Common Reasons for Social Security Claim Denials
Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) are critical safety nets for individuals who can't work due to physical or mental disabilities. Unfortunately, many applicants face challenges during the claims process, and a significant portion of applications are initially denied.
At Reese Legal in Orlando, Florida, Attorney Michael Reese has been assisting clients with their SSDI and SSI denials for years. Reviewing the common reasons for these claim denials can help applicants avoid pitfalls and potentially increase their chances of success when applying for benefits. Here are some of the most common reasons why your claim may be denied.
1. Failure to Meet the Eligibility Requirements
Both SSDI and SSI programs have specific criteria, and applicants must meet all of them to qualify for benefits.
Work History for SSDI
Applicants must have a sufficient work history and have paid into the Social Security system through payroll taxes. Typically, individuals need to have worked for at least five out of the last ten years before becoming disabled. If an applicant doesn't meet the required work history, they won't be eligible for SSDI, even if they have a severe disability.
Income and Asset Limits for SSI
SSI eligibility requires that an individual has no more than $2,000 in assets (or $3,000 for a couple), and their monthly income must fall below a specific threshold, which is adjusted annually. Many claimants who fail to meet these financial thresholds are denied SSI benefits.
2. Lack of Sufficient Medical Evidence
Social Security is a disability program, and medical documentation is a critical part of the claims process. Applicants must provide evidence that their medical conditions are severe enough to prevent them from engaging in substantial gainful activity (SGA). A claim can be denied if the medical evidence is insufficient to support the applicant's disability.
Failure to Submit Complete Medical Records
The Social Security Administration (SSA) requires detailed documentation from healthcare providers, including medical history, test results, diagnoses, and treatment plans. If these records are incomplete or absent, the SSA may not have enough information to make an informed decision, leading to claim denials.
Inadequate Medical Opinions
In addition to medical records, Social Security may require medical opinions from healthcare providers. These are professional opinions about the severity of the claimant's condition and its impact on their ability to work. If the opinions are vague or don't adequately describe the limitations caused by the disability, the SSA may deny the claim.
3. Not Meeting the Social Security Definition of Disability
The SSA has a specific definition of disability, which may differ from the way people typically understand the term. To be eligible for benefits, an individual’s condition must be severe enough to prevent them from engaging in any substantial gainful activity. It must also be expected to last at least 12 months or result in death.
Failure to Prove Inability to Work
Many claims are denied because applicants fail to demonstrate that they can't perform any substantial work due to their condition. Social Security uses a five-step sequential evaluation process to determine whether an applicant meets the disability definition. If it's determined that an applicant can still perform their past job or adjust to other types of work in the national economy, the claim will be denied.
Partial or Temporary Disabilities
Applicants whose conditions are expected to improve or whose disabilities are temporary may also face denials. Social Security only grants benefits for long-term or permanent disabilities. For example, if an applicant has a disability that's expected to resolve in a few months or a year, their claim may be denied.
4. Failure to Follow Treatment or Recommendations
Social Security expects applicants to follow the prescribed treatment for their conditions, unless doing so would be unreasonable or harmful. If a claimant fails to follow medical advice, such as not taking prescribed medication, not attending therapy sessions, or not undergoing recommended surgeries, the SSA may view this as a sign that the disability isn't as severe as claimed.
Lack of Compliance With Treatment
If an applicant doesn't comply with treatment or actively works to improve their condition, the SSA may assume that their disability isn't as severe as initially stated. For example, if an applicant with a mental health condition refuses to take prescribed medications or attend counseling sessions, the SSA may view this as evidence that the person isn't fully disabled.
Not Seeking Appropriate Medical Care
In some cases, claimants are denied because they haven't sought the proper care for their condition. Social Security expects that applicants will seek out reasonable medical treatment for their impairments. If an individual has failed to receive regular treatment or see professionals when necessary, this may result in a denial.
5. Non-Compliance with Work Requirements for SSDI
To qualify for SSDI, applicants must meet the work requirement and demonstrate that they've worked long enough and recently enough to be eligible. A common issue for applicants is failing to meet the required number of work credits.
Work Credits Not Met
For SSDI, the SSA uses a "work credit" system to determine eligibility. Work credits are earned by working and paying Social Security taxes on income. Applicants must have earned enough credits based on their age at the time they became disabled. If an applicant hasn't earned enough credits, they won't qualify for SSDI benefits, and their claim will be denied.
6. Inconsistent or Conflicting Information
Claimants who provide inconsistent or conflicting information during the application process may face delays or denials. The SSA carefully reviews the information provided on the claim form, including the applicant's medical history, work history, and personal details.
If the SSA finds discrepancies, such as conflicting statements regarding employment, medical conditions, or dates of disability, this can raise red flags and lead to a denial.
Contradictory Statements
For example, if an applicant claims they're unable to work due to a disability but later reports engaging in activities that require significant physical exertion, the SSA may view this as inconsistent. Similarly, if an applicant provides conflicting statements about their medical condition or previous work experience, it can cast doubt on the credibility of their claim.
7. Failure to Meet Deadlines or Provide Requested Information
The claims process for Social Security benefits involves various deadlines for submitting documents and responding to requests for additional information. Missing deadlines or failing to provide requested information can result in a denial of benefits.
Missed Deadlines
If an applicant misses deadlines to submit medical records, appeal a decision, or attend hearings, it can lead to the denial or dismissal of their claim. Deadlines are critical in the Social Security process, and applicants must stay on top of them to avoid losing their benefits.
Failure to Respond to Requests
The SSA often requests additional information or documentation during the claims process. Applicants must respond promptly to these requests. Failure to provide the necessary documents or follow up with the SSA can result in delays or denials.
8. Not Appealing a Claim Denial in Time
In Florida, as in other states, many initial claims for Social Security benefits are denied. However, a claim denial isn't the end of the road; applicants have the right to appeal the decision. Failure to appeal a claim denial within the required time frame is a common reason for applicants to lose their chance at receiving benefits.
Missed Appeal Deadlines
The appeal process has strict deadlines, and failure to file an appeal within 60 days from the date of the denial notice can result in the closure of the claim. Applicants should seek legal advice or consult with a Social Security disability lawyer to help make sure they file an appeal on time.
Social Security claim denials can be frustrating, especially for individuals who are already dealing with the stress of a disabling condition. By reviewing these reasons for claim denials, applicants can take steps to avoid common mistakes, gather necessary documentation, and increase their chances of success in the claims process.
Contact a Social Security Disability Attorney Today
If your SSDI/SSI claim has been denied, it's in your best interest to work with Attorney Michael Reese. Contact Reese Legal today for more information about SSDI/SSI appeals or to schedule a consultation.