Having Appropriate Treatment for Your Medical Conditions is Crucial for Your Case! SSD in a Nutshell Series Blog 4

Seems like an obvious statement, right?  Well surprisingly there are many Social Security Disability claimants who are not receiving sufficient treatment for their conditions.  Not only does a person benefit by having sufficient health treatment for his medical conditions but his disability case will also benefit.

Until very canstockphoto0076124recently, it was near impossible for someone without medical coverage to get appropriate medical treatment that he could afford. If health insurance was not offered through employment it was also likely that purchasing coverage as an individual was cost prohibitive. After the new health care laws were implemented it has become easier for most people to access medical care and/or afford medical coverage.  By no means is the process perfect or make coverage available to all who should have access. Many states have a program implemented to make affordable insurance accessible to everyone.  To get into detail on this matter would require a whole other blog series but suffice it to say that someone who has lacked medical treatment in the past can now get care in most circumstances.

Social Security (SSA) is not supposed to deny someone disability benefits for lack of medical treatment.  SSA can send the claimant for examinations and there are many reasons a person may lack medical treatment for reasons out of her control. A good disability advocate that is representing a disability claimant will assist his client in finding medical care to address the client’s conditions. The advocate can help the client work with her insurance provider to find a physician or to locate community healthcare for no or little cost. What one does not want to rely of if at all possible is SSA sending the claimant on an examination.

SSA examinations are usually only a one time event where the claimant is briefly examined by a physician that may or may not specialize in the area of the claimant’s alleged impairment. As I have mentioned in a previous blogs, many physicians that perform examinations for SSA operate at the highest of medical and professional standards.  Not all of these physicians submit accurate reports of the claimant’s conditions, unfortunately. Perhaps these physicians believe they will no longer get business from SSA by honestly stating that a claimant may be disabled. Some of these physicians lack the ability to properly examine the claimant or simply do not thoroughly examine the claimant. These bad reports can be used against the claimant, unfortunately.  Sometimes the reports are supportive of a finding of disability and somehow a creative reason is found for disregarding the findings of the examining physician by SSA. It is always best to have the claimant’s own physicians opinions on the record.

Consideration must be given to the opinions of the claimant’s own physician. Sometimes SSA will still require an additional exam from one of its physicians but having one’s own physician providing records of treatment, diagnoses, prognosis, tests, etc., is always a benefit to a claim.

One should always make sure her physicians are noting her health concerns.  Keeping record of medication side effects, seizures, headaches, days where one cannot get around well due to pain, etc., are a great way to keep the physician informed of important details of the claimant’s conditions, but will also support the disability case. Always ask for a written prescription for canes and other assistive devices.

If a person is having difficulty getting healthcare treatment and he has no insurance effort must be made to get him established for care with his own physician. Some resources and information can be found at:

Medicaid Website

Healthcare.gov

It may also be helpful to search the web for low-cost medical treatment in the area the claimant resides. There is often lag time before Medicaid or insurance coverage will begin, and sometimes coverage under either is unavailable for the claimant. Seeking treatment at a free clinic may be a great way to establish care.

 

Feel free to comment or ask questions!

©2016 April L. Roberts and Aaria Consulting, LLC. All Rights Reserved.

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Why do so many Social Security Disability claims get denied? SSD in a Nutshell Blog Series 3

200160a20c6107eb2cc73ddd05030d3dOver 70% of initial disability claims are denied.

For a process intended to be non-adversarial it can seem the claimant is up against a system designed to discourage people from applying for disability. Considering all my cases past and present I cannot easily sum up all the reasons for so many claims denials. But in retrospect and in dealing with current cases I have identified some common issues claimants face in the process. While there is no way to completely avoid less-than-fair case outcomes there are ways a claimant can minimize problems in the process. Following are some reasons a case gets denied and how these issues can be helped.

The unrepresented or poorly represented claimant.

Claimants that are represented by a qualified advocate have an increased chance of the claim being approved.  It is important the claimant choose the right person and/or firm to represent him and I will address this in more detail in a later blog. If a claimant chooses to go the process alone, he must be proactive and willing to do a lot of legwork on his own.

