Reasons First Time Applicants are Denied Social Security Benefits

Strengthen your disability benefits claim. Learn the most common reasons why most applicants for Social Security Disability are denied the first time they file.

There are medical and non-medical reasons why your Social Security Disability Insurance application may be denied.

Some of the more common reasons to have SSDI denied include:

• Incomplete forms
• Lack of establishing medical records
• Lack of sufficient work history
• Your medical condition or impairments do not qualify as a disability
• You are still able to work at some kind of job
• You exceed substantial gainful activity limits

Here is a breakdown of the medical and non-medical reasons first-time applicants are denied Social Security disability benefits.

Non-Medical Reasons First-Time Applicants are Denied

You may be disabled, but if your SSD disability claim is incomplete or includes incorrect information, your application will be denied for non-medical reasons without further evaluation or explanation. Here’s what to look for:

1. You Didn’t Meet One of the Earnings Tests

The first is a “Recent Work” Test based on your age when you became disabled. If you meet the test, you are currently insured. (This test does not apply to certain blind workers.) Here, summarized, are several general examples:

• If disability began before age 24, you must have worked and earned six-quarters of coverage during the previous three years.
• If it began after 24 but before 31, you’ll need to have worked and earned half the quarters of coverage possible between age 21 and when you became disabled.
• If it began after 31, you’d need to have worked and earned twenty quarters of coverage in the ten years just before becoming disabled.

Second, you must meet a “Duration of Work” Test to show you worked long enough under Social Security—and therefore paid into the system via payroll deductions (FICA) or self-employment tax. You can consider these payments “premiums,” since—unlike SSI—SSD is an insurance program. Like any other insurance, you’re not eligible for any benefits unless you’ve paid the required premiums.

Here are a few examples of how much work, you need to meet the test:

If disability began…You generally need…

2. You Didn’t Provide All the Required Documents and Information.

The Application for Social Security Disability, the Adult Disability Report, and the Work History Report you are required to submit must provide enough information for the SSA and your state’s Disability Determination Services (DDS) to make a sound decision about your eligibility for SSD benefits. The information needed includes the following:

• Social Security number (SSN)
• Copy of your birth certificate or baptismal certificate
• Names, addresses, and phone numbers of the doctors, caseworkers, hospitals, and clinics that took care of you—regarding your disability—and the dates of your visits
• Names and dosage of all the medicines you take
• Laboratory and test results regarding your disability
• Medical records from your doctors, therapists, hospitals, clinics, and caseworkers you have on hand
• Summary of where you worked and the kind(s) of work you did
• Copy of your most recent IRS W-2 Form (if self-employed, include a copy of your federal tax return for the past year)
• Form giving the SSA permission to obtain details about your condition

If it’s difficult for you to obtain any of this information, the SSA may be able to help you get it.

3. Higher Income Limit Than Allowed

Your earnings record may show income (Substantial Gainful Activity) higher than the allowed limit for workers receiving SSD after the date you claim you became disabled, so the SSA doesn’t consider your disability severe enough to affect earnings.

In 2020, if you’re not blind, the monthly limit is $1,260; if you’re blind, it’s $2,110. The limits are subject to change each year.

4. There Were Other Problems with the Application Itself

Several minor errors can get a claim rejected. Perhaps you didn’t answer all the questions or answer them fully. Maybe it was impossible to read your writing, or there were other problems relating to the paperwork you submitted. If you’re unsure about anything that may have gone wrong, consider having a law firm experienced in SSD/SSI applications and appeals handle the process.

**Spanish-language version is also available, as are interpreters for over a dozen languages. Just ask the SSA.

Medical Reasons First Time Applicants are Denied Social Security Benefits

You may not be able to work now, and your doctor may not be sure when you can return to work, but the SSA has its own criteria for awarding benefits. Medically speaking, you may have been denied for the following reasons.

