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Avoiding Hearings

Although a Social Security claim should be approved if the treating physician’s opinion is well supported by the medical evidence, most disability applications are denied initially by the state agency. The next step is a hearing before a Social Security administrative law judge (“ALJ”), which is about a two year wait. If the ALJ applied the treating physician rule properly, then the disability application should be approved.

While it may seem unfair to make a claimant wait years to have the treating physician rule applied properly, there is an alternative. A claimant can make an “on-the-record” (“OTR”) request for a fully favorable decision pending the hearing. The OTR basically asks that the application be approved because the medical evidence is so strong that a hearing is unnecessary.

When submitting an OTR, it is important to have a file that clearly shows an entitlement to benefits. Thus, while a single supporting physician should suffice at a hearing, it may not suffice when submitting an OTR. Therefore, furnishing medical evidence from additional treating sources is important.

I represent a 45 year old school crossing guard, whose application was denied even though it was supported by an arthritis specialist who provided a detailed report summarizing the clinical, diagnostic and subjective medical findings, and concluded that the claimant was unable to perform sedentary work. In connection with an OTR, a second report was submitted from the claimant’s treating orthopedist. Like the arthritis specialist, the orthopedist’s report summarized the clinical, diagnostic and subjective medical findings, and concluded that the claimant was unable to perform sedentary work.

The OTR was approved. As a result, the claimant did not have to wait for a hearing, go through the stress of a hearing, and had a smaller attorney fee. While it is possible that the OTR may have been approved without the report from the orthopedist, experience has shown that an OTR is usually denied when based upon medical evidence from a single supporting physician

Working Does Not Preclude Benefits

The Social Security Administration (“SSA”) wants to encourage people to work. Depending on the circumstances, the SSA may allow a person to collect Social Security Disability (“SSD”) benefits during a time period in which they worked. One such circumstance is called an “unsuccessful work attempt (“UWA”)”.

I received an approval in a case today involving an UWA. The SSA originally concluded that the onset of a claimant’s disability was April 26, 2000, which is when she stopped working at a department store. Because the claimant had to prove that she became disabled before December 31, 1999, the SSA denied SSD benefits.

I took over the case when the claimant had to go to federal court. I pointed out that the claimant was injured at work in February 1997, and had not worked since the accident except for March and April 2000 at the department store. I argued that because the department store work lasted less than three months, it was an UWA, and denial of SSD benefits was wrong. The federal court agreed and remanded the case to the SSA for a new hearing.

At the second hearing, the SSA determined that the work at the department store constituted an UWA. Therefore, the SSA concluded that the claimant’s onset date was February 1997, not April 26, 2000. Because the claimant established that her disability began prior to December 31, 1999, the SSA found that she was entitled to retroactive SSD benefits, including benefits for March and April 2000.

Be Wary of Forms

Applying for disability benefits normally means having to complete forms. However, even if forms appear to be clear they may be skewed in a manner that makes it difficult to be approved for disability benefits.

A Social Security Disability (“SSD”) claimant to me after the Social Security Administration (the “SSA”) rejected her application. A review of the claimant’s file indicated that her treating doctor completed an SSA form that seemed to favor her claim. The doctor checked off the most restrictive box that the form had for sitting, which was less than six hours during an eight hour day. The least strenuous type of work is se3dentary, which requires the ability to sit for most of the day. Nonetheless, the claim had been denied because a disability examiner concluded that there were many jobs where the claimant could sit for about five hours a day, and stand and walk for the remainder.

On appeal, I had the same doctor complete one of my own forms to assess the claimant’s ability to sit during an eight hour day. The form gave the doctor nine options to circle; that is, from zero through eight hours. The doctor selected two hours, which eviscerated the argument that the medical evidence supported the claimant’s ability to perform a job where she could sit five hours a day. Accordingly, the claimant’s SSD application was approved.

There was nothing incorrect with the SSA form. However, the SSA form is designed to make some functional assessments appear less severe and possibly capable of gainful activity. When applying for disability it is important to recognize how form questions can be misleading

Exam Secrets

The Social Security Administration (the “SSA”) has many regulations and secrets concerning a consultative examination (“CE”). A CE is when a doctor selected by the SSA examines a claimant.

One secret is that even though the SSA has claimants sign authorizations so they can receive copies of CE reports, the SSA never provides them. The SSA also does not tell claimants that it pays the same doctors to examine thousands of claimants, and these CE doctors rarely conclude that claimants cannot work.

Being familiar with CE secrets and regulations can be critical to obtaining benefits. I just succeeded in having a 43 year old client’s disability application approved without a hearing based on such knowledge.

As usual, Disability Determination Services “DDS” represented that the claimant had to attend a CE. I advised the DDS it is not allowed to order a CE simply for a “second opinion”. However, I told the DDS that if it contended a CE was needed to provide additional information, then the regulations required that the CE be performed by the “preferred source,” which is the treating physician. The DDS agreed and the treating physician’s CE report completely supported the client’s inability to work. Nonetheless, the DDS still denied the disability application despite lacking any grounds whatsoever for doing so.
The good news is that the DDS’s conduct was so patently wrong that the SSA approved the client’s disability application less than a month after it was submitted. Had I permitted the claimant to attend a CE by the SSA’s non-preferred source, it is very unlikely that the disability application would have been approved without a hearing.

