S Y A W 10 T E G TO D E I N DE Helpful Advice From Members of The National Association of Disability Representatives
10 Ways to Get Denied Disability claims are complex and there are many things an applicant can do (unintentionally) to pave the way for a claim denial. This information was compiled by NADR members with years of experience and are just a few of the reasons that it is important to have a knowledgeable representative to assist on your side. 1. Exaggerating Limitations or Lying Disability adjudicators base decisions on medical evidence and claimant testimony. If a claimant attends a hearing using a walker, but there is no mention of a walker being used or being prescribed in the medical records, the judge may find that the claimant is not credible. SSA Ruling 16-3p describes symptom evaluation based on claimants’ statements, “We will consider
an individual's statements about the intensity, persistence, and limiting effects of symptoms, and we will evaluate whether the statements are consistent with objective medical evidence and the other evidence.” Lying about limitations or impairments is a sure way to get denied and could even result in a fraud investigation or prosecution!
2. Overstating or Mistating Job Duties Claimants complete work history forms when applying for benefits. It is absolutely crucial that these forms give an accurate picture of the work that was performed. An NADR member stated, “People think that if their job was more complex it will be easier to say they can’t return to it. Do not report that you were a supervisor if you did not hire and fire employees.” Overstating job duties could give an applicant additional skills and can make it harder for SSA to approve the claim. Also, if job duties were really a combination of two or three positions, the applicant should be sure to explain all job responsibilities clearly. It’s a good idea to have an experienced representative review any form before it is submitted to SSA to make sure it is complete and accurate.
3. Not Complaining to Doctors Because SSA bases decisions off of objective evidence, they review a claimant’s doctor visits for information that will support the allegations of disability. If a claimant is saying they can’t work because of excruciating back pain, but the primary care medical records consistently report that the patient has no complaints and is feeling okay, the adjudicator may deny the claim. NADR members encourage applicants to always describe any problem with functioning to ANY doctor they see, even if they are not being treated by that doctor for that particular impairment. Disability adjudicators need to see that a claimant’s limitations are consistent throughout the entire record.
4. Not Receiving Consistent Medical Treatment Social Security needs medical proof that impairments exist and result in limitations that would meet SSA’s definition of disability. If an applicant has not been to the doctor for a problem that is limiting their ability to function on a regular basis, the adjudicator will have a hard time approving the claim because of a lack of evidence. Sometimes representatives see medical records where claimants tell the doctor they are there because they are filing for disability. This kind of statement can damage a claim because it makes it look like the impairment is not severe enough for the claimant to go to the doctor to manage it and that the claimant is only interested in proving their limitations to Social Security. Likewise, if a claimant reports to SSA that they are unable to receive medical care because they can’t afford it, they need to be prepared to show why they were unable to obtain insurance through the ACA, or receive medical care from free or reduced cost clinics. If they have not tried to receive medical care, the adjudicator may assume that the impairment must not be very limiting.
5. Rating Pain as a “10” or HIGHER Pain is subjective, and many times claimants do not know how to describe it well. When judges ask claimants what their pain is on a scale of 1 to 10 with 10 being extremely acute and severe, and a claimant reports “10”, the judge is likely to find that testimony inconsistent. A pain level of “10” would be so severe that the claimant would need to go to the ER. How would it look to a judge if the medical history does not indicate high pain levels at doctor visits, but the claimant is reporting a “10” at the hearing? NADR members advise claimants to always be truthful with their statements made to SSA and describe pain levels as accurately as possible, the same way that they are described to treating physicians.
6. Talking About Traveling, Without Describing Difficulties Oftentimes, an applicant will report to a doctor or counselor that they recently took a trip without discussing difficulties they may have had. This could cause a problem for the claim, especially in cases where they are alleging difficulties in leaving their homes due to mental health conditions, or allege that they have difficulty sitting for long periods of time due to pain issues. When discussing a trip with a doctor or SSA, it is crucial that the applicant also report functional limitations, such as requiring frequent rest breaks or having to spend extended periods in bed due to increased pain. Remember, doctors frequently include patient reports in records. If the claimant leaves those factors out when reporting the trip to their doctor, the adjudicator may have a hard time understanding why the claimant seems able enough to take a fun vacation and find that the claimant’s statements made within the application or hearing are inconsistent with what they reported to their doctor.
7. Noncompliance with Treatment One of the factors Social Security evaluates is whether or not the claimant has been compliant with treatment. If a doctor prescribed physical therapy and the claimant stopped going without a good reason, the adjudicator may conclude that if the claimant had finished the physical therapy, they would be less limited. Medications are another compliance issue. If a claimant’s medical records document that the patient consistently does not take medication as prescribed, an assumption might be made that the impairment could be successfully treated if the claimant was actually taking their medicine. NADR members encourage their clients to always discuss treatment issues with their doctors. If they are unable to continue prescribed treatment for any reason, do not stop without first discussing it with their doctor. Many times, doctors will document the problems they are having and will be able to try other options. It is much better to tell the judge all of the treatment options a claimant has tried but have not worked, versus the one treatment option the claimant tried and quit without trying anything else.
8. Working To qualify for Social Security Disability, a claimant cannot be working at a substantial level. It is often hard for someone who has worked their whole life to come to grips with the fact that they can no longer provide for their household. Sometimes they may attempt to work a few hours before realizing that they aren’t even able to do that. Claimants sometimes report to their doctor that they are working, but fail to explain that it is just a few hours, volunteer work, or a sheltered work situation. When SSA sees the medical record without any explanation of the work, this may lead to a denial. Be sure to speak with a representative before attempting to do any work while applying for benefits, and never report that you are working to your doctor without explaining how you are able to do so!
9. Not Having a Representative When asked about unrepresented claimants, one NADR member answered: “Most claimant mistakes generally wouldn’t happen with a representative. For example some people tell me that they want to apply for disability for one specific impairment so they don’t expect to discuss their other impairments with me at all. They seem baffled when I delve into all medical issues.” Disability representatives understand that sometimes limitations from a single impairment are not enough to prove disability, so it’s important to tell SSA about all of your conditions that would make it difficult to sustain full time competitive work. Representatives also ensure that you are alleging the correct onset date of disability, therefore maximizing your benefit. Many claimants may think that having a representative to help them with their claim is too expensive, but the truth is representatives cannot charge you a fee for representational services without approval from SSA. This standard fee agreement is 25% of any back due benefits up to a maximum of $6,000, contingent on approval of the claim. This means that you do not owe a fee unless your claim is allowed.
10. Not Applying for Benefits Soon Enough Did you know that you only have a limited amount of time that you are insured for disability benefits? Disability benefits are based on your work earnings, so if you stop working you only have a limited period to file for disability. Frequently, people think that they will get better and be able to return to work, or maybe they just don’t want to admit that they are disabled. Unfortunately, some Social Security Disability applicants wait until it’s too late to apply. Representatives often speak with individuals who want to apply for benefits but because they waited so long to apply, they have to prove their disability began several years ago, while they were still insured. This can be very difficult to do if their providers no longer have medical records. If an individual is unable to work, and it appears that they may be unable to return to work for at least a year, it is time to speak with a representative about applying for benefits. NADR can help you find a representative in your area; simply call 1-800-747-6131.