Articles Posted in Social Security Disability Insurance

When applying for Social Security disability benefits, claimants should be aware of the two types of disability programs available. The Social Security Administration (SSA) offers Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI).
For both programs, the SSA reviews whether the claimant meets the applicable definition of disabled. The SSA defines “disabled” as follows:

An individual shall be considered to be disabled for purposes of this title if he is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than twelve months.

On the SSA’s website, the SSA further describes its standard of disability and how it decides whether the claimant is disabled. If adequate proof of disability is not provided, a claim for either SSDI or SSI benefits will be denied. If a claim for SSDI or SSI benefits is denied, the claimant has a maximum of 65 days to timely appeal.

Social Security Disability Insurance (Title II)

SSDI benefits act as a federal insurance program to workers. Taxes are deducted out of workers’ payroll checks. The tax deductions serve as a premium to qualify for SSDI. If a worker has earned 20 Social Security credits in 10 years, then they will have enough work credits to be eligible or SSDI benefits. The SSA’s website provides more details on how work credits are earned.

To be eligible for SSDI benefits, the claimant must also be under 65 years old. For SSDI claimants, there are no requirements that the claimant have a limited amount of resources. However, as of June 2014, the SSDI claimant cannot be earning $1070 per month in wages. Of course, to be eligible for SSDI benefits, claimants must meet all other work earnings requirements and proof of disability requirements.
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Functional Capacity Evaluations (“FCEs”) are a type of test used to determine the severity of someone’s physical impairments. FCEs are common in disability insurance claims, workers compensation claims, and other contexts where the level of a claimant’s injury or sickness needs to be evaluated.

FCEs are usually administered by a physical therapist or physician who specializes in occupational medicine. Common measurements during an FCE include how much the claimant can lift, how much they can push and pull, how long they can walk and stand, how long they can sit, the ability to reach in all directions, the ability to grasp and manipulate with each hand, the degree to which a claimant can move all joints, the ability to squat and bend, and the ability to stoop and balance. FCEs can vary in duration: some FCEs are very brief – only a couple of hours – and some FCEs are actually performed over the course of two days.

In long term disability insurance cases, many insurance policies allow the insurance company to request that a claimant undergo an FCE at a facility of their choosing. A claimant’s refusal to undergo such testing may give the insurance company grounds to deny disability benefits. Therefore, it is likely that the claimant will have to comply with the insurance company’s request for an FCE. However, a claimant may want to consider the following tips before attending an FCE:
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As type II diabetes becomes more and more common, many people suffer from peripheral neuropathy, which is a result of nerve damage. Neuropathy may cause weakness, pain, or numbness in the hands and feet, although it may occur in other parts of the body. Sometimes this nerve damage becomes so severe that it prevents people from maintaining their normal lifestyle, including the ability to work.

If neuropathy forces someone to stop working and they apply for disability benefits, there are some important tips to help document the disability. First, establishing treatment with a neurologist is very important. A Neurologist is the appropriate specialist to diagnose and treat neuropathy. If a person does not properly document their neuropathy, they will face a tough challenge in having their disability claim approved. Diagnosis requires considering full medical history, neurological examination (such as checking reflexes, sensation, and coordination), physical examination, and appropriate testing. The testing most commonly used for diagnosing neuropathy includes electromyography, nerve conduction tests, nerve biopsy or skin biopsy, blood tests, MRIs or other medical imaging tests, and lumbar puncture (or spinal tap).

Second, it is necessary for the disability claimant to maintain regular treatment with their neurologist and other medical care providers. If it is shown that the disabled person has not complied with recommended treatment, then disability benefits may be denied.
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Applying for disability benefits from the Social Security Administration is a layered process. If a claimant is denied initially, then they must file a request for reconsideration. If their request for reconsideration is denied, then they must file a request for a hearing before an Administrative Law Judge. Claimants should be aware that each of these appeals must be filed within 60 days of receiving a denial letter.

At the hearing level, the claimant’s chances of success improve. However, even strong claims can be denied by an Administrative Law Judge for a variety of reasons. It is a nationwide trend that more Social Security disability cases are being denied.

