Social Security Disability: Eight Reasons You May Be Denied Benefits

Unhappy family financial stress

In some cases, the reasons are beyond your control. In other circumstances, you may be able to avoid doing something that leads to denial.

1: You Earn Too Much Income from Working

For SSDI, the benefit program for workers who have paid into the Social Security system over multiple years, one of the most basic reasons you could be denied benefits is that, when you apply, your income is above the limit where it is considered “substantial gainful activity” (SGA). This means you earn too much money to be considered disabled. The SGA limit for non-blind people is $1,180 per month in 2018, and the figure is adjusted annually. Income from investments does not count toward the SGA — only earned income counts, as it shows your ability to work.

For SSI, which is the disability benefit for low-income people, when you apply for SSI, you can’t be making over the substantial gainful activity level. Also, the upper income limit for earned and unearned income combined is around $1,500 per month. Any time your income is over the federal benefit rate ($735 in 2017) your SSI payment will be reduced. If you make too much, your payment would be reduced to zero.

2: Your Disability Won’t Last Long Enough

To qualify for SSDI or SSI benefits, the Social Security Administration (SSA) must believe that your impairment is severe enough to last at least 12 months or result in your death. The only exception to this duration requirement is for blind SSI applicants. Remember that you can file for disability before 12 months has passed from the onset of your disability.

3: The SSA Cannot Find You

The SSA and the Disability Determination Service (DDS) — the agency that determines your medical eligibility for benefits — must be able to communicate with you regarding your application. If these agencies cannot reach you to schedule examinations or communicate with you about critical matters, your benefits may be denied. If you retain an attorney to handle your case, you may not need to get in touch with the SSA, but be sure to stay in touch with your attorney. If you move while your application is being considered, make sure the SSA and your attorney know how to contact you. Claimants (those who are applying for Social Security disability) get denied every day because the SSA cannot find them.

4: You Refuse to Cooperate

Your medical records are vital to granting your disability. If you refuse to release those records to the SSA, your claim could be denied. Similarly, the SSA may need additional information about your impairments, either because your treating doctor’s medical records are incomplete or because you have no treating doctor. In these instances, the SSA will request that you be examined by an SSA doctor in something called a consultative examination (CE), at government expense. In some cases, the SSA will require you to attend more than one CE. If you refuse to attend or request that the SSA make a determination based on the medical records already in your file, you may be denied disability because of inadequate medical information or failure to attend the CE. If you can’t make it to a scheduled CE because of the time or location, talk to your claim examiner so the DDS can schedule a CE at a time or place that is convenient for you. If you repeatedly fail to show up for a CE, your claim will most likely be denied.

5: You Fail to Follow Prescribed Therapy

If you are being treated by a doctor, but fail to follow the doctor’s prescribed therapy when you have the ability to do so, you can be denied disability benefits. The SSA recognizes certain legitimate excuses for failing to follow prescribed therapy, but generally you should make every effort to follow your doctor’s orders.

Acceptable medical excuses. Failure to follow prescribed therapy can be excused for reasons beyond your control. Some examples follow.

  • You have a mental illness so severe that you cannot comply with prescribed therapy.
  • You have a fear of surgery so intense that surgery would not be appropriate. Your treating doctor must confirm the severity of your fear.
  • You physically cannot follow prescribed therapy without assistance.

Acceptable nonmedical excuses. It is possible that you cannot follow a prescribed therapy for a reason that has nothing to do with your medical condition. Acceptable nonmedical excuses for failing to follow prescribed therapy follow.

  • You don’t have the money to pay for treatment.
  • Your religious beliefs prohibit you from receiving medical therapy.
  • Your doctor prescribes treatment that another doctor disagrees with.

For the SSA to deny your claim for failing to follow therapy, the therapy that you fail to follow must be one that is clearly expected to restore your ability to do substantial gainful activity. If your treating doctor tells the SSA that the prescribed therapy is not likely to result in your ability to work, the SSA won’t fault you if you don’t follow such therapy.

6: Your Disability Is Based on Drug Addiction or Alcoholism

The SSA will deny benefits to anyone whose drug addiction or alcoholism (DAA) is a contributing factor to his or her disability. The key factor is whether or not the SSA would still find you disabled if you stopped using drugs or alcohol. It is best to refrain from the use of drugs and alcohol when making a claim for disability benefits.

7: You Have Been Convicted of a Crime

Certain conditions related to conviction of a crime or imprisonment will prevent you from receiving Social Security benefits.

  • If you were injured while committing a felony and were convicted of the crime, the impairment suffered — or the worsening of an existing impairment — during the commission of a felony cannot be used as a basis for applying for disability benefits.
  • If you were injured while in prison, the impairment suffered — or the worsening of an existing impairment — while you are in prison cannot be used to obtain benefits. But you can generally receive benefits after being released from prison.

8: You Commit Fraud

If you obtain disability benefits by dishonest means, the SSA can terminate your benefits and prosecute you for fraud. Filing a tax return for self-employment in order to receive a refund is a common problem.