A qualified disability advocate is anyone (attorney or non-attorney) that has knowledge of the administrative law process; especially that of Social Security Disability. The best advocate is someone who has a legal education and/or specific training and passion for representing claimants of disability. A qualified disability advocate can charge a fee for services and receive direct payment for those fees. Such an advocate must either be an attorney or have met specific criteria set forth by SSA. A lousy advocate, even if technically qualified can actually hinder the outcome of the claim.  A lousy advocate can be both an attorney non attorney. When a claimant is not represented or poorly represented the disability process can go unchecked:

  1. Important forms are not completed and/or received by SSA.  This could be due to SSA not having the most updated address for the claimant.  Or perhaps the claimant is unable to complete the forms on her own due to being in the hospital, illiterate, or otherwise unable to complete the forms on her own.
  2. The claimant does not attend medical exams arranged by SSA.
  3. Medical records are not obtained by SSA.  This can be due to having the wrong doctor or treatment date information on file.
  4. The claims adjudicator and claimant do not have contact to discuss the development of the claim file.

Like most workers in today’s world, SSA claims adjudicators have heavy work loads and limited resources to get work done. This has not prevented most claims adjudicators I have encountered from being compassionate and detail oriented professionals that will do what it takes to get the job done right. This is not the case with everyone in a decision-making position regarding claims at SSA. If a claimant is unrepresented or represented by an absent advocate it can result in the claims adjudicator making less effort to dot all i’s and cross all t’s. A good advocate will make sure the claimant completes and returns forms and that SSA receives the forms.  A good advocate will also make sure that the claims file is well-developed and that medical information is correct and assist in getting medical records on file if necessary. The advocate will communicate with SSA and the client to ensure the integrity of the process and prevent or address issues, promptly. Being well represented a claimant stands a better chance of getting approved.

The ‘weak case’.

Some of those 70% of case denials are a result of cases that should be denied. This may sound a bit harsh but there are many claimants that file a claim for disability who are not disabled and should not be found disabled per the SSDI/SSI rules.If you have read my earlier blogs or others similar to mine you are already aware that SSA looks at whether a person can perform ANY substantial work on a sustained basis. SSA does not have to be concerned with where a person lives and the state of the job market.  SSA does not have to be concerned with the fact that a person may no longer be able to earn the kind of money he used to before he developed serious health problems. SSA does not have to be concerned with the fact a person cannot drive herself to work.

SSA has an outdated method of determining what work is available in the national economy. For the most part common sense can be applied and often is when considering if a person can perform substantial work of any kind and if a substantial number of such jobs exist in the US. SSA considers a person’s past jobs and skills that could transfer into other types of work if he can no longer do the work he used to. A determination that a claimant can perform his past work or adjust to other types of work he is likely to be found not disabled.

A case can be weak due to no medical evidence to support the allegations.  If there is insufficient evidence in the file then SSA is supposed to arrange at least one medical exam to address the claimant’s conditions and how they affect her ability to work. These exams are often very short and sometimes not sufficient to fully evaluate the claimant’s impairments and how they affect her ability to work. There are problems with some of the physicians that examine SSA claimants. Many operate with the highest standards in medical practice and honest reporting to SSA. There are some that do not.  I have seen reports that could only be pure fiction citing no serious medical problems when the average layperson could see the claimant suffers from severe physical impairments.  This may be that the physician did not have the right methods or specialty to observe the claimant properly.  Unfortunately there is always the physician who will state in a report what she thinks SSA wants to hear by falsely downplaying symptoms and exaggerating physical or mental capabilities.   These bad reports are used by some adjudicators and judges to deny claims even in the face of other supporting evidence.

A difficult jurisdiction.

There are far too many speculations on why in one region of the country a claimant has a better chance of getting approved than in others. There is even more speculation as to why one judge would approve a case and another would not. We want the judges to have broad discretion because disability cases are very sensitive and personal to the claimant. The problem lies in where there is a major discrepancy in the approval rate of one judge to another or one region to another.  For example, when comparing two judges in the same hearing office one approves 40% of his cases while the other approves only 20%. A good advocate will approach a case with these facts in mind, but these issues unfortunately add to the high number of denials.

Claimant ineligible to receive benefits despite having severe medical impairments.

A person may not have earned enough work credits with SSA to receive SSDI benefits or he may be past the date where his eligibility for SSDI expired. If the same person is not eligible for SSI then despite his having a strong medical claim, SSA cannot provide him with any benefit program that he would be eligible for.

Current state of affairs.

According to my colleagues who have experience practicing in disability in the 80s and 90s, it was much easier to get a claim approved than it is, today.  One reason is the current economic downturn.  Before the latest bust, employers could afford a large workforce that included challenged workers.  When cuts had to be made these workers were among the first to go. Unfortunately many of these workers were older, aged 50 or more and experience extreme difficulty finding other work they can perform with their physical limitations and employers willing to work around them. This has resulted in a higher number of people applying for disability benefits.

