Your Adult Social Security Disability or SSI Claim:

The First 15 Minutes (continued) 

Diagnosis  : Taking a look at the diagnoses that a claimant alleges is extremely important because there are several diagnoses that will result in a claimant “meeting a listing”. This means that that particular diagnosis is listed as a condition in the Disability “bible” which will result in an automatic approval or allowance of benefits, when the diagnosis is confirmed by an acceptable medical source.

As an example, if a person is receiving regular weekly or biweekly kidney dialysis, all it will take to get a claims allowance is a form (usually faxed) from the facility providing the treatment. When a condition meets a listing contained in the Disability Evaluation under Social Security book, this becomes a claim the examiner can allow and dispose of in less than a week.

If such a diagnoses is for a Supplemental Security Income claim, the claimant may also be eligible for immediate benefits payable under the Presumptive Disability provision of SS disability law. This will allow the immediate presumptive approval of a claim for payment even before all medical evidence needed to adjudicate the claim has been received.

In Presumptive Disability allowances, a claimant may receive a disability check for up to six months while the examiner gains medical evidence supporting the claim.

The diagnoses also tell whether the claimant is alleging just a physical disability or a physical/mental combined disability. As mentioned previously, when combination impairments are alleged, extra processing forms and collateral contact information must be obtained in order to further document the extent of the impairments.

The other thing the diagnoses/allegations section of the application will tell is whether the condition can be expected to resolve in a year or less.

For example, an individual may have a broken arm or a broken leg and be seeking temporary benefits until the fracture is healed. In these instances, unless a non-union of the fracture is subsequently documented by the medical evidence, these cases will be denied because they are not expected to be disabling for at least one year. And it becomes a matter of an examiner just waiting for the medical evidence to come in prior to issuing a decision.

Physical medical conditions that are expected to resolve within one year are easy cases to adjudicate, and are generally put to the back burner while awaiting medical evidence in favor of working on cases that have more of a chance of being allowed/approved.

Medical Treatment History: Claims applications are checked for dates of last medical treatment. If a claimant has not seen a doctor in the past 3 months and there is no pending appointment listed on the application, this indicates that a “consultative evaluation” exam, alias a CE, may need to be scheduled for the claimant. This is when Social Security pays a private contracting physician or psychologist to examine the claimant and document the severity of a any impairment(s).

At this point, a telephone call may then be made to the claimant to verify that there is no pending appointment with a treating physician and/or that there are no current medical records that were not listed on the application. If no current medical documents can be obtained from a treating source, the CE appointment will be scheduled at the earliest possible date.

[Next: Next Steps in Processing the Claim]

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