A common LTD policy provision capping mental health and substance abuse benefits at 24 months — even if disability continues. Insurers force depression, anxiety, PTSD, and bipolar claims into this limit. Co-occurring physical conditions can extend benefits past 24 months.

SSA's mandatory analytical framework for every disability claim: (1) Are you working at SGA? (2) Is your condition severe? (3) Does it meet/equal a listing? (4) Can you do your past work? (5) Can you do any other work? Claims approve at Step 3 (listing) or Step 5 (medical-vocational allowance).

The internal review process required by ERISA before a claimant can file in federal court. Typically must be filed within 180 days of the denial letter. Failure to exhaust administrative appeals bars litigation.

Federal judges who conduct disability hearings and issue written decisions on appealed claims. ALJs are not bound by initial DDS denials and conduct a de novo (fresh) review of all evidence. ALJ hearings have the highest approval rate.

The complete file of evidence considered by the LTD insurer during the claim and administrative appeal. Under ERISA, this is the ONLY evidence the court can consider in litigation. Building the record correctly during the appeal window is the most important strategic decision in an LTD case.

The date a claimant alleges they became disabled. SSA reviews medical evidence to determine whether this date is supported. The AOD affects retroactive benefit calculations — earlier AOD means more potential back pay (up to 12 months pre-application).

An LTD policy definition that pays benefits only if the insured can't perform any job they're reasonably qualified for by education, training, or experience. Most policies switch from "own occupation" to "any occupation" after 24 months of benefits.

The fourth level of SSDI appeals (after initial, reconsideration, and ALJ hearing). The Appeals Council reviews ALJ decisions for errors of law or substantial evidence problems. Most cases are denied review; remand or reversal happens in roughly 12-15% of cases.

The deferential standard of review most federal courts apply to ERISA LTD denials. The insurer's decision stands unless it was arbitrary, capricious, an abuse of discretion, or unsupported by substantial evidence. Heavily tilts cases in the insurer's favor.

The base calculation SSA uses to determine SSDI benefit amount. Average of your highest-earning 35 years of wages, indexed to current values. The AIME feeds into the PIA formula that produces your monthly benefit.

Compensation and Pension Examination — a VA-arranged medical exam to evaluate service-connected disability claims. C&P exam reports become part of the C-file and are persuasive evidence in both VA and SSDI proceedings.

A veteran's complete VA claims file containing all medical records, service records, examination reports, and decisions. The C-file is powerful evidence in SSDI claims and is obtainable on request — most pro se SSDI applicants never get it added to their record.

A determination that a claimant was disabled for a discrete period (at least 12 months) that has since ended due to medical improvement or return to work. Approves retroactive benefits for the closed period without ongoing benefit eligibility.

A program that fast-tracks SSDI approvals for ~280+ serious medical conditions including aggressive cancers, ALS, early-onset Alzheimer's, and certain rare diseases. CAL claims typically approve in weeks rather than months.

A medical examination scheduled by SSA at the agency's expense. CEs are arranged when existing medical evidence is insufficient. Attending the CE is mandatory — refusing can terminate the claim. CEs are different from IMEs (which are conducted by private insurers).

Periodic review SSA conducts to verify ongoing disability. Frequency depends on expected improvement: 6-18 months (improvement expected), 3 years (possible), or 7 years (not expected). Failing a CDR can terminate benefits.

Annual increase to SSDI and SSI benefits to keep pace with inflation. Calculated based on the Consumer Price Index for Urban Wage Earners (CPI-W). Announced each October for the following calendar year.

The date a worker's SSDI insured status expires after they stop working. To qualify for SSDI, you must prove you became disabled on or before your DLI. After this date, you're no longer covered for SSDI (though SSI may still be available).

The most recent date the claimant performed substantial gainful work. Important for establishing the alleged onset date and for determining whether SGA-level work has occurred during the relevant period.

The Certificate of Release or Discharge from Active Duty. Documents service dates, MOS (Military Occupational Specialty), deployments, decorations, and discharge characterization. The foundational document for any veterans disability claim.

Federal agency administering veterans benefits including disability compensation, pension, healthcare, and education. VA disability is separate from SSDI and uses a different evaluation framework based on percentage ratings.

State agencies that make initial medical decisions on SSDI/SSI claims under contract with SSA. They obtain medical records, schedule consultative exams, and apply SSA's listing criteria to determine eligibility.

The formal name for SSDI cash benefits paid to disabled workers. Used in SSA documents and case law to distinguish from SSI or auxiliary benefits.

