The top four reasons why Social Security Disability cases are denied at the initial and reconsideration stages of review

In thinking about my cases over the past year, I realize I can see patterns in why Social Security Disability cases are denied.  I am going to summarize them here.  Before I do, however, a few points are worth mentioning.  First, I only see the denied cases.  I see people who have been denied Social Security at the initial and reconsideration stages.  People who win their cases do not seek out my help.  Thus, it seems to me that Social Security is always denying cases because that is what I see.  Second, my comments are only based on my own cases.  Other attorneys may have different experiences.  With that in mind, here are the top four reasons Social Security Disability cases are denied.

1.  The claimant has had little or no medical or mental health treatment.

A claimant has to prove he or she is disabled.  If there are no medical records because the person has not sought out treatment, the Social Security Administration (“SSA”)  is likely to deny it.  If a claimant does not hurt badly enough to see a doctor, the SSA feels the claimant must not be disabled.

Now, I often hear my clients say that they have no medical insurance and they cannot obtain treatment.  This may be true for some folks, but if you live in Solano County or San Francisco County, indigent claimants may obtain medical help.  In Solano County, folks may apply for County Medical Services Program, “CMSP.”  In San Francisco, the program is called “Healthy San Francisco.”  There is no excuse for not obtaining medical care if you live in one of these two counties.  Many other counties also have similar programs.

2.  Social Security did not obtain the records prior to making a decision

At least 95% of the time in the cases that I see, the SSA makes a decision based on an incomplete record.  Although Social Security may request the records, they do not always receive them.   In my own practice it often takes multiple attempts to obtain medical records.  My assistant and I spend a lot of time following up on records’ requests.  Just because a claimant tells Social Security about a medical doctor who has provided treatment  does not mean that Social Security orders records from that source.  If a claimant wants to make sure that every record is considered, he or she needs to obtain the records and bring or mail them in to the Social Security district office.

It is often appalling what I see when I receive a copy of the file after my client has requested a hearing in front of an administrative law judge.  (Soon after the request is filed, the hearing office mails the attorney a CD and/or a link to obtain the file online.)  Sometimes I see that the SSA made only one attempt to obtain records and did not follow up.

Other times I see that the medical source sent Social Security a bill requesting SSA to pay for the copies before they would send the records.  More often than not, SSA did not pay the bill and thus the medical source did not send the records.

Another common scenario is that a claimant alleges a condition which occurred two years ago but the SSA only requests one year of medical records.  SSA then denies the claim because the claimant did not prove he or she was disabled on or before a certain date.  The claimant was denied because Social Security did not request those older records!

3.  The claimant is under the age of 50

Sad, but true.  If a claimant is under the age of 50 and even with convincing medical and/or mental health evidence, the claim is likely to be denied.  The SSA believes folks under the age of 50 can work either at their past job or some other job.  The SSA’s attitude is if folks under 50 are not working, it is because they choose not to do.  This is not to say that folks under 50 cannot win.  They can win, but they win at the hearing stage – the third level of review.  It is rarely granted before then.

4.  The Social Security Administration works in a culture of “no”

In my opinion, the SSA’s attitude at the first two levels of review is, “How can we deny this claim?”  The review of a claim is not an objective look at the evidence at the first two levels.  They are looking for ways to deny.  When reviewing a file, I look at the internal notes of Social Security personnel.  The disability examiner’s language to the reviewing doctor is something like, “Can we affirm the prior denial?”  It is not written from a perspective of balance and fairness.

I see many files where people gave up after the initial or reconsideration stage.  They did not want to go forward with a hearing in front of an administrative law judge.  They then filed again.  They wasted time and they lost money in starting over again.  I think the SSA wants people to give up.  Do not be freaked out by the hearing stage of the process. This is actually the best level because you  finally will see the person making the decision.  You have the opportunity to tell the decision maker why it is that you cannot work.  If we could skip the first two steps of review and go immediately to the judge, I think the system would work faster and better.

What can be learned from these patterns of denials?   The most important concept to take away is that if you are a claimant, you will need to seek medical treatment.  In my review of cases, no treatment equals no benefits.  Another important lesson is that you have to collect the evidence if you want it considered.  You cannot depend on Social Security to do it.  Finally, you have to hang in there and expect to appeal.   The system is not set up to look at your case objectively from the start.   Chances are good that your claim will be denied at the initial and reconsideration stages through no fault of your own.  If you do not appeal, you cannot collect benefits.

I would be interested in hearing about  your experiences with denials and what patterns you all see.  Feel free to comment.

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3 Responses to The top four reasons why Social Security Disability cases are denied at the initial and reconsideration stages of review

  1. Also, the disability determination office (DDS) is taught to be very strict during the first two stages as there is very little contact with the claimant during these stages. Thus, they cannot be lenient based on paperwork alone.

    What do you think about directly holding a hearing after paperwork has been filed in order to speed up the process for claimants?

  2. Jack Toliver says:

    Wish I had known about this blog in Dec2000, the last available filing date for a SSDI client, who still has an SSI case going, but she had not pursued medical review of her condition, since corrected, and the “barn door” had closed. The crutial point here is don’t stall once you are unable to work because of a medical condition. Get to a doctor. If you have a work history, you’ve likely paid into the system long enough and are eligible for SSDI, but will need the proof that your condition is the cause of your not being able to be “gainfully employed” in lowest levels of work. And make sure you also file an SSI case with your SSDI one, they are based on different criteria.

  3. I would add to your list two other factors: 1 – SSA wants on-going (“longitudinal”) treatment records showing regular treatment; and 2 – judges expect physicians to translate medical impairments in to specific work limitations (which is what a good functional capacity form or narrative report can do). In my experience, judges weigh the medical evidence about 85% and testimony about 15%.

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