Generally, it's not the name of your particular medical condition that matters in a Social Security disability or SSI case, but the functional limitations that the condition causes you. Many people think that people who have medical conditions that qualify under Social Security's listing of impairments are the ones that win people disability benefits most often. But that's not true.
Half of all approved disability applications do not meet an impairment listing (54% of SSDI applicants and 45% of SSI applicants). Instead, the applicants qualified for disability because Social Security looked at their limitations, work history, age, and education and agreed that the applicants couldn't work. Only 37% of applications (averaged between SSDI and SSI) were approved because the applicants' medical condition met the requirements of a listing, and another 6% were approved because a medical condition was considered equivalent to an impairment listing.
Social Security's listing of impairments sets out over 200 medical conditions and illnesses with 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.
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. The list of impairments is simply a way for Social Security to fast-track some obvious disability determinations. If someone meets the specific two or three requirements in an impairment listing, the claims examiner at Social Security doesn't even have to consider how the impairment affects the applicant's ability to work—the applicant is approved on the spot.
If you don't meet a listing, Social Security 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 physical restrictions limit the jobs you can do. For mental or emotional claims, the examiner will consider how your symptoms limit what you can do.
To win a disability case, you need good medical records.
Cases that win are 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 often?
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 (for back problems) or exercise stress test (for heart problems), 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 too much value. But 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 (in other words, why the claimant's symptoms cause disabling limitations). 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.
Martindale-Nolo recently surveyed readers who had won and lost their disability cases and analyzed the factors that helped win or lose cases. The results supported the idea that going to the doctor was key to winning disability, and also found that quitting work before applying and going to a hearing with a lawyer were important factors. The survey also analyzed what effect age, gender, and type of benefit (SSDI or SSI) had on the success of a disability application. For more information, see Martindale-Nolo's survey statistics on the types of cases most likely to be approved for disability benefits.
Written by: Tim Moore, former Social Security disability claims examiner