Materiality analysis under SSR 13-2p. If substance use is "material" to disability — meaning disability would resolve without it — the claim must be denied. Documented sustained sobriety with continuing disability is the path forward.

Federal law governing most employer-sponsored disability insurance plans. ERISA pre-empts state law, requires exhaustion of administrative appeals before litigation, limits judicial review to the administrative record, and bars punitive damages — heavily favoring insurers.

The date SSA determines a claimant actually became disabled, based on medical evidence. May differ from the AOD. Earlier EOD means more retroactive benefits; later EOD reduces back pay.

A 36-month period following the Trial Work Period during which SSDI benefits resume in any month earnings fall below SGA. Provides a safety net for beneficiaries attempting return to work.

A multi-hour evaluation by a physical or occupational therapist documenting exactly what physical activities a claimant can perform. FCEs produce objective, measurable evidence of functional limitations and are particularly powerful in LTD insurance disputes.

One of three modern VA appeal options. A senior reviewer re-evaluates the existing record (no new evidence) for errors of law or fact. Must be requested within 1 year of the rating decision. Average completion: ~5 months.

An examination by a doctor selected and paid by an insurance company or disability insurer (not your treating doctor). Despite the "independent" label, IME doctors often have ongoing relationships with insurers and tend to produce opinions favorable to the insurer.

SSA's official compendium of medical conditions and the criteria that qualify each as disabling. Organized by body system (musculoskeletal, mental, cardiovascular, etc.). Meeting a listing means automatic medical approval without needing to prove inability to work.

A claim that meets the specific criteria of a Blue Book listing. Listing-level claims are approved on medical evidence alone without RFC analysis. Most successful migraine, lupus, and cancer claims meet listing-level criteria.

Private insurance providing income replacement (typically 50-70% of salary) when illness or injury prevents work for extended periods. Distinct from SSDI. Most LTD policies are employer-sponsored and governed by ERISA. Common insurers: Unum, MetLife, Hartford, Cigna.

A physician witness who testifies at ALJ hearings to interpret medical evidence and offer opinions on listing equivalence or functional limitations. Not all hearings include MEs — typically scheduled when the medical record is complex or contradictory.

A form completed by a treating physician describing a patient's functional limitations in SSA-friendly language. Properly-drafted MSS forms are among the most persuasive evidence in disability cases, particularly when they address specific listing criteria or RFC limitations.

Approval at Step 5 of the disability evaluation when the claimant doesn't meet a listing but can't perform any work in the national economy given their RFC, age, education, and work experience. The most common approval path for chronic pain and complex multi-system claims.

Sexual assault or repeated, threatening sexual harassment occurring during military service. The VA has streamlined evidentiary processes for MST-related PTSD claims that often produce records useful for SSDI claims. We represent MST survivors with discretion.

Under the legacy VA appeals system, the document a veteran filed to appeal a rating decision. Replaced for new claims by the Higher-Level Review, Supplemental Claim, and Board appeal options under the Appeals Modernization Act (effective 2019).

The former name of what is now called OHO (Office of Hearings Operations). Renamed in 2017 but still used colloquially in older records and by some practitioners. Same function: where ALJ hearings are held.

SSA field office where ALJs hold disability hearings. Formerly called ODAR (Office of Disability Adjudication and Review). Arizona has two: Phoenix OHO (serves Phoenix metro and East Valley) and Tucson OHO (serves Southern Arizona).

The date a claimant became disabled under SSA's definition. Critical for back pay calculations. Established by medical evidence, work history, and claimant statements. May be alleged (AOD) vs. established (EOD).

An LTD policy definition that pays benefits if the insured can't perform the substantial duties of their specific job. Most policies use "own occupation" for the first 24 months, then switch to "any occupation." The transition is a common point at which insurers terminate benefits.

The functional criteria used to evaluate mental disorder listings (12.04, 12.06, 12.08, 12.10, 12.15, etc.). Requires "marked" limitation in 2 of 4 areas, or "extreme" limitation in 1: understanding/applying info, interacting with others, concentrating, adapting/managing self.

An alternative path for chronic mental disorder listings, requiring documented serious and persistent mental disorder with: (1) medically-documented history of 2+ years, (2) ongoing medical treatment, and (3) marginal adjustment.

An LTD policy provision excluding coverage for conditions for which the insured received treatment in a defined look-back period (typically 3-6 months) before coverage started. Frequently invoked to deny early claims.

