Our Approach to SSA Disability Claims

Our Approach to SSA Disability Claims

Qualifying for disability benefits

Qualifying for disability is much more than suffering from an injury or disability and meeting SSA’s basic requirements. SSA uses its “Blue Book,” which describes recognized impairments and sets out specific medical conditions and their severity levels for disability consideration. On the other hand, if you suffer from a condition that makes it very hard to work for an extended time, you should consider applying for Disability benefits.

It is important to understand that qualifying for disability benefits is not just about having a medically diagnosed injury or disability; it is about proving that your condition or impairment (disability) prevents you from completely being able to work— — —at any job. A disability attorney can work with you to develop your case under these strict standards.

Although SSA follows the guidelines in the Blue Book, that publication is not an exhaustive list of every disability. If you have a disability not in the Blue Book, contact Dan Wimmer because SSA has approved disability benefits if it can be shown that your condition is “functionally equivalent” to a listed impairment. “Functionally equivalent” means your disability is not explicitly listed in the “Blue Book,” but SSA may consider your disability to have a severe effect on your daily activities. SSA has granted benefits when a disability is not in the Blue Book, but the effect is “functionally equivalent” to a listing. Call The Law Office of Dan Wimmer for a free, no-obligation consultation if you have such a situation.

Although it is recommended that you engage a Social Security disability attorney, an attorney is not required to file your application or to win an administrative appeal. A person can mail their application to SSA, use SSA’s online process, or visit the local SSA office. If you choose to pursue your claim without legal representation, we suggest using the new SSA online process but keep copies of everything you provide to the SSA. Regardless of how you file your initial application, the rules, laws, and statutes governing who is disabled are based on specific conditions and numerous case law determinations.

Initial application

If your “initial application” is complete and accompanied by relevant medical records and non-medical evidence to support the SSA’s Blue Book standards, it is probably ready to be filed. Statistics show that properly prepared “initial applications” have the best chance of approval.

Our approach focuses on working with our clients to be approved———at the initial application stage. We recognize that between 65% and 73% of the initial applications are denied. These figures vary depending on which state’s DDS office reviewed the application. Our approach involves carefully reviewing a claimant’s application before filing the claim. We examine the medical and non-medical evidence and apply SSA’s Five-Step Evaluation Process to make our own internal analysis about the likelihood of approval. We do this knowing that many valid claim applications are denied for various reasons. However, if your initial application was denied for lack of sufficient information, this might suggest that some detail or inconsistency was overlooked. Even so, if your claim was denied, contact Social Security Disability attorney Dan Wimmer.

The SSDI/SSI initial application process:

Once your “initial application” is submitted and SSA determines you qualify for benefits, your file is sent to a DDS (Disability Determination Service) office. A typical DDS office is staffed with disability examiners, medical consultants, vocational experts, and other employees experienced with disability claims.

The DDS will request your medical records from the health professionals you have provided. The DDS office analyzes your medical records and decides whether you are disabled under SSA standards. If the DDS office does not have sufficient information to render a decision about your disability, it can require you to obtain a consultative examination, and the DDS pays for those examinations. If you were represented by a disability attorney from the beginning of your disability, they would have prepared you for the “consultative examination.”

Being prepared means certain things should not be said and certain things that should always be said during an examination. However, always be truthful when asked a question. Never lie or fabricate statements because your statement is a declaration being made to a federal agency under penalty of perjury if the statement is untrue. If you disagree with a decision made by SSA or DDS regarding your initial application, you have four opportunities to appeal those decisions.

Reconsideration

If your initial application is denied, your first official appeal is a request for “reconsideration.” A “reconsideration” appeal is precisely what it means; you are asking the SSA/DDS to “reconsider their decision and your initial application,” but with new and different examiners. This means reconsidering my claim with examiners who did not participate in the initial decision.

The Law Office of Dan Wimmer handles these types of appeals. As your legal representative, we will file all necessary documents. While “reconsideration” is an official appeal, it is also an opportunity to include new evidence and to evaluate previously submitted documents. For example, your attorney could analyze whether the medical records provided to SSA/DDS were complete. Compete medical records describe your medical condition and state how your disability affects your ability to work and how you carry on with your normal daily activities. Before filing any appeal, our firm will analyze every word in your medical records to determine if your alleged symptoms were properly recorded in your medical records. Moreover, if we had represented you from the beginning, we would have given you training sessions about how to explain your symptoms to your doctor, and at each visit, ensuring those statements become part of your medical records.

The most important records your attorney will need to win your disability case is your medical records.

Medical records include all current and past medical visits concerning your disability symptom(s) and any new treatments occurring after filing your initial application.

If your case is denied at the reconsideration appeal level, you should file an appeal for a hearing before an Administrative Law Judge (ALJ). The Law Office of Dan Wimmer can represent you at ALJ appeals hearings.

Request For An Administration Law Judge (ALJ) Hearing

At the ALJ hearing, you can present new evidence. This is an excellent opportunity to strengthen your case. Because about 50% of the cases appearing before an ALJ receive approval, you should almost always consider this level of appeal. At the Law Office of Dan Wimmer, we offer free claim evaluations if your claim was denied.

ALJs are independent federal judges who preside over SSA legal hearings. During the hearings, ALJs can ask questions of you and all testifying witnesses, including SSA vocational and medical experts. Your attorney may also cross-examine those experts, including their findings, conclusions, and statements. An ALJ hearing is not an adversarial trial setting, as you might see on TV, but it is their job to analyze the evidence and decide whether you qualify for SSDI benefits.