Social Security Disability and SSI for Depression

Learn about your options for getting Social Security disability benefits based on depression

American doctor with depressed woman patient
American doctor with depressed  patient

To qualify for disability benefits, an individual with depression must either meet certain specific disability criteria (found in Social Security’s impairment listing manual), or be granted a medical-vocational allowance based on the severity of their depression and a combination of other factors (such as other impairments, work history, age, and a level of education).

Social Security publishes a list of common, serious illnesses (“Listings”) that qualify for disability if they meet the specified criteria. The purpose of the list is to grant disability quickly for severe impairments. Depression is covered in impairment listing 12.04 Depressive, Bipolar and related disorders. To qualify for either Social Security disability or SSI disability benefits solely on the basis of depression, you must show you have severe depression by having at least five of the following symptoms:

  • depressed mood
  • diminished interest in almost all activities
  • appetite disturbance with change in weight
  • sleep disturbance
  • observable psychomotor agitation or retardation
  • decreased energy
  • feelings of worthlessness or guilt
  • difficulty concentrating or thinking, or
  • thoughts of suicide or of death.

Bipolar disorder must be characterized by three or more of these symptoms:

  • pressured speech
  • flight of ideas
  • inflated self esteem
  • decreased need for sleep
  • distractibility
  • involvement in activities that have a high probability of personal consequences that are not recognized or
  • increase in goal-directed activities or psychomotor agitation

You will have to prove by treatment records from your therapist that these symptoms exist and that they cause serious functional limitations despite treatment for some period of time. If you regularly see a psychiatrist or psychologist, he or she should be recording your symptoms. If not, you may want to track your condition using a self-rated depression scale:

(http://healthnet.umassmed.edu/mhealt/ZungSelfRatedDepressionScale.pdf)

Social Security requires that your symptoms of depression cause you serious difficulties (one extreme or two marked) with:

  • understand, remember or apply information
  • interact with others
  • concentrate, persist, maintain pace, and
  • adapt or manage oneself

Affleck & Gordon are experienced attorneys who represent individuals in Social Security disability appeals. We offer a free consultation and will be happy to answer any questions you may have.

Will Your Lawyer Pay Your Doctor Bills on Your Personal Injury Case?

Will Your Lawyer Pay Your Doctor Bills on Your Personal Injury Case?
Will Your Lawyer Pay Your Doctor Bills on Your Personal Injury Case?

Your lawyer may pay a doctor to review your medical chart and render an expert opinion, but your lawyer won’t pay your regular medical bills. But what if your lawyer sends you to a doctor to be examined? Your lawyer may pay for you to be examined by a doctor on a one-time basis to render an opinion that your condition was caused by the accident, but not for ongoing regular treatments. For example, you were involved in a car wreck on June 15, 2017 and had a lumbar strain and saw the doctor every week and the physical therapist three times a week for three months. You’ll need a statement from your doctor that it’s her opinion that your lumbar strain and resulting medical care was caused by the June 15, 2017 car wreck. However, your doctor may be unwilling to get involved or sign a statement. Your attorney will either have your records reviewed or send you to a doctor to obtain a causation and disability statement. This is an expense that your attorney will probably pay for. However, no lawyer can pay your ongoing medical bills.

Treatment that is provided by your doctor is a regular medical bill. You will need to treat these bills as you would any other medical expense. If you have health insurance, your health insurance carrier should be billed. Be sure to tell your attorney about all types of insurance coverage including Medicare, a Medicare supplemental provider, any other health insurance carriers, TRICARE, or the VA.

Why is it vital to maximize your health insurance policies coverage? The answer is simple. Any unpaid medical bills will have to be subtracted from your settlement. When you hear the settlement offer you may feel it’s favorable until after all your doctor and hospital bills are paid and you are left with the net amount and feel disappointed. Wait. You’re still worried. You recall signing something that if you obtained a recovery that the insurance company is entitled to be reimbursed. Lo and behold, there is a statute that considers this. If your case settles and does not go to trial, you can argue that the insurance carriers are not entitled to reimbursement on the grounds that you were not fully compensated by the recovery or “made whole” for all your economic and non-economic losses. You will need to consult an attorney to ensure that your settlement documents provide such a statement.

For those involved in a motor vehicle accident, our firm will look to see if you will benefit from MEDPAY or Medical Payments coverage. Medical Payments coverage is a form of no-fault medical coverage which follows your vehicle. If you or passengers in your vehicle are injured, whether you are at fault, Medical Payments may be available to contribute towards your medical bills.

For those who do not have health insurance, there are some doctors who treat on a lien basis. You will need to sign an agreement that you will pay the doctor out of your settlement or verdict. Of course, not all doctors are willing to treat on a lien basis and you may have to do some searching until you find a doctor willing to treat you based on a lien. Your attorney will be able to assist you with this.

In summary, a good personal injury attorney will assist you with identifying all possible sources of insurance coverage for payment of medical bills. The coordination of medical benefits is likely to ensure that you receive the best possible medical care and increase the value of your personal injury settlement.