Appeals Council

When an Administrative Law Judge denies a claim, then the next step is to request a review from the Appeals Council. This request must be made within 60 days of the denial notice. The Appeals Council is located in Falls Church, Virginia and performs a review of the claimant’s evidence. There is no hearing at this stage, and requests for review must be made in writing. Unfortunately, the time it takes for the Appeals Council to make a decision is extremely long. The Social Security Administration’s website states that “the average processing time was 395 days” for the period of October 2011 – September 2012.
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If a disability forces someone to stop working, he or she may be unsure of available disability benefits. In Indiana, some employees may be eligible for the Public Employees’ Retirement Fund (PERF) and Indiana Public Retirement System (INPRS). Indiana employees who may be eligible for these benefits include those working at public universities, school corporations, municipalities, and state agencies.

Disability Benefits under PERF
As of January 2014, the PERF Employer Handbook is available online at the following link: http://www.in.gov/inprs/2416.htm#. According to the PERF Employer Handbook, employees are eligible to apply for disability benefits if they meet the following criteria:

Have five or more years of creditable service under PERF before the termination of salary, or employer provided income protection benefits (disability insurance), or leave under the Family and Medical Leave Act (FMLA), or worker’s compensation benefits,

Are determined by the Social Security Administration to be disabled, and
Are receiving salary, or employer provided income protection benefits, or are on leave under the Family and Medical Leave Act (FMLA) as of the onset date established by the Social Security Administration.

If an employee is eligible for PERF disability benefits under the above criteria, they should apply for disability benefits as soon as possible. As mentioned in the first requirement, the employee may first receive “employer provided income protection benefits” or disability insurance. Employer provided income protection benefits differ from PERF disability benefits and requires a separate disability application – usually this application should be filed as soon as the employee stops working due to disability.

Even though the PERF Employer Handbook sets out the above criteria, Indiana Code actually lists an additional requirement once PERF disability benefits have been approved: “at least once each year until the member reaches age 65, PERF verifies the member’s continued disability.” Ind. Code 5-10.2-4-6. If an employee is approved for disability benefits, then they will continue to receive benefits until age 65 so long as the Social Security Administration continues to approve disability and the employee provides the appropriate information to PERF.
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Headaches are an uncommon occurrence for most people. For some people, though, headaches occur frequently, and can be so severe and intense that they are debilitating. When headaches occur frequently, they can force a person to stop working altogether.
Disabling headaches are a non-specific symptom and may be caused by a range of conditions. Therefore, it is crucial for a person to seek medical treatment to learn the cause of their headaches. If a family doctor cannot diagnose the condition causing headaches, then the patient will likely be referred to a neurologist.

Objective testing that explains the cause of the headaches may strengthen the disability claim, so it is important for the patient to undergo any sort of applicable testing. However, the cause of headaches is often not detectable in CT scans or other testing. If the headaches are not explained by test results, then the patient should work with their physicians to determine if any environmental factors are contributing to their headaches.

In cases where the headaches are severe, a patient may be experiencing migraine headaches. Migraines are characterized by moderate to severe headaches along with some of the following symptoms: photophobia (sensitivity to light), phonophobia (sensitivity to sound), pulsating, pain on one side of the head, and nausea/vomiting. Again, it is essential for a patient to explain his or her symptoms to their physicians so that the best course of treatment can be planned. Treatment for migraines may include prescription medications, injections, and attempting to remove trigger sources.
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Some may associate disability with physical impairments like the inability to walk or stand. However, disabilities are not limited to physical ailments and many people suffer from disabling mental health conditions. Proving that a mental health condition is disabling can be challenging because disorders like major depression and bipolar disorder may take time to conclusively diagnose.

In order to prove that a mental health condition is disabling, a person’s medical treatment must document the severity of symptoms over an extended duration. This requires that the claimant regularly treat with a psychiatrist and/or licensed psychologist. Although a therapist or counselor may treat someone for mental health problems, the Social Security Administration and long term disability insurers give more weight to the opinions of licensed psychologists and psychiatrists rather than therapists or counselors. Generally, the Social Security Administration affords more weight to the opinions of accepted medical sources, like a treating psychiatrist or psychologist, while long term disability insurance companies more freely pick-and-choose which medical opinions they rely upon to make a determination.