Some large disability firms have a policy of taking in as many cases as possible despite the merits of the individual cases.  These cases are piled onto a system that is already backlogged frustrating the process and hindering it for those whose cases do have merit.  T

Humans being humans.

No one person is perfect and this includes SSA employees. Mistakes can be made such as not processing  documents properly or not considering medical evidence properly per the very complex rules set forth by SSA. There is always the person who has a bad day.  There are adjudicators, claims managers, and judges that unfairly deny a deserving client her benefits. All of these situations contribute to that unsightly 70% of denied claims.

In no way is this an exhaustive list of the reasons disability cases are denied. These are the situations I and many of my colleagues in the practice experience as a general rule and can be overcome most of the time.

Feel free to comment or  message me with your thoughts or questions!

Up next: Having Appropriate Treatment for Your Medical Conditions is Crucial for Your Case! 

©2016 April L. Roberts and Aaria Consulting, LLC. All Rights Reserved.

 

 

 

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Why Do So Many People Who Should Not Get Disability Get Approved for it? SSD in a Nutshell Series Blog 2

canstockphoto15449778The Social Security Disability Program is difficult to navigate and understand. Adding to those difficulties is the perception there are mass numbers of people receiving benefits that should not be. The purpose of today’s blog is to explain some of these misconceptions.  Indeed there are people receiving disability benefits that should not be. However the reality is not as bad as it seems.

“I know of people who are getting disability and there is not anything wrong with them!  Why is it so hard for me to get approved?”, say many people I talk to.

Most claimants have some if not a lot of difficulty getting approved for benefits.  This is especially frustrating for people who have worked hard most of their life and get denied disability despite strong medical evidence. Some cases that get approved seem that they should not have been.  The disparity between which cases get approved versus those that do not has many factors.  The reasons could be the region the claimant resides, if he had a good advocate or not, agency error on the part of SSA, just to name some.

The trend of a higher percentage of cases being denied compared to a decade or so ago is very real.  There are people getting benefits who were approved when it was easier to do so versus getting approved, today. If these same individuals were to apply for benefits now, they would have a higher likelihood of being denied.

The recent economic turn-down forced a higher number of people to apply for disability. Employers who could no longer afford lower productivity from challenged workers. Of course these workers were among the first to go. Many of these people are from the older population not yet eligible for retirement but have extreme difficulty finding new work. Combine that with today’s tighter scrutiny on SSA’s approved cases and it is simply more difficult to get approved for disability these days.

The Hidden Disability: “You get disability?  You don’t look like there is anything wrong with you!” say many people to my client with lupus.

A very misunderstood population is sufferers of ‘hidden disabilities’.  Hidden disabilities can include the following conditions that may not cause many visual symptoms.  These could be:

  • mental disabilities
  • chronic pain and fatigue disorders
  • lupus and other autoimmune disorders
  • diabetes
  • neurological disorders

These conditions have manifestations that effect each sufferer, differently. A person suffering from lupus may experience symptoms during periodic flare-ups.  Perhaps she feels generally well for a month or so and functions normally. But when her symptoms flare she may experience debilitating even life threatening symptoms that can last for weeks or months.  A person that has suffered diabetes long-term may have developed secondary conditions such as diabetic neuropathy, loss of eyesight, and other serious diseases that prevent the person from being able to work on a sustained basis. A person suffering from a severe mental condition may seem fine around his home or familiar environments.  What his neighbors and friends may not know is that he cannot function outside of his comfort zone due to severe anxiety, paranoia, or other severe distress. A disabled person may have good days. If he has more bad days than good in terms of severe symptoms that would cause him to miss a lot of work, he may meet the requirements for disability.

On another note… Social Security (SSA) is supposed to conduct periodic reviews of approved cases to see if claimants have medically improved enough to perform substantial work. As an advocate I have seen many seriously impaired people be reviewed every 3 years by SSA. At the same time, others with conditions that can easily improve over time never experience a review. The process is not a perfect one and I promise to address the issue of continuing disability reviews in a future blog.

There are problems with unscrupulous attorneys, advocates, and doctors along with a margin of error that plague any disability process. Given the uphill battle to win a disability case across the board, most people who are receiving benefits are rightfully doing so.

“I know people who get approved simply because they are drug addicts!”

What? I hear this a lot from frustrated clients and friends. On one hand SSA is not supposed to deny a claimant disability because of evidence of drug and alcohol abuse. Yet substance abuse noted in medical records can cause a person to be denied his disability benefits, unfairly.