SSD for Firefighter

The fact that a firefighter was found disabled by the fire department does not mean that he must be found disabled by Social Security because the two agencies have different standards. A disability pension from the fire department requires proving the inability to work as a fire fighter while disability benefits from the Social Security Administration (the “SSA”) requires proving the inability to do any type of work in most circumstances. Nonetheless, it is important to inform the SSA if a fire fighter has received a disability pension.

There are five steps to the SSA hearing process. The fourth step is can the claimant perform past work, and the fifth is can the claimant perform any other work. While the claimant has the burden of proof at the fourth step the SSA has the burden of proof at the fifth step. Since the fire department is in a better position than the SSA to determine that a claimant cannot continue to work as a fire fighter, it would be nearly impossible for the SSA to issue a contrary ruling. Therefore, the fire department’s ruling effectively shifts the burden of proof to the SSA.

The burden of proof shift is very important. I represent a firefighter who came to me after his application was denied based on the report from the SSA doctor. I obtained reports from the claimant’s doctors that contradicted the SSA doctor. Even if there were a stalemate between the doctors, the claimant would be entitled to benefits because the SSA had the burden of proof. As a result, the SSA approved the fire fighter’s benefits.

Consultative Examinations

Social Security Disability claims are usually denied based on the reports of consultative examinations (“CEs”). I advise my clients not to attend CEs because the regulations provide that the preferred source for performing a CE is the treating physician, and not a doctor selected by the state agency processing the initial application. There are three possible outcomes where a claimant does not attend a CE by a state agency consultant.

The first possibility is that the medical evidence supplied by the claimant and obtained by the state agency is so strong that the application gets approved despite refusal to attend the CE.

The second possibility is that the application will be denied on the grounds of non-cooperation. However, if the state agency is advised how the regulations would be violated if the CE is not performed by the treating physician, and the claimant offers to supply whatever specific medical information the state agency contends is needed to adjudicate the claim, then there is no valid basis for asserting non-cooperation. If then application is denied, the non-cooperation argument does not stand up on appeal.

The third possibility is that the state agency will agree to have the treating physician perform the CE. This is rarely the case, but when it happens, it virtually guarantees that the application will be approved on appeal if the state agency denies the application. I just had a lightning fast approval of such a case.

I represented a client whose application was denied despite the fact that I persuaded the state agency to have the treating orthopedist perform the CE, who concluded that the claimant was totally disabled and could not do any type of work. The day the claim file was transferred to the hearing office I submitted a request asking that the claimant’s application be approved based upon the evidence currently in the file. I argued that all the medical evidence, including the CE paid for by the state agency, showed the claimant was entitled to disability benefits. I received a telephone call in less than a week advising me that the application would be approved, and a written decision was received a couple of weeks later.

Purpose of SSD Hearing

It is a relatively rare situation where the Social Security Administration (the “SSA”) contests a claimant’s alleged medical impairments. While the diagnoses are not at issue, the severity of the claimant’s medical condition is the primary issue at the vast majority of Social Security Disability (“SSD”) hearings.

When preparing for a hearing, it is critical to focus on the real purpose for holding a hearing. A hearing is required when the SSA has determined that the objective medical evidence in the file does not suffice to establish the claimant’s entitlement to SSD benefits. Therefore, a hearing is held to see if the subjective medical evidence, the claimant’s sworn testimony, is enough to establish the claimant’s entitlement to SSD benefits when added to the objective medical evidence.

Since the purpose of the hearing is to assess whether the claimant’s subjective complaints are credible, evidence establishing credibility in general should be provided. I received a fully favorable decision today that illustrates this point.

The claimant was under 50 years of age, had a high school education, and a skilled sedentary job, which qualified her as a young, skilled, well educated person. An application by such a claimant is subject to the strictest standard for entitlement to SSD benefits. While an older, less skilled or less educated person with the same medical records may have been entitled to SSD benefits, my client had to rely on her subjective complaints to augment her claim.

I did two things to bolster the claimant’s credibility. First, I conducted a direct examination eliciting the claimant’s entire work history based on her SSA earnings record, which extended 31 years including the last 13 years with the same employer. I advised the ALJ on the record that the federal courts hold that where a claimant has a long work history of continuous work at the same employer, her testimony as to her capabilities is entitled to substantial credibility, and, that a claimant’s long and honorable work history justifies the inference that when she stopped working she did so for the reasons testified to. I then pointed out that the claimant’s SSD benefits would not come close to the income of her well paying job, and that commonsense dictated that she would have continued working if able to do so.

The other tactic that I intended to use to bolster the claimant’s testimony was to have the claimant’s mother testify as a witness, but the ALJ stated that would not be necessary. That indicated the ALJ accepted the claimant’s credibility and would approve SSD benefits because failing to develop the administrative hearing record by precluding witness testimony would have been reversible error