1. Your disability is/was temporary or short-term. As noted above, your disabling physical or medical condition must have lasted, or be expected to last at least 12 months or be expected to result in death.
2. Your disability is not considered severe enough to qualify for SSD benefits because:
   1. If you can work and earn more than the specified limit, the SSA assumes your disability isn’t too severe. (The objective is to help people who are too disabled to earn a sufficient income.)
   2. Your state’s Disability Determination Services decided that your condition did not significantly limit your ability to do basic work activities—walking, sitting, remembering, etc.—for at least one year.
   3. Your medical condition is not on the SSA’s List of Impairments—conditions considered so severe that they automatically mean you are disabled as defined by law. Nor is your medical condition (or combination of conditions) considered as severe as a condition on the list.
   4. The DDS decided your condition does not prevent you from doing the kind of work you did before.
   5. The DDS also decided—based on your age, education, work experience, skills, etc.—that your medical condition does not prevent you from doing some other kinds of work.
   6. If you claimed blindness, your condition did not meet the SSA’s definition: Your vision can’t be corrected to better than 20/200 in your better eye, or your visual field is 20 degrees or less in your better eye.
3. You did not provide sufficient medical evidence describing your impairment and/or its severity. Documentation must come from “acceptable” medical professionals (physicians, psychologists, etc.), and those who treated you or evaluated you concerning your disability must have credentials. They can significantly reduce the need for additional medical evidence to complete your claim.
   Here’s a list of possible documentation you could submit:
   1. Work-related medical reports are requested regarding what you can still do despite impairment: Ability to sit, stand, walk, lift, carry, hear, speak, handle objects, travel, etc.
   2. A statement—if 18 or older and claiming mental functional limitations—that describes your capacity to understand, remember and carry out instructions, respond appropriately to supervision, etc.
      1. If the applicant is under 18, a statement that describes their functional limitations, compared to children without impairments, in acquiring and using information, attending to and completing tasks, interacting with others, moving about, manipulating objects, caring for themself, etc.
   3. Further evidence of disability, like a special examination or medical test.
   4. Information from others: public and private agencies, schools, parents, caregivers, social workers, employers, or other practitioners (naturopaths, chiropractors, audiologists, etc.).
4. Additional information or consultative examinations are requested.

If the evidence provided by your medical sources is inadequate to determine if you meet the SSA’s strict definition of disabled, further proof may be sought by re-contacting the treating source for more information or clarification or arranging a consultative examination (CE).

The treating source is preferred for a CE—if qualified, equipped, and willing to examine the authorized fee. However, SSA’s rules provide for using an independent source (other than the treating source) for a CE or diagnostic study if:

• The treating source prefers not to perform the examination.
• The treating source does not have the equipment to provide the specific data needed.
• Conflicts or inconsistencies in the file can’t be resolved by returning to the treating source.
• You prefer another source for a strong reason.
• The SSA knows from experience that the treating source may not be productive.

What a Consultative Examination Report Shows

A complete CE report involves all the elements of a standard examination in the applicable medical specialty. It typically includes the following:

• The claimant’s major or chief complaint(s).
• A detailed description, as per the examiner’s specialty, of the history of the major complaint(s).
• A description, and disposition, of pertinent “positive” and “negative” detailed findings based on the history, examination, and laboratory tests related to the major complaint(s), and any other abnormalities or lack thereof reported or found during examination or laboratory testing.
• Results of laboratory and other tests (e.g., x-rays) performed according to the requirements stated in the SSA’s Listing of Impairments.
• A diagnosis and prognosis regarding the claimant’s impairment(s).
• A statement regarding what kind of activities the claimant can still do, despite his or her impairment(s), unless the claim is based on statutory blindness.
  The consultative exam report will not include a determination of disability.
• If the claimant is age 18 or over, it should describe (in the consultant’s opinion) the claimant’s ability, despite the impairment(s), to do work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.
• If the claimant is under 18, it should describe the child’s functional limitations compared to children of the same age who do not have impairments in acquiring and using information, attending and completing tasks, interacting and relating with others, moving about, manipulating objects, caring for himself/herself, and health and physical well-being.
• A statement, in adult cases of mental impairment(s) or mental functional limitations, also describes the claimant’s capacity to understand, carry out and remember instructions, and respond appropriately to supervision, co-workers, and work pressures in a work setting.
• The consultant’s explanation, comments, and conclusions regarding the claimant’s major complaint(s) and any other abnormalities found via the history and examination, or reported from the laboratory tests.