Severe mental health problems can also be evidenced by visits to the hospital and inpatient treatment. Some mental health listings under the Social Security Administration require episodes of decompensation. Medical records of a hospitalization can serve as strong evidence of an episode of decompensation. Moreover, the opinions from third parties, like a family member or friend, may help show episodes of decompensation. Any person who has been able to observe the claimant’s personality or behavioral health over time can provide relevant evidence revealing the severity of the claimant’s mental health condition.
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Most disability insurance policies do not explicitly require that a claimant provide objective evidence to support their disability. Yet, it is all too common when a claimant receives a denial letter in the mail from their insurance company claiming that disability benefits have been denied due to a lack of objective evidence. Unfortunately, many courts have determined that insurance companies are permitted to rely upon objective evidence when making a determination of disability.

Objective medical evidence is documentation from tests including but not limited to: medical resonance imaging (MRIs), x-rays, blood tests and other chemical tests, electrophysiological studies (electrocardiogram, electroencephalogram, etc.), and psychological tests. Unfortunately, not all medical conditions are detected in these various types of objective testing, which can put some disability claimants in a challenging condition. For example, someone with fibromyalgia may not be able to produce traditional objective medical evidence of their condition. For more information about fibromyalgia, see this entry: Fibromyalgia Disability Claims.

In order to improve the chances of being approved for disability insurance benefits, a claimant should make sure that their treating providers have ordered all of the necessary tests to properly diagnose their condition. Without objective documentation, the insurance company is much more likely to deny benefits. For example, a claimant with Multiple Sclerosis should undergo any applicable testing, like an MRI of the brain, a spinal tap, and tests measuring electrical activity in the brain. For more information about Multiple Sclerosis, see this entry: Multiple Sclerosis Disability Claims.
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In both private disability insurance claims and Social Security disability claims, vocational evidence is usually considered when determining whether an individual is disabled or not. Vocational evidence is information about an individual’s occupation or the occupations they may be able to perform when considering their functional capacity, training, education, and work experience. This kind of evidence can consist of job descriptions from the employer, self-reported job duties, information from the Dictionary of Occupational Titles or other similar resources, and the opinions of vocational experts (also known as vocational rehabilitation consultants).

Long Term Disability Insurance

When someone becomes disabled and their employer provides long term disability insurance, then that person often applies for disability benefits under the requirement that they are unable to perform the duties of their “own occupation.” Under this type of definition of disability, the individual must show to the insurance company that because of their medical condition(s), they cannot return to their previous job.

During this stage of the disability claims review, the insurance company may consider the individual’s job duties and may gather information from the employer, the claimant, publications like the Dictionary of Occupational Titles, or a vocational expert. It is most common for the insurance company to at least gather the employer’s job description as part of their claims analysis.

Most private disability insurance policies limit the time for which a person can receive disability benefits under the “own occupation” definition and after a predefined amount of time (often 24 months), the definition of disability requires that the individual prove that because of their medical condition(s), they cannot perform the duties of “any occupation”. At this stage of the disability review, vocational evidence becomes even more important because the claimant has to prove that there are no occupations he or she can perform. The insurance company may use the opinions of vocational experts and resources like the Dictionary of Occupational Titles or ONET (Occupational Information Network) to find other occupations that the claimant may perform.
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After claimants go through the long process of completing paperwork to apply for Social Security disability benefits, it is common for them to receive the unfortunate news that their claim has been denied. The Social Security Administration (SSA)’s initial review is conducted by a state agency, the Disability Determination Bureau (DDB). The DDB is responsible for processing the claim, ordering consultative examinations if necessary, obtaining medical records, and determining whether the claimant meets the standards of Social Security disability benefits.

Request for Reconsideration

About 75% of claims for Social Security Disability Insurance and Supplemental Security Insurance are denied. A claimant has a maximum of 65 days from the date of the denial letter to appeal the decision. It is of the utmost importance to file a timely appeal. Otherwise, a denied claimant may be forced to file a new claim unless they can prove that there was an exceptional circumstance to explain why their appeal was not timely filed. When the claimant is appealing the DDB’s initial denial, this is called a “request for reconsideration.” A claimant has the right to legal representation and a qualified attorney can help a claimant file a request for reconsideration.
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