It’s no secret that insurance companies will look for any reason to deny a claim, and sometimes will deny it for no reason at all. The Social Security Administration is no different. With a high rate of early denials, SSA knows that a good percent of denials will not file an appeal. The appeal process is regarded as rigid and complex, and many people simply don’t have the patience or the stomach to pursue it. Those that do, especially with the help of good representation, are often rewarded with a “Favorable Decision” following a hearing with a judge. But why is it such a lengthy battle before our own government will approve disability benefits? Here are 3 reasons why SSA denies disability benefits before a hearing.
#1 - The 1-Year Rule
SSA provides disability benefits for a severely diagnosed medical condition (or conditions) that has lasted or is expected to last for at least 12 months or is expected to end in death.
Since many people file for disability within a few months of when they stop working, it is common for both the initial determination and first appeal decision (Request for Reconsideration) to be made before 12 months has passed since the claimant has last worked. Thus, the most popular basis for a denial by SSA includes the speculative statement “your condition is expected to improve.” This is a difficult assertion to refute since we have yet to invent a time machine to provide SSA with future medical records. And trust me, I have seen this denial reason for conditions that are known to be progressive or chronic in nature.
Since it usually takes at least a year to have a hearing with a judge, there is a statistical spike in approvals at the hearing level because the judge is able to look at a full 12-month+ period of medical records that document actual medical improvement (or lack thereof) with at least some conservative treatment.
#2 - Quack Doctors
As part of the disability determination process, it is common for SSA to schedule consultative exams for claimants to attend. There are various types of consultative exams that you may be scheduled for depending on your disability. These exams include physical, psychological, neurological, and more. The exam is paid for by SSA. While examining medical sources are supposed to be neutral and objective in their findings despite receiving ongoing pay from SSA for conducting exams, their medical opinions are often based on a minimal encounter with the claimant. Some clients have reported that their physical exam did not last longer than 10 minutes. Other clients have found untrue statements when reviewing the CE report (i.e., doctor’s claiming that certain tests were administered when they were not).
SSA determinations are commonly based on the opinions and findings of medical doctors who have seen the claimant just once, as well as medical consultants who are paid by SSA to review records and provide an opinion as to the claimant’s physical and mental limitations. How can a doctor who spends 10 minutes with a claimant offer an opinion that the claimant can sit for 6 hours in an 8 hour period?
Fortunately, judges are tasked with reviewing all the evidence, including opinions from the claimant’s own doctors (known as treating sources). While it’s up to the judge to assign credibility to medical opinions as he or she deems fit, there’s a great argument that a treating source’s opinion should be given greater weight than the opinion of a medical consultant or consultative examiner with little or no interaction with the claimant.
#3 - Technicalities
Finally, a lot of claims are rejected on the basis of technicalities like missing deadlines, incomplete forms, or erroneous information. Sometimes claimants make minor errors as a result of the complex application process, which ultimately results in their denial. We advise carefully reading everything SSA sends and taking your time filling out any forms they need in order to prevent getting a technical denial. Additionally, if you intend to file an appeal, get started right away to avoid missing any deadlines.
To ensure you don’t miss any important information, be sure to stay in touch with your case manager at the Disability Determination Services (DDS). Case managers frequently call claimants to get new details or clarity on a matter. If you miss these important calls, your claim may be denied. It can be helpful to have an attorney representative in these situations. Having representation ensures that your claim will stay up-to-date and on track because your paralegal will stay in communication with your DDS case manager for you.
Receiving an early denial from SSA can be disheartening, but bear in mind these reasons for early denials and remember that the majority of claims are ultimately approved at the hearing level. Make sure to file your appeal before the 60-day deadline, and consider hiring an attorney to represent you and ensure your claim is on track to win. If you’ve received a denial, don’t lose hope!