This is a tough area of disability and thankfully there are some amazing mental health professionals working with SSA to educate adjudicators and judges on how to recognize severe mental disabilities in the presence of substance abuse.

Simply put, SSA is supposed to consider substance abuse and its contribution if any, to the person’s disability. Consider a person with a severe spinal condition that abuses alcohol on a regular basis. Her spinal condition will not be miraculously cured if she stops drinking. Despite even heavy alcohol abuse, SSA is to consider the contribution of the alcohol to her conditions.  Even if she stops drinking she is very likely still to suffer from pain and immobility. In this case alcohol abuse is not material to her disability and should not be a reason for SSA to deny her disability.

Mental disorders can lead to drug and/or alcohol abuse.  It can be said that substance abuse only worsens the symptoms of mental problems.  However, a person who suffers from severe bipolar disorder may never be able to function normally even if he stopped using drugs.  Therefore, the drug use may not be considered material to his disability. If a person suffers from permanent and severe health problems resulting from substance abuse he  can be found disabled. This may not seem fair on the surface. Alcohol abuse can be due to severe PTSD secondary to being a combat veteran or severe abuse victim.  These sufferers sometimes lack the insight to seek treatment for many reasons. If he was able to stop abusing drugs and alcohol but his physicians believe he would still suffer severe mental symptoms, he should be found disabled.

Despite all the reasoning in the world, our adjudicators and judges are people just like you and me. These people must carefully consider all the facts in cases like these and are expected to be unbiased.  By no means can it be said that a person is given disability benefits simply because she is a drug addict or alcoholic. In my experience it is quite difficult to get someone approved for disability that has drug and/or alcohol abuse in the medical file.

Stand back and consider for a moment…

Most American adults of working age pay into the SSDI program.  Barring a few issues that can prevent a person from having access to his disability benefits, he has a right to his benefits if his conditions render him disabled. We may not approve of someone’s lifestyle or choices but this does not mean that a person should be denied his rights.  That would be un-American.  Not everyone wishes to disclose the reason they receive benefits and when not required by law, many reserve that right.  For example, the neighbor that tells you he is disabled due to a bad back but seems to have no back issues may actually be suffering from a mental illness and does not believe it is anyone else’s business to know that.

It is important not to jump to judgement or let media reports sway you regarding these issues. SSA does not, never did, and probably never will hand out disability benefits to just anyone. Hidden disabilities are very real and can happen to anyone. That said, it is not easy to dupe SSA into giving someone benefits that is not disabled though it does happen. SSA takes very seriously allegations of fraud. If you suspect that someone is collecting benefits due to a fraudulent claim, report it.  Visit SSA’s Website for more information.

Share your comments and questions regarding this blog and I will be happy to respond!

 

Next up, “What are Some of the Main Reasons a Person Gets Denied Disability?”

©2016 Aaria Consulting, LLC and April L. Roberts.  All rights reserved.

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Social Security Disability in a Nutshell Series Blog 1

canstockphoto10669314What is Social Security Disability? I can tell you that it is not a welfare program  and is certainly NOT handed out to just anyone.  If this were true I would be driving a Rolls and not a Jeep Patriot.

My name is April Roberts and I am a professional disability advocate. I represent individuals that are applying for Social Security Disability and Medicare benefits. I have had the privilege of representing claimants around the country. I have traveled to over 50  SSA (Social Security Administration) hearing offices in 16 states to argue hearings in front of Administrative Law Judges.  I have learned that many Americans do not understand the Social Security Programs and how they work.  This lack of understanding is used by the media and other special interests to play on public fears.

In truth it is not easy to get approved for Social Security Disability and there are inconsistencies in how the rules are applied by the administration, itself. In fact over 70% of all applications are denied upon initial review. This is not because SSA ‘has’ to deny claimants the first time. There are many reasons for this unfortunate percentage which I will address in future blogs.

There are great people who work at SSA and most are just like anyone else trying to do a job.Like any organization there are problems and mistakes are made. There are times when a claimant does not need a representative or attorney to help them. Most of the time claimants can benefit from having someone advocate for them.  Some representatives and attorneys are great.  Some representatives and attorneys are not.

With that said, my intentions are to educate people on these things and hopefully publish a simple book to help people better understand the disability process and rights to those benefits. Since I have never written a book I am hoping all of you can help me.  By that I mean commenting on each blog I publish with your thoughts and questions. Hopefully your input can help me direct my writing to cover all the areas where people have questions . So, with no further adieu…

What is Social Security Disability?

