, interfere with the individual’s ability to perform basic work activities.
While that seems like a pretty straightforward definition, don’t be fooled. What they mean by a severe impairment is one that’s going to prevent you from trying to make a dignified living doing even the most mundane, dead-end, unskilled job. It’s not a job that would enable you to make a living or feed your family.
To determine your level of impairment, the Agency will use your doctors’ reports, but more importantly objective medical evidence such as blood work, MRIs, cardiac stress tests, etc. The statements you make on your application, or in the myriad of SSA forms they make you fill out, don’t really mean much to them. They will look primarily at the objective medical evidence in making their determination. Make no mistake, not all diagnoses will qualify, and just about every diagnosis (or combination of diagnoses) must be to a very serious degree for SSA to approve your case.
If your disability is a psychiatric one, click here.
In addition, during the application process, at what we call the initial claim stage, the state agency called Disability Determination Services (DDS) will often send you what they call a Consultative Exam (CE). This Consultative Exam is at the government’s expense, and is often a superficial, summary exchange of information with you and a doctor of SSA’s choosing. In fact, many decisions are made after the results of the CE are returned back to the DDS Examiner. If you appeal your case to the Reconsideration level, you’ll most likely undergo a second CE – likely with the same results.
So your medical condition must be quite severe.
YOU FILE AN INITIAL CLAIM
In order to start the process, you have to file what the Agency calls an Initial Application or Initial Claim (IC). This application is generally filed online, but the original SSA forms can be completed by hand and mailed in to your local SSA Field Office. At SSLG, we help our clients from Initial Application through all levels of appeal. We most certainly recommend hiring us to file this Initial Application on your behalf. The Initial Application is broken down into 2 parts. The Non-Medical/Earnings portion and the Medical portion:
The Non-Medical / Earnings Portion
This part of the application process deals strictly with questions that are not medical-related. These questions ask about the earnings for the current and prior years. Remember, if you’re currently working, they won’t waste their time and resources in taking your application. They will ask whether you’re married or have minor children. If you’re a widow(er). All of these questions impact the amount and type of benefits you’ll be entitled to if approved.
They ask if you’ve worked with the Railroads or receive Worker’s Compensation. These questions are meant to cross reference any additional benefits you may have, or to ensure you’re not receiving payments from another Federal or State program, like unemployment or welfare. If you are, there is often coordination between these benefits. This means that if you received food stamps or welfare, you may be required to pay some of that back to the state agencies from your SSA backpay if you’re approved. See the post award section of our website for more detail.
If you’re receiving Long-Term Disability (LTD) benefits, the Agency will want to know this information because earnings figures will start to show up on your work record, and they will think that you’re actually working when those earnings represent employee benefits like sick pay, vacation pay, etc. This part of the application process is pretty straightforward.
The Medical Portion
This part of the application process is much more detailed, and much more important. These questions ask about all the doctors that are treating you. SSA will require the dates of treatment, the reason for the treatment, and the type of treatment you receive. They will also want to know if you’ve undergone any tests like MRIs, Nerve Conduction Studies, etc. Furthermore, they will also ask you to list any medications these doctors prescribed along with dosages and any side effects these medications may give you.
They will ask the same questions about any hospitalizations you may have undergone. They will want to know whether the hospitalization was an Emergency Room visit, or an inpatient visit and there are detailed questions about these treatments as well. After they finish the medical sources portion, they then ask you about the specifics of your last job and all the jobs you’ve had for the last 15 years. They will ask the types of tasks that you performed, how much you lifted, how long you sat, etc. These two sub-portions make up the Initial Application.
When you hire the Social Security Law Group, we help you with this Initial Application (both portions). More importantly, our technology captures your answers so that these responses can be used throughout the entire SSDI process and you’re not filling out the same government forms asking for the same information four or five times over. You’ll find our technology incredibly easy to use, and you can update your medical profile continuously during the application and appeal phases. This is not only a big-time saver, it ensures your statements remain consistent throughout the entire process.
