What Social Security Disability and SSI Cases Win?

It's hard to say which cases (or impairments) generally win disability benefits, but here are the factors that matter.

It isn't possible to say that a particular medical condition is more likely to win disability benefits than another (except for maybe a heart, liver, or kidney transplant—they're shoe-ins). But generally, it's not the name of your condition that matters, but what functional limitations the condition causes you.

Does My Condition Have to Be in the Blue Book?

Many people think that medical conditions listed in the "blue book" are the ones that win people disability benefits most often. But that's not true. The Blue Book is Social Security's listing of impairments that qualify for disability.

Listed Conditions

In Social Security's listing of impairments, each medical condition or illness has criteria for automatically qualifying for disability benefits. But not every medical condition is listed in the manual and, of the ones that are, the requirements are fairly tough to meet. Here's an example. Myocardial infarctions, commonly referred to as heart attacks, are discussed in Social Security's impairment listings. But if you've had one heart attack and one "cabbage" (CABG, a coronary artery bypass graft), you probably won't be approved for disability benefits based on this listing. In fact, if you've suffered a heart attack and had to have a CABG X 2 (that is, two main arteries bypassed and grafted), the odds are still good that you won't be approved. That's because the listing for coronary artery disease requires that you continue to have specific abnormal stress test results, ischemic episodes, or abnormal imaging results post-surgery.

What the Listings Are For

Not having a condition that's on the list—or not having a condition that meets the required severity of a condition on the list—doesn't mean you won't get disability benefits. In fact, most people who receive SSDI and SSI don't have a condition that matches the requirements of an impairment in Social Security's listings. The impairments in the blue book, as specified, represent only the most severe disabilities; the list of impairments is simply a way for the SSA to fast-track some obvious disability determinations. If someone meets the specific two or three requirements in an impairment listing, the claims examiner at the SSA doesn't even have to consider how the impairment affects the applicant's ability to work—the applicant is approved on the spot.

When a Listing Is Not Met

If you don't meet a listing, the SSA is will consider the effect that a person's medical condition has on his or her ability to work. A disability examiner at Social Security will determine what level of exertion you are capable of, and what phyiscal restrictions limit the jobs you can do. For mental or emotional claims, the examiner will consider how your symptoms limit what you can do.

What Factors Win a Disability Case?

Good Medical Records

Cases that win tend to be the cases that are better documented, meaning applicants who have good medical records are more likely to be granted disability benefits if they have a serious medical condition. In my job as claims examiner, I saw applicants time and again who hadn't been to a doctor in months, or would only see a doctor every four months. It is almost impossible to win a disability case with medical treatment so infrequent. How can you have good medical records with sufficient documentation of your symptoms and limitations if you don't go to the doctor?

Functional Medical Evidence

What disability applicants need to know and realize is this: Social Security bases its decisions on functional medical evidence. Examples of good functional evidence would be the results of a straight-leg test or exercise stress test, evidence of the inability to stand up from a seated position or to balance while standing, or, for mental claims, the results of intelligence or memory tests or clinical psychiatric notes.

In most cases, statements from employers, relatives, and so on, don't have much value. Supporting statements from physicians about a patient's limitations do count as functional medical evidence, as long as the statements point out to the disability claims examiner (or the judge in the case) exactly why the claimant is disabled. For this reason, a doctor's statement must be detailed, preferably in the form of an RFC form (residual functional capacity form). Having a doctor fill out an RFC form for you—or something similar that sets out your limitations—is probably the single most important document you have at your disposal to win your disability case. But of couse, even an RFC form has to be backed up by medical evidence. Your doctor should point out which medical evidence is tied to which limitations on your RFC form.

Learn more about the importance of your residual functional capacity.

Written by: Tim Moore, former Social Security disability claims examiner

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