Medical conditions the VA presumes are service-connected for veterans who served in qualifying locations and time periods. Examples: Type 2 diabetes for Vietnam vets exposed to Agent Orange; certain cancers and respiratory conditions for burn pit exposure under the PACT Act.

Your monthly SSDI benefit before any deductions, based on a progressive formula applied to your AIME. The PIA also determines benefits for dependents (auxiliary benefits).

Latin for "for oneself." A claimant who represents themselves without an attorney. Pro se claimants have substantially lower approval rates at the hearing level — particularly when vocational expert testimony is involved.

A predictive computer model that identifies claims highly likely to be approved and routes them for expedited processing. Similar to CAL but applies to a broader range of conditions. QDD claims typically decide within 20 days.

The first level of appeal after an initial SSDI denial. The same DDS that denied your claim reviews it again, usually with the same outcome. Reconsideration approval rates are typically 10-15%, making it the level with the lowest reversal rate.

An assessment of what work-related activities a claimant can still perform despite their impairments. Includes physical limits (sitting, standing, lifting), mental limits (concentration, social interaction), and environmental restrictions. The RFC is central to the Step 4 and Step 5 analysis.

The VA's percentage-based disability rating (0%-100%) based on the Schedule for Rating Disabilities. Multiple ratings are combined using the VA's combined ratings table (not simple addition). 100% schedular pays the maximum monthly compensation.

A VA determination that a disability is related to military service — through direct service-connection, presumptive service-connection (e.g., Agent Orange-related conditions), aggravation, or secondary service-connection. Required for VA disability compensation.

Private insurance providing income replacement for brief periods of disability (typically 3-6 months). Usually transitions into LTD if disability continues. Many STD policies are not governed by ERISA, allowing broader legal remedies.

Federal insurance program providing income to workers who become disabled before retirement age. Funded by payroll taxes (FICA). To qualify you need both work credits and a medical condition expected to last 12+ months or result in death.

Social Security Ruling governing fibromyalgia disability claims. Requires either the 1990 ACR criteria (widespread pain plus 11 of 18 tender points) or the 2010 ACR criteria (widespread pain plus symptom severity). Many fibromyalgia claims fail because the diagnostic record doesn't satisfy these standards.

Social Security Ruling governing how SSA evaluates pain and other subjective symptoms. Replaced the "credibility" analysis with a two-step framework: (1) Is there a medically-determinable impairment that could produce the symptoms? (2) How do the symptoms limit functioning? Central to chronic pain claims.

Social Security Ruling on evaluating headache disorders, including migraine. Establishes the framework for documenting headache frequency, severity, and treatment-resistance. SSA evaluates migraine under analogous listing 11.02 (epilepsy) per this ruling.

The earnings threshold SSA uses to determine whether work activity prevents disability eligibility. In 2026: $1,620/month for non-blind individuals, $2,700/month for statutory blindness. Earning above SGA generally disqualifies you from SSDI.

A modern VA appeal option allowing submission of new and relevant evidence. Requested within 1 year of the rating decision to preserve effective date. Often combined with TDIU claims or used after Higher-Level Review.

Federal need-based program for disabled, blind, or elderly people with limited income and assets — regardless of work history. Unlike SSDI, SSI doesn't require work credits but has strict income and resource limits ($2,000 single / $3,000 couple).

The section of the Social Security Act that covers retirement, survivors, and disability insurance (including SSDI). Title II benefits are based on work history. Compare to Title XVI (SSI).

The section of the Social Security Act that covers Supplemental Security Income (SSI) — needs-based benefits for disabled, blind, or elderly individuals. Compare to Title II (SSDI).

VA benefit allowing veterans with service-connected conditions preventing gainful employment to receive compensation at the 100% rate without having a 100% schedular rating. Requires one condition rated 60%+ OR multiple combining to 70%+, plus inability to maintain substantial gainful work.

The principle that treating physician opinions deserve substantial weight in disability decisions because of their longitudinal knowledge of the patient. SSA's regulations were modified in 2017 to give less automatic deference to treating sources, but they remain important evidence.

A 9-month period during which SSDI recipients can test their ability to work without losing benefits, regardless of how much they earn. The months don't need to be consecutive. A TWP month is any month with earnings over $1,160 (2026).

An expert witness who testifies at ALJ hearings about jobs that exist in the national economy and whether the claimant could perform them given their RFC. VE testimony is often the decisive factor at Step 5. Skilled cross-examination of VEs is critical to winning hearings.