Successfully Applying for Disability Benefits in California

Applying for Disability in California

How to apply and qualify for SSD, SSI in California (CA)

Note: If you have already filed a claim and been denied for disability, or are wondering what to do in the event of a Social Security denial, proceed to the reconsideration and hearing appeal sections below.

Level I: Disability Application - Statistics vary from year to year, but, typically, individuals applying for disability in California will have approximately a 30 percent chance of being awarded benefits. Up to 70 percent of all claims may be denied in any given year making it necessary for the majority of claimants to pursue the Social Security appeal process before eventually becoming eligible to receive benefits.

Claims at the initial level are typically decided in under 120 days, though decisions can take much longer due to a variety of factors, one of which may include any difficulty the examiner has in obtaining medical records from the listed medical treatment sources.

Disability claims in California may be initiated online or through a local Social Security office. However, online filing will not allow an SSI claim to be taken; as claimants are unlikely to know in advance if their claim will involve the SSI program, the SSD program, or both programs in the form of a concurrent claim, claimants may wish to eschew the online process in favor of contacting a local office.

Online filing, it should also be noted, does not allow for a face-to-face interview with a Social Security Claims Representative (CR) who may answer whatever questions the claimant has. This, in and of itself, may reduce confusion and minimize the potential for making mistakes with regard to the application and any subsequent appeals that may follow.

Starting the disability claim

After contacting a local field office, an appointment will be set for a disability application interview. The interview may be conducted in person at the Social Security office, or conducted over the phone for those individuals who have medical mobility or transportation issues.

The purpose of the disability interview is for SSA to gather all the information that is needed to process the claim. However, the most fundamental information that will be acquired during the interview concerns a) the claimant's medical treatment history and b) the claimant's vocational work history.

The Importance of the Medical history information

The medical treatment history will be used by Social Security to determine whether or not the claimant qualifies for disability by having a condition that is listed in the blue book, also known as the Social Security Disability list of impairments.

Note: The approval criteria for a listing tends to be fairly specific and detailed and the majority of claims are not approved on the basis of a listing.

However, there is a second, more common route to being approved. The disability examiner assigned to the case will also review the medical evidence to determine a) what the claimant's physical and mental functional limitations are and b) the extent to which these limitations restrict their ability to engage in normal activities of daily living (ADLs), including basic work activities. The severity of the claimant's limitations is rated on an RFC, or residual functional capacity, assessment.

Claimants who are found to have a listing-level condition, or are found to have limitations that are severe enough to rule out their ability to perform their past work activity, or other types of work (for which their age, work skills, and education might otherwise suit them) will be considered to have met the qualifications for disability. This is known as a medical vocational allowance.

Individuals who are approved on the basis of a medical vocational allowance may be eligible to receive both ongoing monthly disability benefits, as well as some amount of disability back pay.

The Importance of the Work history information

The information obtained from a claimant's work history is as important as that which is obtained from the medical records. This is because, as stated, while some claims are approved on the basis of just the medical records (satisfying the requirments of a listing), most claims are granted through a medical vocational allowance.

In this type of approval, Social Security must have enough information about the claimant's former jobs--their past work for the entire 15 year period prior to becoming disabled--to determine if they a) still retain the functional capacity to return to a past job, and b) have acquired skills that may allow them to switch to some type of other work if they cannot return to their past work.

Be careful when submitting the medical treatment and work histories

Because both the medical and vocational histories are crucial to making a determination on a disability claim, claimants may wish to write down both prior to the appointment time for their disability interview. This may allow for more completeness, but also avoid accidentally leaving out critical pieces of information.

In supplying the medical history, claimants should be careful to provide the names of all diagnosed conditions, the names of all treating physicians (who may be asked at a later date to supply a statement in support of the case), and the full names and addresses of all medical treatment providers, including all doctor's offices, all clinics, and all hospitals. The latter is often crucial since the disability examiner who is assigned to the case will use the information submitted by the claimant at the time of application to send out medical record requests.

Note: The single largest delay on any disability claim has to do with how long it takes Social Security to obtain the claimant's medical records.