THE INITIAL APPLICATION EVALUATION PROCESS
Once your Initial Application is complete, it gets received by your local SSA Field Office (FO) who will then assign it to a staffer within the FO called a Claims Representative (CR). You may receive a phone call from the CR assigned your case asking for additional non-medical information. Occasionally, you may get a call from a Service Representative (SR) who is also a member of your local Field Office team.
From there, the CR assigned to your case will run some preliminary research into your SSN. They will determine if you have sufficient FICA contributions to qualify for SSDI. If you’re a widow(er), they will cross reference your deceased spouse’s SSN to see if you may be eligible for other types of benefits based on your deceased spouse’s work record. Widow(er)’s benefits can be complex, so if you are a Widow(er), have not filed any claim and have questions, please call us. If you are already receiving widow(er)’s benefits from SSA, you need to call them directly.
The CR at the Field Office may send you additional SSA forms to complete like a Work Activity Report or some other type of non-medical form that requires you to certify whether you’re working, or answer some tax and earnings-related questions that they may have.
Once the Field Office is satisfied that they have done their preliminary portions, they will forward your claim to the Disability Determination Services (DDS) within your state. It is the DDS that will make the medical determination of whether you meet SSA’s definition of disability. Once again, your file will be assigned to an examiner at DDS. He or she is supposed to call us as your Attorney if they need any information, but very often they will call you directly (which we don’t want them to do). If we are representing you, we naturally want you to forward all calls to us and we can attempt to get them the information they need (and better control the information they are using to make their decision). The DDS Examiner is tasked with reaching out to all of the medical sources that you listed on the medical portion of your application and getting all the medical records for the dates you specified in your application. The DDS will also send you a myriad of SSA forms for you to complete. Here are some examples:
- Work History Report
- Function Report
- Headache Questionnaire
- Seizure Questionnaire
- Pain Questionnaire
Completing these forms is critical to their analysis of your disability. As a client of ours, we assist you with these forms and provide guidance as well. As we stated earlier, your DDS Examiner will most likely schedule one or more examinations that they call Consultative Exams (CE). These are visits with private practitioners who have a money making, side-hustle by agreeing to perform examinations for SSA. Some examiners make a living out of strictly doing SSA exams, so it’s important you’re aware of what these exams entail. We share the results of some of these examinations (sanitized for privacy, of course) that we find noteworthy on the private pages of our website which our clients have access to.
Once the DDS Examiner has compiled all of the medical evidence that your treating sources have furnished, they perform a task that they call the “medical workup.” The medical workup is a sheet that describes all of your impairments, the medical sources used, and the recommendations of the Examiner. The Examiner will then analyze your medical records to determine if your impairment(s) is severe enough to meet what they call an SSA “Listing.” The Agency’s Listing of Impairments describes, for each major body system, specific impairments considered severe enough to prevent an individual from doing any Substantial Gainful Activity (or in the case of children under age 18 applying for SSI, severe enough to cause marked and severe functional limitation). If your medical condition meets a Listing, you are entitled to what SSA calls a “Presumptive Disability.” If your condition is severe enough to MEET the Listing, it means that absent any evidence to the contrary, your case is approved. We explain the Social Security Listings (MEET or EQUAL) in greater detail in a different section of this website.
The Examiner can’t make the determination that your medical condition meets the Listing, only a doctor can. So if the Examiner believes your medical condition is severe enough to meet the Listing, he or she will make a recommendation as to which Listing he or she believes your medical condition satisfies. They then send the workup and recommendation to a doctor inside of DDS whose title is Medical Advisor.
It’s the Medical Advisor who will make the final call as to whether your condition is severe enough to meet the Listing. The DDS Examiner would not send a recommendation that your condition does not meet the Listing, only to have the Medical Advisor overturn his or her decision. In order to meet the Listing, the medical condition must be accompanied by specific objective findings and if those findings are not present, then your condition doesn’t meet the Listing and the DDS Examiner cannot recommend that your condition be approved on the basis that it meets a Social Security Listing.
