Life is full of uncertainties. People get hurt, develop illnesses and find themselves unable to work. The bills don't stop even when the income does. This article will discuss the process of how to appeal the denial of a Social Security disability insurance benefits claim.
To make this process clearer, I'll use the hypothetical case of Deanna Jones. Ms. Jones has worked as a sales person in a large discount store for fifteen years. She develops diabetes which at first is manageable by medication. Unfortunately the diabetes becomes more severe and she is placed on insulin.
She begins to suffer from fatigue and diabetic neuropathy in her feet which creates even more problems for her because she is required by her job to stand up 40 hours per week. Her employer makes an effort to give her lighter duties but eventually her health problems are so bad that she can no longer do her job and she is fired.
She begins her application for Social Security Administration ( SSA ) disability insurance benefits by going to the local Social Security office. She completes their application and signs medical releases authorizing the SSA to obtain her medical records.
The local office forwards Ms. Jones file to Raleigh where a state agency called the Disability Determination section reviews the material to make a determination as to whether Ms. Jones meets the qualifications to receive disability benefits.
If the claim is approved, then the system moves on efficiently and Deanna begins to receive monthly disability checks after a five month waiting period from the onset date that the SSA determines she is disabled.
However if the SSA determines that Deanna is not disabled, then she will receive a letter from the SSA called the initial denial. This letter is mostly a form but will include a brief listing of all the medical information which the SSA relied upon in making the decision to deny her claim. Deanna then has 60 days from the date of the denial letter to appeal her claim.
If she does not appeal within the 60 day period then the SSA will close her file and take no further action. Obviously it is important to file a timely request for the next level of review.
A substantial number of people who have filed disability claims become discouraged by this initial denial letter and just let their claim drop. This can be a mistake as many claims that are initially denied are ultimately approved by an Administrative Law Judge.
The next level of appeal after the initial denial is the Reconsideration. Deanna can request the Reconsideration by either going to the local SSA office to pick up the forms or by calling them and requesting the forms be sent by mail. The Reconsideration request forms must be mailed within the 60 day period after the initial denial. These forms are fairly easy to complete.
They essentially consist of a request for reconsideration and a statement as to any changes that may have occurred in Deanna's medical condition and any medical treatment she has had since her initial application. Deanna should carefully review the list of medical sources of treatment on the denial letter to see if the SSA may have missed any medical providers who could provide helpful information about her condition.
Deanna will not have the right to personally appear before the Agency making the initial denial or Reconsideration determination. Those two steps of the claim process are done by staff obtaining and reviewing various medical documents. However she may very well be contacted by telephone to discuss her situation with the case worker assigned to her claim.
The Reconsideration is made again by the State Agency Disability Determination. A different set of employees reviews the reconsideration requests, but usually the results are the same as the initial decision and they deny the claim.
Deanna will then be notified by mail that her claim has been denied at the Reconsideration level. As in the Initial Denial stage, Deanna then has 60 days to request the next level of review which is a hearing before an Administrative Law Judge. Once again this request must be made within the 60 days or the case is closed and the SSA will take no further action on the claim.
The hearing before the Administrative Law Judge is extremely important. It is the only point in the whole process where the Claimant actually gets to appear in front of the person who is deciding if she is disabled.
The Administrative Law Judge is independent of the SSA and will make a new decision based upon the evidence that is presented to him at the hearing. The Judge will have reviewed Deanna's case file and any additional medical information submitted by her or her attorney prior to the hearing.
The Administrative Law Judge is not bound by the fact that Deanna has been denied twice by the State Agency.
The hearing before the Administrative Law Judge is closed to the public. In some cases the Judge may have the case assigned to a doctor paid by the SSA to render a professional opinion regarding the Claimant. This doctor will not personally exam the Claimant but will have reviewed the Claimant's medical records and will observe the hearing and may ask questions of the Claimant.
The doctor will then offer expert testimony regarding the Claimant's medical condition. In some cases the Judge may also assign a Vocational Expert to review the file and attend the hearing.
The Vocational Expert will then offer expert testimony as to whether the Claimant is able to maintain full time employment based upon the claimant's work history, physical limitations, educational background and other vocational factors.
The Judge typically does not announce his decision after the hearing but writes a written decision outlining the reasons for his decision. The Judge will frequently overrule earlier denials and grant the disability claim.
However if the Judge denies Deanna's claim, then she has another level of appeal to the Appeals Council. The Appeals Council is in Virginia and Deanna will not have the opportunity to personally appear before this agency.
The Appeals Council can approve the Judge's decision, overturn his decision or send it back to the Judge for another hearing to take additional evidence. If the Appeals Council upholds the denial of Deanna's claim then she has the right to file a complaint in the U.S. District Court to review the Appeals Council's decision.
As shown above the entire process is fairly complex. However with adequate preparation and with competent legal representation many disability claims that are initially denied by the SSA can be approved at the Administrative Law Judge hearing.
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