In supplying the vocational work history, claimants should be careful to supply all jobs worked during the past 15 years, including job titles, employers, and detailed descriptions of the duties associated with each job. Social Security will use this information to identify the claimant's individual's jobs in a reference source known as the DOT, or dictionary of occupational titles.

The DOT allows Social Security to determine what the physical and mental demands of a claimant's past work might have been. This, in turn, may be compared to the current level of functioning possessed by the claimant, which may lead to two separate conclusions: Is the claimant capable of returning to their past work?; Is the claimant capable of performing some type of other work?

Claimants who are incapable of doing either (returning to their past or doing other work) may meet the requirements for disability. However, it should be very clear that the outcome of a case may be influenced by the accuracy of the work history information provided by a claimant.

Qualifications - There are two ways of being approved for disability

A disability claim is approved by the Social Security Administration when the evidence of the case satisfies the SSA definition of disability.

Under this definition, for an individual to be considered disabled, they must have one or more medically determinable impairments (corrobated by medical records provided by licensed medical sources). The impairment may be physical or mental in nature, or both. It must also be severe to the extent that it lasts for at least one full year and prevents the individual from engaging in substantial and gainful work activity.

Individuals filing for disability in California will have the evidence of their case evaluated for three possible outcomes:

1) Being approved on the basis of satisfying the requirements of a listing in the Social Security list of impairments;

2) Being approved on the basis of a medical vocational allowance;

3) Receiving a denial of their claim, in which case claimants should file an appeal prior to the expiration of the appeal deadline.

Qualifying for disability as a child

Children apply for disability benefits through the SSI program. As with adult claims, a child may qualify for disability based on having a medical condition (a physical problem or mental problem) that is included in the disability listings. This type of approval is made on the basis of medical records.

Whereas adult claimants have a secondary route to approval through a medical vocational allowance that takes into account their vocational work history, a child may also be found disabled if they are unable to engage in what SSA refers to as age-appropriate activities. When the child is of school age, this will usually mean that medical records will be reviewed, as well as any academic records that are available, such as grade reports, IEPs, and the results of IQ and achievement testing.

Social Security Disability versus SSI

The Social Security Administration provides disability benefits through two separate programs: the title 16 Supplemental Security Income program, otherwise known as SSI, and the title II Social Security Disability program, referred to as SSD, and sometimes as SSDI (Social Security Disability Insurance).

In terms of how disability claims are examined and decisions are made, there are no differences between title II and title 16 benefits. Whether or not a claim will be for SSI or SSD will be determined sometime during, or after, an initial claim has been filed with a Social Security office. Which program applies to a person's claim is dependent upon their insured status.

SSD is for individuals who have worked long enough to acquire work credits which insure them.

SSI is for a) individuals who have no work history (e.g. children), b) individuals who were once insured for SSD but have lost their insured status because they have not worked in a long time, and c) individuals who are currently insured for SSD but are only eligible to receive a small monthly benefit amount (in such instances, the claim may be concurrent and involve both programs).

From a benefit standpoint, both SSD and SSI provide for monthly disability benefits. SSI beneficiaries receive an amount that is determined annually by the federal government, while SSD beneficiaries receive an amount based on their earnings history.

SSI beneficiaries also receive medicaid benefits, while SSD beneficiaries will become eligible for medicare coverage.

Denials on disability claims in California

The high rate of denials on disability applications necessitates that the majority of claimants will need to file one or more appeals in order to qualify for disability benefits. Appeals must be filed within 60 days (plus an added 5 days for mailing time) of the date of the denial. This date is usually stamped in the upper right hand corner of the denial letter, or notice of disapproved claim. However, claimants should take note that the appeal must actually be received by Social Security by the 65th day, not simply postmarked by that date.

Claimants who submit appeals are advised to do the following:

1. Keep a copy of all appeal paperwork submitted.

2. Within 10-14 days of submitting the appeal, make a followup status call to Social Security to verify that the appeal was received, to avoid the possibility of a late appeal situation.

