Disability cases get denied for what reasons ?

Why do disability cases get denied? On the face of it, you could simply say that social security disability and SSI disability cases get denied because of a failure to satisfy the social security administration definition of disability. What is that definition? Essentially, it can be boiled down as follow: you must have an impairment that is severe, it must last at least one year or longer, and it must prevent you being able to earn at least SGA, or substantial gainful activity (a somewhat arbritrary monetary amount that is adjusted each year for inflation) while working at either a past work job (a job you've done in the past 15 years) or while engaging in some form of "other work".

However, this is a superficial answer and if you buy into it you are forced to accept the absurd notion that all disability decisions rendered by the social security administration are accurate and fair. The truth, of course, is that many of these decisions are not fair, not objective, nor accurate. And to validate this supposition, you only need to look to the fact that at least half of all claimants who appear at a social security hearing win their cases. Yet, these were the same individuals who were previously denied at the disability application level and at the reconsideration appeal level.

So, let's approach the issue in a different way. Why do cases get denied? In most cases, it boils down to the medical evidence, or, rather, a general lack of medical evidence.

Many claimants simply do not have enough medical record documentation to substantiate their case. Sometimes this is the result of not being treated at all for a specific medical condition, and sometimes this is the result of not understanding the importance of being treated for a condition so that documentation may be generated which may be useful for proving a claim.

In the former example, I can state that it is a fairly common occurrence for disability examiners (the individuals who make decisions on disability claims for SSA) to open new cases, observe that "depression" has been listed as an allegation (a claimed impairment), and yet find not one single instance of the claimant ever having received treatment for depression.

In the latter example, I have seen numerous cases involving claimants who did not understand that it is not enough to have simply received a prior diagnosis for a potentially disabling impairment. To be considered disabled and eligible to receive continuing disability benefits, a claimant's records must state, in some way, that their condition currently limits their ability to work (at the SGA level, as mentioned earlier). In other words, a two year old diagnosis of rheumatoid arthritis is meaningless without the accompany evidence to state how limiting the condition currently is.

Of course, this is understandable since the social security administration does little to nothing to educate claimants about the manner in which disability cases are determined (and to be honest, even the individuals who work in social security field offices know little about disability adjudication since they don't actually work on the claims themselves, but, rather, disability examiners do).

What can a claimant do to assist the development of their case, from a medical record standpoint? Here's a short three-item list of things to consider.

1. If you plan to list a physical or medical impairment on your application for disability, make sure it is one that you received treatment for. Does this mean that you shouldn't list depression or anxiety or back pain if you have not been treated for any of these conditions? Not at all. However, if you intend to list them as allegations and have not been treated for them, make it a point to get treatment soon, because without medical record documentation, it will be difficult to demonstrate that a condition, physical or mental, has any bearing on your ability to work.

2. If you plan to file for disability or already have a pending claim for SSD or SSI, make sure that you maintain regular visits to your treatment provider(s). As I stated earlier, it won't be enough to have simply received a medical diagnosis for a specific condition. Social security disability and SSI disability are two programs that do not work that way. To prove your case, you will need to demonstrate (via your medical records) that you are currently disabled. And to do that, your records need to illustrate a certain level of functional limitation that precludes the ability to work.

3. At some point, view copies of your own medical records, simply to get a handle on what your records currently say about you. Why do this? Because you may (or may not) be surprised at what the records have to say. And you may also be surprised about the absolute lack of detail, with regard to the notation of functional limitations, contained within them. Physicians typically do not put much effort into recording a patient's functional capacity and some record their treatment notes in a fashion that make them nearly useless for proving a disability claim.





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