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Social Security Disability Claims

by Carl Weisbrod

Please note: This article is reprinted from the July 1989 issue of the publication Everyday Law with the permission of the National Organization of Social Security Claimants' Representatives (NOSSCR) at 19 E. Central Avenue, Pearl River, NY 10965, 1-800-431-2804.

It's easy to be pessimistic about getting a disability claim through the bureaucratic maze of the Social Security Administration. But claims can be successful, even after the Administration just says "no."

Each year we work, the government methodically squirrels away pieces of our paycheck for a rainy day. Social Security benefits and age 65 loom for us all, but for most of us, the notion of becoming disabled is pushed into a dark corner. Yet for some 1.5 million people each year, disability is a reality.

Many people don't realize that the old-age pension system masterminded by Franklin D. Roosevelt and passed as the Social Security Act on August 14, 1935, was later expanded to include the disabled. The benefit derived from Social Security disability can be substantial, and lifesaving.

THE BENEFITS

Since 1957, Social Security benefits paid to disabled workers have increased from $10,904,000 paid to 149,850 workers in 1957 to $1,498,637,000 paid to 2,830,284 workers in 1988. These cash benefits belonged to disabled workers, born of those dollars the federal government collects and sets aside. Though the appeals process can be long and discouraging, the rewards can help change the lives of disabled workers and their families. Understanding the process can help make the road to an approved claim a little easier.

In January, 1989, the average monthly Social Security disability benefit was $529. But benefits payable to dependent spouses and children of disabled wage earners can add another 50 percent to those family payments. For a young disabled person with a high earning record, the total family benefit can be as much as $1,634 a month, plus the cost of living increases that kick in every year.

Even more important to disabled people who lack health insurance is the medical coverage that comes with Social Security and Supplemental Security Income (SSI) disability entitlement. People who have qualified for Social Security disability benefits for two years receive Medicare coverage. SSI disability recipients qualify for Medicaid immediately.

The SSI program differs form the Social Security disability program in that it is a federal needs-based or welfare program, that is financed out of the government's general revenues, rather than a special trust fund. To be eligible for SSI benefits, claimants must be either 65 or older, blind or disabled under the Social Security Administrations criteria. Claimants do not have to have contributed to Social Security to be eligible for Supplemental Security Income.

Many people do not apply for these benefits simply because they don't know they exist. Even more often, people apply for the benefit but give up early because they don't understand the system. Here's a walk through the process within the Social Security Administration and the appeals process that can follow.

WHAT TO PREPARE FOR

To be eligible for Social Security disability benefits, a claimant must meet the Administration's definition of disabled: a disability or condition that is expected to last at least 12 months or to the result in death, and that prevents one from performing any job in the economy.

Note: The Social Security Administration Operations Manual includes a new criteria for Spinal Cord Injury: "Allegation of inability to ambulate without the use of a walker or bilateral hand-held assistive device more than two weeks following a spinal cord injury with verification of such status from an appropriate medical professional" (Form SSA-3367-F4, page 2). With these new guidelines, a social worker or other appropriate representative can have a claim expedited based on a presumptive disability. July, 1998.

People with diseases like lupus, multiple sclerosis, or anything that does not cause a visible disfigurement have more troubles winning benefits. Where the primary symptoms cannot be readily observed -- like fatigue, weakness, or pain -- applicants generally have a tougher time as well.

Lack of adequate medical documentation is the most common reason claims are denied. Medical reports do more than simply state the doctor's conclusion that a person is disabled. The report must explain the specific medical findings on which the diagnosis is based, and describe the functional limitations that prevent a person from working. Mental aspects of a disability, such as the loss of ability to concentrate or to tolerate work stresses, are particularly important and should not be avoided, even though they may be embarrassing for the claimant and family members to admit.

FILING FOR BENEFITS

If you've been disabled for at least a year or expect to be disabled that long, you can apply for Social Security disability benefits without even going to the Social Security office. A Social Security claims representative will take down the necessary information over the phone.

Note: To find an office near you, visit Social Security Online (www.ssa.gov) and their Regional Listings.