What Symptom-Related Evidence Shows

The SSA investigates all evidence presented concerning the effects of symptoms—such as pain, shortness of breath, or fatigue—on a claimant’s ability to function. This includes information provided by the treating sources and other sources regarding:

• The claimant’s daily activities.
• The pain’s location, duration, frequency, and intensity or other symptoms.
• Factors that precipitate or aggravate the symptoms.
• The type, dosage, effectiveness, and side effects of any medication taken.
• Treatments, other than medications, for the relief of pain or other symptoms.
• Any other measures the claimant has used to relieve pain or other symptoms.
• Other factors related to the claimant’s functional limitations due to pain or other symptoms.

Once the existence of your impairment is fully established, the evidence assessing its severity is considered. The SSA may review your records in later years to see if you continue to meet their disability criteria.

If you are turned down, you have several options as your next steps. Let’s take a closer look at each of them.

How to Reapply

Denial doesn’t have to be the end. Here’s what you can do:

File a New Application

Don’t make the common mistake of refining the same one. First, suppose you were denied benefits initially, without the assistance of someone familiar with the filing process, such as a disability attorney. In that case, there’s a good chance you will make the same mistakes again, despite your best efforts. The other solid reason is that Social Security will look at your file and see that you already filed once and were turned down for benefits. Like it or not, this raises a red flag and will likely invite questions about why you started the entire process over again.

File an Appeal

Far and away, this gives you the best chance of having an SSDI denial overturned. Social Security gives you several levels of appeal you can go through. The only downside is that the appeals process can take months before your case is decided, if not a couple of years.

The first level of appeal is known as Reconsideration. With a Reconsideration, a second claims examiner and a medical consultant will look at your files and pertinent records to see if you do qualify for benefits. You have 65 days from your initial denial notice date to file a request for Reconsideration. During that time, you can gather additional medical records and other supporting documentation to strengthen your claim, which you can then submit as part of the overall review process. While an initial review of an application can take up to five months or more, Reconsideration is generally decided more quickly because most, if not all of the needed records are already in hand by Social Security.

If your claim is denied in a Reconsideration, the next level of appeal is to request a hearing in front of an Administrative Law Judge (ALJ). Due to a long backlog throughout the nation, it can take quite a while to get a date for a hearing, so be prepared to wait as long as a year or more for your chance to plead your case.

If you
use your time wisely leading up to the ALJ hearing, you can get substantial medical expert evidence to back your claim to put your best case forward. This level is where the highest percentage of denials are overturned, and benefits are granted, so do everything you can to create a compelling argument in your favor.

When that chance comes, you or your legal representative can present your case before the ALJ. In preparation for your hearing, the judge will review your files and be familiar with your case. The judge will ask direct questions designed to determine if you meet all the criteria for approval. Your best strategy is, to be honest, forthcoming, and complete in explaining your situation, also presenting any additional evidence to support your claim.

If you are denied benefits by an ALJ, your next step is to seek benefits approval by requesting an Appeals Council review. Appeals Councils will review the processes and methodology used by the ALJ to reach their decision, ensuring that all medical evidence was considered appropriately and that the judge’s efforts were thorough and in line with accepted hearing practices. The Appeals Council will then affirm the judge’s decision by denying benefits, overruling the judge and granting benefits, or remanding the case back to the original ALJ for further review.

If you are denied benefits at this level, you can go outside the Social Security system and file a suit in Federal Court to hear your case. This is a last-ditch effort that sometimes works, but in most cases, it does not.

Remember: there are strict deadlines for filing an appeal at all levels. It is vital not to miss these filing deadlines, or your request may be denied before it is even considered. If this happens, you have the choice of either filing a new disability application and starting the process over, or you may request that your appeal move forward because you had good cause why you missed your deadline and filed late.

Explore Expedited Claims Processes

For those people who have severe or terminal impairments, they may be eligible to be processed in an expedited manner. Social Security speeds approval under the Compassionate Allowance program if a person has a condition on the Compassionate Allowances list, allowing for approval in several days instead of several months. There are about 220 qualifying conditions, and the current list of those Compassionate Allowances can be found on SSA’s website.

For those who can prove they have a terminal condition and aren’t expected to live more than six months, a quick decision may be made through the Terminal Illness Program (TERI). For Supplemental Security Income applicants, if they have an obvious disability or condition, immediate benefits may be payable through the Presumptive Disability Program. Benefits for this are not available for SSDI applicants.