Simply put, Social Security Disability (otherwise known as SSDI) is a disability insurance program. Most working Americans pay into this insurance program via income tax withholding. Once a person has achieved a required minimum of earnings and time worked, she will become eligible for disability income should she become disabled. There is much more to this and I will address it in a later blog. But here are some basics.

The ONLY ways someone is eligible to receive benefits through the SSDI program are:

  1. Be disabled per Social Security’s rules and meet the minimum work and earnings requirements or;
  2. Be the dependant of a person who is receiving SSDI benefits or;
  3. Be the Substitution of Party (ie surviving family member or appointed person) of a deceased person to whom SSA still owes benefits to

Since this is a program you have to pay into to become eligible, this program is NOT a welfare program.  SSDI can be compared to the Social Security Retirement benefits in that a person has to work and pay into the program. SSDI is too often mistaken for SSI or Supplemental Security Income which IS a welfare  or “needs based” program.

What is SSI?

SSI is a needs based disability program through Social Security. SSI rules for medical eligibility are the same as SSI. SSI recipients must be very low income and have limited assets. He may not have the requisite earnings and time worked to have earned any SSDI benefits. A person who is eligible for an SSDI benefit that is below a certian threshhold may qualify for SSI in addition to his SSDI benefit. A disabled child whose parents’ income and assets fall below a certain threshold may be eligible for SSI. The thing to remember with SSI is that the medical rules are the same as SSDI but is based on the needs of the indigent claimant.

SSA keeps tabs on recipients of SSI to make sure that at no time does a claimant rise above the minimum income or assets to continue recieving SSI. If a person does rise above the threshold, SSA can stop the benefits and sometimes even demand return of any over-payments that may have been received by the claimant.

Who is eligible to receive Disability Benefits?

This is where things begin to get more complicated but I promise to keep it simple and break these issues down over the course of time.

Once a person becomes unable to perform “SGA” or Substantial Gainful Activity due to health problems she becomes medically eligible to receive disability through Social Security. I will focus on adult disability for now.

SSA has a five step sequential process in how it must determine if an adult claimant meets the medical requirements for eligibility. There are many thing that affects these steps but the basic breakdown is as follows.

1. Is the person working at “SGA” levels since he alleged his disability began? For 2016 a person earning more than $1130/mo is working at SGA levels and will likely be found not disabled right off the bat. SGA also refers also to how much a claimant works and working alot of hours may cause a person to be found not disabled. There are many variables that can be considered regarding these factors but for the most part if someone is working less than 30 hours and earning less than $1130/month due to an inability to work any more than this, he may still be found disabled despite the fact he is working. If a person has worked since his disability started and the work is under the monthly SGA amount or he has not worked at all, then SSA proceeds to step 2. (Yikes I can work while getting disability? Yes! I am saving that for another blog)

2. Does the claimant suffer from  a severe impairment? The claimant must suffer from a mental and/or physical condition that is so severe that it will be expected to prevent her from working at SGA  levels for twelve months; or result in death. Of course these conditions must be diagnosed by a medical doctor. If SSA finds there is a severe medical condition at this step the process moves to step 3.

3. Do the claimant’s  impairments meet or equal the criteria under certain medical conditions set forth by SSA? These lists of criteria are referred to as listings or body systems. In other words if your diagnoses, symptoms, and prognosis fit under certain specific disease listings then SSA may have to find you disabled. If SSA does not find that the claimant’s conditions fit into one or more of these listings then process moves to step 4.

4. Can the claimant return to his past relevant work? Past Relevant Work is work that a claimant has performed in the past for a period long enough to have learned each job. If SSA finds the person cannot perform any work he has done before then the process moves to step 5.

5. Can the claimant perform other work? What SSA means by ‘other’ work is any other type of work that is performed in the general national economy that the claimant might be able to perform.  SSA considers the claimant’s age, level of education completed, residual functional capacity (ie what can the claimant do now), and transfer-ability of job skills from past  work that could be used in other jobs.

If the claimant cannot perform any of his past work and any other work he may be approved for SSDI and/or SSI.

This I hope gives a clear basic picture of the Social Security Disability process. Please leave comments and questions here on the blog site, Facebook, or Twitter for me. I am open to your input and happy to answer questions.

Next up, “Why do so many people who should not get disability get approved for it?”

©2016 April L. Roberts and Aaria Consulting, LLC. All Rights Reserved.

 

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Filed under Basics of Social Security Disability, Disability Advocates, Medicare & Medicaid, Spouse's Benefits, SSDI, SSI, Uncategorized