Appealing a Social Security Disability (SSDI) Denial in Pennsylvania

Disability benefits are there to help people who are seriously ill or injured pay for their medical bills and other expenses while their health keeps them out of work. At the end of 2019, the SSA (Social Security Administration) reported over 16 million Americans were receiving some form of disability with an average monthly benefit of $1,259. However, successfully qualifying is known for being a difficult process which often requires the applicant to appeal. In this post, our Philadelphia disability attorney from Young, Marr & Associates will take a closer look at how the appeals process works, and what to do if your social security disability claim was denied. 

How Many Disability Applicants Are Rejected in Pennsylvania?

Unfortunately, being approved for disability is no easy feat. While submitting a claim may seem like a simple task, once applications are received by the SSA, they undergo an extremely stringent review process which, more often than not, ends in a rejection notice. 

Statistically speaking, you are far more likely to be denied than approved. The national average rejection rate is about 65%, meaning only 35% of applicants — barely one third — will be approved. In Pennsylvania, the rejection rate is estimated to range somewhere between 63% and 69%, making it roughly equal to the national rate. 

Why Was My Disability Claim Denied?

If you are like most disability claimants, your application for monthly benefits will be denied — at least initially. The good news is, that denial is not necessarily final. There are additional steps you can take to get approved, even if you have already been rejected by the SSA. 

But before you begin the appeals process, you should make sure you understand why your claim was rejected by the SSA. This will give you a better chance of being approved on your next attempt. 

Rejections are divided into two basic categories: technical denials, which are less common, and medical denials, which are more common. 

Some typical reasons for a technical denial might include missing a deadline, or earning too much money (more than $1,310 per month, or more than $2,190 per month for blind claimants). 

Medical denials generally occur when a claimant’s disability fails to match or equal the severity standards in the “Blue Book,” or Listing of Impairments, or when a medical condition doesn’t meet the SSA’s 12-month duration requirement. (However, there are some exceptions for advanced and very severe illnesses, known as Compassionate Allowances.) 

Medical Evidence

One of the crucial elements required in a disability claim is solid medical documentation and evidence to support the severity of your condition. If you lack sufficient medical proof, it will almost be impossible to establish that your condition impairs your ability to work. Your medical records must not only meet the SSA’s criteria for your particular condition, but the evidence must also demonstrate you cannot perform your ordinary work-related tasks. 

Following Up and Completing Treatment

Medical evidence of your condition is vital, but it is also essential to continue with any prescribed treatments. If you fail to comply with your doctor’s directions regarding follow-up medical treatments, you will significantly decrease your chances. 

While having evidence regarding your disability is critical, it is equally important to follow through with any treatments prescribed by your physician. Failure to comply with medical treatments and recommendations will significantly increase the chance your claim is denied. The SSA needs to determine if your condition is treatable to assess if you could work. If you do not comply with the recommendations and treatments ordered by your doctor, the SSA will be unable to evaluate whether your condition could improve. 

Filing an Appeal vs. a New Claim

When a claim is denied, it is not uncommon for a person to believe the best option available is to file another claim – hopefully, not making the same errors that resulted in the initial denial. However, it is better to appeal a denied claim and provide additional evidence than to file a new one. If an SSA examiner notices that you had a previously denied claim, they will likely deny your new one. When you appeal a claim, you are providing new evidence and demonstrating that you are putting in the effort to have your initial claim approved. 

Another thing to remember is cooperation is an important factor during the application and appeal process. If you are not cooperative, missing deadlines or not providing information the SSA requests, your claim or appeal will probably be denied. This includes keeping scheduled medical appointments and appointments with the SSA. 

When your claim is rejected, the SSA should send you a written notification which explains the reasoning behind the decision. If you disagree with this explanation, it may be time to appeal. 

How Do I Start the Disability Appeals Process?

The appeals process unfolds in a series of steps. Exactly how many of these steps you will have to go through depends on how your claim is assessed at each stage. 

Request for Reconsideration

The first step in the appeal process is filing a request that your initial denial or termination of your benefits be reviewed. When your initial claim is denied, you will receive a denial notice that will include information about your right to request reconsideration. The notice will include a paragraph describing your medical impairment. 

When the SSA reconsiders a claim, it is a complete review. This review is conducted at the Disability Determination Services (DDS). However, the actual review is performed by an examiner and medical consultant who were not involved in the original decision. Basically, the SSA is getting a set of new eyes to review your initial claim. 