Most of the time, appearing before an ALJ is the first opportunity for a disabled person to appear before a government official and explain how their medical condition keeps them from working. ALJ hearings could last one hour and, on some occasions, a little longer, and many are now handled telephonically or with Video Teleconferences like Zoom. Claimants also have a legal right to appear before the ALJ in person.

If your case is denied at the Administrative Law Judge level, it can be appealed to the Social Security Appeals Council.

Social Security Appeals Council

In rare cases, the Social Security Appeals Council will grant a review of a claim that an ALJ has heard. The chance of getting before this judicial body is very low, but ALJs have occasionally applied an incorrect rule, law, or standard of review. This is rare because ALJs are generally very experienced and knowledgeable. Even so, ALJs can make mistakes. This is the final administrative appeal. If the Appeals Council denies your claim, the next appellate level is a Federal District Court.

Federal Court Review

If the Appeals Council declines to review your case, you can file a civil lawsuit against SSA in the appropriate federal district court. However, this form of appeal has a very low chance of success. We strongly encourage injured persons to hire a disability attorney at the beginning of their cases. Disability attorneys can provide claimants with information about the federal court process. Federal district court cases are expensive, but on occasion, claimants prevail. If you have exhausted your administrative efforts for benefits, we would be happy to discuss the ramifications involving a federal district consideration.

Do you need a SSA Disability attorney? No.

There are two situations when a SSA Disability Attorney should be considered:
Before a claim is filed, and
After a claim has been denied.

Here is how an SSA disability attorney can assist you!

It is common for the SSA/DDS to require additional forms after the initial application, SSA Form 16, has been filed. One of the most important is the Function Report—Adult Form SSA-3373. The SSA sends this form to the disabled person. It can be requested at any stage, but most frequently, it is asked for at either the “initial application” stage or at “reconsideration.”

Download the Function Report—Adult Form SSA-3373 and look at Question 20 a, under Section D. You will see various boxes to be completed or checked. You may fall into a trap if your explanations are inconsistent with other prior oral or written statements or answers when checking any of these boxes. Consistency helps initial applications.

Follow along with these hints.

The SSA receives over 1,500,000 disability claim applications every year. This number of applications suggests that the many SSA rules, federal statutes, and case law decisions must be interpreted and applied to each claim. Because every initial application involves numerous forms and questions, our legal training enables us to help clients fully understand what a question is asking and how to frame and present truthful and accurate answers. Above all, NEVER mislead or misstate your medical injury status.

Back to SSA-Form 3373 and Question 20(a).

Example: If you checked the box indicating that lifting items over a certain weight affects your daily activities, in essence, you are saying that your injury prevents you from “lifting” items, say over 10 pounds. Suppose your job requires you to lift 25–50-pound boxes. It was probably the constant lifting of heavy boxes over the years that contributed to or caused the painful, disjointed, and degenerative back condition you are experiencing.

However, if in any other SSA document you said that you are not working because of “back pain” but stay home to provide care for two small children between the ages of 2-5, we may have a problem. Under this fact scenario, and absent a properly worded explanation, the SSA would likely construe that caring for two young children requires you to occasionally lift the children and/or do household work or lift heavy loads of laundry. Because your activities are not adequately explained, a DDS Claims Examiner could conclude that your stated limitations are inaccurate. This means that your asserted disability is NOT TRUE. WORDS MATTER.

On the other hand, a disability attorney would ask you if someone else was in the house doing the heavy lifting of laundry or assisting with the children. You might easily skip over this small detail because you know what is happening in your home. However, a disability attorney would know how important it is to frame your answer so that it honestly reflects your actual day-to-day disabilities and limitations. WORDS MATTER.

Another example: If you stated in your “initial application” that you cannot work because your condition seriously restricts arm motion or movement, meaning that you cannot lift your arms above your shoulders because of excruciating pain. However, when SSA/DDS interviewed you, you stated that you spend time working in your garden or cleaning your house, doing heavy laundry, or playing with a child while staying home. Statements or answers like this are red flags and suggest to the SSA/DDS and ALJs that you are not disabled if you can do these activities. What words you use and where you place them in sentences matters. Be careful because words mean different things to different people.

You have a right to be represented by an attorney during every interview, hearing, or interaction with any SSA personnel.

A disability attorney can assist you with framing answers to questions and can also help you explain how your symptom(s) and condition impact your ability to work. A disability attorney can also help you to prepare for what to say and what not to say when visiting doctors. This is a better approach than just saying you have pain here and there but never the symptoms. It is essential that your medical records reflect where you are hurting and how those pains affect your overall mental and physical health. This information must be in your medical records. In fact, pain that impacts and frequently disrupts your sleep with tingling nerves has been found to cause other health issues. Doctors should be told about these symptoms during every visit. If you fail to describe or explain your symptoms to your doctor and how they affect your quality of life, you have missed an opportunity to have your medical records properly reflect your condition. WORDS MATTER.

Because WORDS MATTER so much in the approval process for Social Security disability claims, the risk of being denied can be very high without representation. We strongly encourage you to call a Social Security Disability attorney for a free consultation. At Dan Wimmer Law, we offer free case evaluations. Contact us today.