If the DDS Examiner does not believe your medical condition is severe enough to meet a Social Security Listing, then he or she will make a recommendation of what they believe is your Residual Functional Capacity. (RFC). A person’s Residual Functional Capacity is the amount of bandwidth/ability/endurance, etc. that a particular person is capable of, in spite of their medical conditions. For example, the DDS Examiner may make the determination that you cannot perform your past work which was considered Light under the Federal Directory of Occupational Titles (DOT), but is of the opinion that you can perform sedentary work. As a result, he or she would make a recommendation to the Medical Advisor that you have the residual functional capacity for Sedentary work.
Once the workup is delivered to the Medical Advisor, he or she, as a doctor, will either agree that the medical condition is severe enough to meet the requirements of a particular Social Security Listing, certify that finding, and approve your case. Or, if your condition does not meet the Listing, the Medical Advisor will then agree or disagree with the Residual Function Capacity recommendation of the DDS Examiner. On occasion, the Medical Advisor may not agree with the DDS Examiner’s opinion, and send the case back for additional workup.
If the Medical Advisor agrees with the DDS Examiner in that you have the Residual Functional Capacity for other work, the Medical Advisor will make that certification, and the DDS will deny your claim. The official terminology within DDS is that your claim has been “closed.” When your claim has been closed, that means they have made a decision and responsibility for sending out the decision is kicked back to the Claims Representative at the local SSA field office. In reality, a computer generates all these notices and they’re mailed to you.
When they deny your claim, they will send you a Notice of Decision which will list the treatment sources that SSA obtained, any Consultative Exams you may have attended, and then provide a brief, very lame rationale for why they denied your claim at the Initial Application stage.
That stated, if after their initial workup the DDS Examiner believes that you your condition doesn’t meet a Listing but you don’t maintain the Residual Functional Capacity for any sedentary work, he/she is authorized under the Regulations to make that recommendation to the Medical Advisor as well. This recommendation means that the DDS examiner believes that you are disabled and meet the definition under Social Security regulations.
The Medical Advisor would review the recommendation of the DDS Examiner and agree that your impairment, while not severe enough to meet the Listing, is severe enough to prevent you from performing those unskilled sedentary jobs that we keep talking about and approve your claim.
Wait a minute. Just when you thought your case was approved, you may find yourself in front of one more set of rolling logs that you need to outmaneuver to get to the other side of the river. The Social Security Administration calls it “Quality Control.” We call it one last attempt to cheat you out of your Past-Due Benefits and SSA backpay. It used to be called “Disability Quality Branch (DQB).” It is now called “Quality Determination Review (QDR).”
The QDR is not a branch of DDS, but rather a branch of the Social Security Administration. The QDR staff are Examiners who are Social Security employees. They review favorable Initial and Reconsideration decisions to ensure that their claims procedures are being followed, and that the claims DDS Examiners are approving are ones the Agency wants them to. The QDR has the authority to agree with the DDS recommendation and send your claim into pay.
They also have the authority to return your favorable decision back to DDS for further evaluation. And, unfortunately, when this happens they will very often change the date of your disability which will result in a dramatic decrease in your backpay and past-due benefits. Finally, QDR can order your favorable decision be returned to DDS and be overturned into a denial.
You will know that your case was a victim of the QDR process if you get a notice in the mail whose first sentence reads:
In order to qualify for disability, you must meet certain medical and non-medical rules. We have found that you meet the medical rules.
If you keep reading, you’ll see that you were cheated out of SSA Past-Due Benefits, Medicare, and your date of disability.
If after this entire process, your claim is finally approved, they will once again Close the claim, and DDS will send it back to the Field Office. From there, the Field Office personnel make some computer entries, and the award process is pretty much automated. If you’re approved, you’ll receive a document from Social Security called a Notice of Award. The Notice of Award will break down your award figures, start date for disability, and other post award information.
Statistically, the SSA approves about 35% of claims at the Initial Application level. Don’t chance it and try this on your own, call the Social Security Law Group today.
Still think you can do this on your own?
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