If your claim is denied at the reconsideration level, you will receive a notice of denial and an explanation of why the claim was denied. The step following a denied reconsideration is requesting a hearing in front of an administrative law judge. 

Reconsidering a Continuing Claim

If your initial claim was approved, your case will still be re-examined periodically. This process is called continuing disability review (CDR). At this point, the SSA could end your disability for a number of reasons. For example, your condition could have improved, you are engaging in SGA, or you have been uncooperative during the review process. 

When your disability benefits are terminated, you could appeal the decision by requesting a reconsideration of the CDR. The first step in reconsideration of terminated benefits is an additional review by a different examiner and medical consultant. If your benefits are not reinstated, your case would go before a disability hearing officer (DHO). 

The DHO will form their own medical opinions regarding the severity and impact of your medical condition. It is important to note here that the SSA must provide evidence that your condition has improved. This is a medical decision and the SSA must consider the opinion of your treating physician. If the DHO rules against you, you are permitted to request a hearing in front of an administrative law judge. 

Administrative Law Judge (ALJ) Hearing

If your request for reconsideration, whether it was for an initial claim or because your benefits were terminated, you need to request a hearing with an administrative law judge. This request must be made within 60 days of your denial. 

ALJs are attorneys who work with the SSA’s Office of Hearings Operations (OHO). The majority of their work involves reviewing decisions to deny initial claims or terminate disability benefits. Typically, a claim will be won at this level approximately fifty percent of the time. Nonetheless, it is a good idea to have an experienced Doylestown disability attorney representing you at a hearing before an ALJ. 

Appeals Council

Should you lose your appeal before an ALJ, you are entitled to request that the Appeals Council reviews your claim. The Appeals Council will randomly select cases for review and has complete discretion to deny, grant, or dismiss a request for review. Furthermore, the Appeals Council could dismiss your claim without a review unless certain circumstances have been shown to exist. 

First, there must have been an abuse of discretion. For instance, your hearing could have been erroneously shortened. This abuse could also include an error of law or procedure, such as not allowing a claimant to cross-examine a witness. 

An ALJ’s decision must be supported by substantial evidence. If this is not the case, the Appeals Council should review the decision. 

Deadlines are important when filing appeals. If your appeal was filed late or you missed any deadlines, your case could be dismissed without review. 

As a matter of procedure, the Appeals Council will be looking for a flaw in the ALJ’s decision before granting a review of your case. The odds of success at the Appeals Council level are very slim. Only about 1% of denials are reviewed and overturned. Approximately 10% are sent back to the ALJ with instructions to look at the claim again. You should not take this step without a knowledgeable disability attorney advocating your position. 

While this might seem hopeless, if you want to continue fighting to have your claim approved, you need to exhaust the Social Security appeals process before filing a lawsuit in federal court. 

Federal Court Lawsuit

The next step in appealing a denied disability claim is filing a lawsuit in U.S. District Court. If, for some reason, you have not engaged a Bucks County disability attorney, you should do so now. 

A federal judge will hear your disability case without a jury. Technically, the judge is supposed to review the case to determine if any legal errors occurred. However, some judges will consider questions of fact as well. In most cases, a federal judge will not reverse a ALJ or Appeal Council decision. Nonetheless, in about half of the cases they hear, a federal judge will remand, or send back, the disability case. They will often instruct the SSA to reconsider the treating physician’s medical opinion or the claimant’s symptoms. 

While you have a relatively good chance of either winning a federal appeal or having your case heard again by the SSA, the process is time-consuming and expensive. A successful outcome could still take years. 

Unfortunately, many initial disability claims are denied. If you engage the services of a pragmatic and seasoned Montgomery County disability attorney, many of the common errors and omissions that result in denials could be avoided. Furthermore, if your initial claim is denied, having an attorney immediately working on gathering additional evidence could be crucial in successfully appealing your case. 

Our Attorneys Can Help with Your Disability Appeal in Pennsylvania

If you or your child has had a claim rejected by the SSA, an experienced Delaware County disability attorney can help guide and represent you throughout the appeals process. To set up a free, confidential legal consultation, call the law offices of Young, Marr, Mallis & Associates at (215) 701-6519 in Pennsylvania, or contact us online.