Note: Claimants in California who are represented by a disability lawyer or a non-attorney disability representative will have their appeal completed by the representative for them. Having said this, a claimant who receives a denial letter should contact their representative to ensure that both parties are aware of the denial. Again, this is to avoid the possibility of an late appeal.

Disability application denial rate: 69 percent.

Disability application approval rate: 31 percent.

Level II: Request for Reconsideration - When a disability application in California is denied, the next step will be to file a request for a reconsideration appeal.

The disability requirements and the approval criteria remain the same for this appeal. The process of qualifying likewise remains unchanged since a reconsideration appeal is also processed by a disability examiner at disability determination services.

Reconsiderations generally result in a faster decision versus initially applying for disability in California. This is because most of the case development will have been performed by the previous-level examiner.

Though a disability application decision will usually be decided in 90-120 days, a reconsideration appeal decision can often be expected in half that time. Claimants should be aware, of course, that reconsiderations may also involve being sent to a consultative medical exam, or CE, if the examiner feels the need for additional evidence.

As is the case in most other states, reconsiderations in California are denied at a higher rate than initial claims, and, ordinarily, the rate of denial rate will exceed 80 percent. Failing to meet the qualifications for disability at this level does not end the process, however, since claimants who are denied will have the option to proceed to the hearing level.

Note: The Reconsideration appeal is currently not being conducted in the following areas in the state of California: the Los Angeles North branch and Los Angeles West branch.

Reconsideration appeal denial rate: 88.3 percent.

Reconsideration appeal approval rate: 11.7 percent.

Level III: Request for Hearing before an Administrative Law Judge - In the vast majority of cases, claimants in California will receive a denial on a reconsideration appeal. In fact, unless new evidence is brought into the case during the reconsideration phase, or the reconsideration examiner discovers an error made by the previous disability examiner, it is very unlikely that the prior denial will be reversed.

A denial at the reconsideration level, of course, will make it necessary for the claimant and/or their disability attorney or disability representative to file a request for a disability hearing. The hearing appeal will need to be requested within 60 days of the date of the denial. Claimants who are not represented at this time may find it wise to consider representation since success at a disability hearing may be highly dependent on thorough case preparation.

Decisions by Administrative Law Judges

Decisions at the hearing level are made by federally appointed ALJs, or administrative law judges. Like examiners, judges make decisions according to the rules and regulations of the Social Security Disability and SSI disability system and may approve cases based on satisfying the requirements of a listing, or based on successfully passing through the five step sequential evaluation system that leads to a medical vocational allowance.

That said, there are a number of substantial differences between the hearing level and the two levels that precede it:

1. Disability hearings may involve the use of expert witnesses who appear at the discretion of the judge. The judge may decide to call a medical expert and/or a vocational expert if he or she feels the need for expert testimony. Both experts may be cross-examined by the claimant or their representative if they have one present.

2. At disability hearings, bringing recent evidence into the case will be the responsibility of the claimant or their representative. Social Security stops all case development at the conclusion of the reconsideration appeal. This means that, by the time a hearing takes place (usually months after the reconsideration appeal), there may be no new evidence in the claimant's file unless the claimant or their representative have obtained this evidence and made it available to the judge.

Note: Social Security Disability and SSI claims cannot be approved for ongoing monthly benefits without recent medical evidence, "recent" being defined as not older than 90 days.

3. While disability examiners may only approve or deny claims, judges may issue approvals that are fully favorable or partially favorable (partially favorable typically means that the case has been approved but with an onset date that is less favorable than the one originally alleged by the claimant). Judges may also, when a claimant does not qualify for ongoing monthly benefits, approve disability benefits for a "closed period", a specified timeframe in the past. A closed period will allow a claimant to receive a certain amount of disability back pay.

4. Unlike disability examiners, judges give credence to the opinions of a claimant's treating physician, which is why a claimant's representative will generally attempt to secure a medical source statement from a treating physician so that it may be entered into the record.

Statistically speaking, the odds of approval are more favorable at the hearing level than at any other level. This is maximized, of course, when the administrative law judge has been presented with recent medical evidence and a compelling rationale for approval.

Disability Hearing denial rate: 49.1 percent

Disability Hearing approval rate: 50.9 percent