Make the phone call as soon as you can, because the first contact with the Social Security Administration "protects" your filing date. Retroactive benefits can only be paid for a year before the date an application has been filed. As in all dealings with a large bureaucracy, it's also a good idea to take down the name and direct telephone number of the person you talk to. But realize that the person who helps you fill out your application has no decision making power. Any advice you receive from Social Security employees about your disability claims is not necessarily reliable.

Your paperwork will be forwarded to an agency in the state where you live. This is assigned to a disability examiner, who performs much like an insurance adjuster. That person sends all your medical records to analyze a case. With an opinion from a doctor who is also an employee of the state agency, and who has never examined you, the examiner decides whether or not you should receive benefits. That decision must be approved by the Social Security Administration.

The decision for or against benefits on these levels of consideration is made by people who never see an applicant. State disability examiners may be subjected to tremendous pressure from budget-conscious administrators in Washington to deny the overwhelming majority of claims. Many people, frustrated with the process, often give up of their benefits are denied after an appeal with the state agency.

APPEALING YOUR CLAIM

If you have a legitimate case, don't be discouraged if a state agency decides against you, even after you've appealed. You can ask for a hearing before an Administrative Law Judge (ALJ). This is the only level in the process where you get the chance to be heard by the person who will actually decide whether or not you will get benefits. People who appeal their claims to the ALJ level -- particularly those who are represented by a lawyer -- generally do very well. More than half of all claimants who appeal to the ALJ win their cases.

Although a lawyer is not required, people who go to these hearings represented by a lawyer, according to Social Security Administration statistics, do twice as well as people who represent themselves.

If you lose at this level, the next level is the Appeals Council in Arlington, Virginia. The Appeals Council has very limited resources and reviews so many cases (about 80,000 every year) that it rarely reverses a denial by an Administrative Law Judge -- unless you can make specific, strong legal point.

TAKING LEGAL ACTION

If the Council doesn't help, a disabled worker who has been denied benefits has a right to file suit in U.S. District Court and have a federal judge review the case. Very few cases get to this point -- less than seven out of ever 1,000.

IN SEARCH OF SOCIAL SECURITY HELP

When the Social Security Administration denied his claim for disability compensation, a 36-year-old trucker from Saginaw, Texas, hired a lawyer, filed an appeal, and won. He and his family now receive $1,053 per month.

The lawyer who took his case was recommended by the National Organization of Social Security Claimants' Representatives (NOSSCR), a nonprofit organization of lawyers and other with specialized training is Social Security law.

Founded in 1979, NOSSCR has over 2,300 members. One of NOSSCR's founders and its executive director, Nancy Shor says members work only on a contingency basis under which they generally receive 25 percent of past due benefits. If there is no award, the lawyer will collect no fee. fees to not apply to future benefits.

"That's very reassuring for claimants who have been out of work for months or years and who are seeking their entitlement to Social Security benefits, but are worried about their ability to pay a lawyer," says Shor.

A monthly newsletter keeps NOSSCR information about changes in the law and major appeals decisions so clients are assured of well-informed representation by lawyers recommended by the organization. For more information about NOSSCR, call 1-800-431-2804.

The Social Security Administration publishes a pamphlet, Your Right to Question the Decision Made on Your Social Security Claim. To order it, contact your local Social Security Administration, or write the Social Security Administration at 6401 Security Boulevard, Baltimore, MD 21235.

The Social Security Administration also has a toll-free information line: 1-800-2345SSA. However, Senator David H. Pryor (D-Ark), chairman of the Senate Committee on Aging, has found evidence that two out of every five calls to the number get a busy signal -- and two out of five calls that actually get through result in the caller getting the wrong answer. The information comes from an internal Social Security Administration memo.

Note: Current committee listings can be found at www.senate.gov, www.house.gov, and the Library of Congress' legislative server thomas.loc.gov.

The Administration claims, reports the Washington Post, that the survey was taken in January, the busiest month, and that busy signals have dropped off significantly since. An Administration spokesperson also said that only 14 percent of the answers given where wrong, and that a more recent survey showed that only 4 percent of the wrong answers actually might affect benefits.

One solution might be to ask your local office for help, or turn to the office of your Senator or Representative. Government agencies tend to be extra careful when they are dealing with the legislators who control their budgets.

Reprinted from Lifeline, December 1990, pages 8-9. For more information on applying for or appealing decisions for Social Security benefits, contact your local Social Security office or visit them online at www.ssa.gov.

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