Often times those who potentially have disability claims will be hesitant to file a claim because they simply don’t know what to expect. The following list is meant to generally inform potential applicants of what to expect during the process; in order from application to appeals.
Point 1
When you apply for Social Security Disability or Long-Term Disability it’s your responsibility to provide the agency or insurer documentation substantiating your disability.
- While the Agency or insurer may write to your medical providers to request documentation. If they are not successful in doing so, your claim may be denied as a result.
- In all my applications I write to medical providers for records and submit them to the agency/insurer with proof of submission.
Point 2
Your doctor’s opinion is not binding on the Agency or insurer.\
- After record submission, the agency or insurer will use internal or contracted medical professionals to review the records.
- They will come to an opinion as to the applicant’s residual functional capacity – meaning what the applicant can or cannot do in terms of physical limitation.
- There is an exception within SSA that if one meets a certain level (generally pretty high) of reduced capacity as a matter of definition they are “disabled”; this is a small number of applicants.
- On the flip side, SSA disqualifies a portion of people at this point (generally people under 50 yrs old) because even though they have reduced functional capacity, it isn’t enough to eliminate them from achieving the duties of sedentary, unskilled positions.
Point 3
For claims not automatically granted for meeting a large reduction of capacity (or presumptively denied for being qualified for sedentary non-skilled occupations), the SSA or insurer must run the applicant’s reduced functional capacity against the functional capacity required by past relevant work (the work done for the last 5 years) or occupations to which the applicant has transferrable skills.
- The agency or insurer will (with the assistance of software) compare the required skills and functional requirements of approximately 13,000 occupations in the Dictionary of Occupational Titles against the skills and functional capacity of the applicant.
- There are 41 skills and exertional functional factor ratings for each occupation in the Dictionary.
- If there is a match – 1) for skills and 2) the job requires less functional demand than the applicant has ability then the applicant is found “not disabled”
- If there are no occupations to which the applicant can transfer via skills or the functional requirements are too high, then the applicant should be ruled “disabled”.
Point 4
There are mandatory internal appeals that must be exhausted as a matter of law/contract before a hearing (in the case of SSDI) or before filing a lawsuit in the case of insurance matters.
- For Social Security the application process is about 6 months, if denied the applicant must request reconsideration which tacks on approximately another six months processing time, this is before the applicant can apply for a hearing with a judge (which will take around another 6 months to 1 year before the hearing is scheduled/heard/and a decision rendered.
- In insurance matters the applicant generally has 180 days to appeal, the insurer has up to 90 days to issue a decision, then the applicant can sue on an adverse decision.
Point 5
The applicant cannot just write a letter on appeal and expect a different outcome.
- Appeal is a time to attain additional evidence and strengthen existing evidence.
- Some files are medically incorrect in that they do not indicate the correct residual capacity.
- Some files are occupationally incorrect in that the claimant either does not have the skills to transfer or they have not accounted correctly for functional limitations.
- Most of the time the SSA and insurers do not consider non-exertional limitations – that is for example sit/stand limitations, off task limitations, required days off limitations (these should be revisited with treating physicians or expert reviews).
Point 6
Ability to work means the ability to fulfill the material functions a job on full-time and consistent basis — 40 hours a week, 50 weeks a year.
- This is often ignored by insurers that will video people on “good days” and extrapolate that the employee can function like this all the time.
Point 7
For the claimant under 50, non-exertional factors (e.g. sit/stand requirements, off task — rest requirements, days off) become very important to get a disability ruling.
- Social Security in particular drops “transferability” from the analysis by requiring those under 50 to show they can’t do an unskilled occupation.
Point 8
Long-term disability policies will almost always have a coordination clause that both requires the applicant apply for SSDI benefits, and reduces benefits by the amount of any benefits received from other sources such as SSDI.
Point 9
Even if the applicant wins an appeal, the SSA or an insurer can reverse the decision at a later date if they later find lack of medical support or improvement in conditions, unless it’s a final ruling by a court.
- This is why at some point LTD claimants will usually find it prudent to settle/surrender the claim/policy in exchange for a lump sum.
- SSA isn’t as aggressive in this but does engage in continuing review (more so in cases where the ALJ orders a specific continuing review).
Point 10
The applicant is able to voluntarily return to work (if they believe they are able) under the SSA ticket to work program, and most private policies now have work trial programs to try to encourage claimants to return to attempt to work without fear of losing benefits immediately or having to re-apply for benefits.
Our Experienced Team Can Help
If you find yourself in the position of considering an application for Social Security disability or long-term disability benefits and are not sure of the next step to take, please do not hesitate to contact The Schipper Law Group or call us at (248) 729-2414. We have assisted hundreds of clients in getting the benefits they deserve and would be happy to help you.
