Process for Obtaining Benefits

You can apply for disability benefits in person, by telephone, by mail, or by filing online. The field office verifies your non-medical information, such as your age, employment, and marital status. Most disability claims are processed through local Social Security Administration (SSA) offices and state agencies called Disability Determination Services (DDS). The field office then sends your claim to a DDS to determine if you have a qualifying disability.

The process of applying for disability benefits can be challenging and you must be careful to follow the required procedures and respond to any questions or requests by the SSA. The following is a rough outline of the steps involved in obtaining disability benefits:

1. Gather medical records and information
2. Consultative Examination by a doctor paid by SSA (if required by SSA)
3. Initial decision regarding disability
4. Request for reconsideration if initial claim denied, but need not request reconsideration in New York
5. Hearing and decision
6. Appeal Council process
7. Continuing Disability Review process

Gathering Medical Evidence of Disability

Your first step is to gather the medical evidence needed to prove your disability. The records should date back to the time when you first became disabled. Sometimes, especially with mental health disability claims, it may be difficult to figure out when your disability began. You can ask family, friends and co-workers to help you figure out when your disability began.

Make sure you follow all your doctor’s orders, especially related to taking medication and attending therapy sessions. SSA may deny your claim if you do not have a good reason for following the treatment your doctor recommends for you. You should provide your doctor with any and all information regarding the limitations you have, so the doctor understands how your condition affects your work and daily activities.

You will need to have the following information when you file your claim:

• Names, contact information, patient ID numbers, and treatment dates for all medical service providers who have treated you;
• List of any prescription medications you are taking;
• Dates of medical tests;
• List of all jobs you have held for the previous 15 years (up to five jobs), including dates; and
• Information regarding any workers’ compensation claims or insurance claims you have filed.

Consultative Examination

The DDS will first look at the medical information you provided to determine if you have a disability. If that information is insufficient, unavailable, incomplete, or inconsistent, the DDS may order a Consultative Examination (CE). This is a physical or mental examination or test used to make the disability determination. It is usually performed by an independent contractor doctor paid by SSA.

The CE must spend a certain minimum amount of time evaluating your condition and must meet accepted professional standards and practices in completing the examination. Before you go to the exam, you should be prepared to give that doctor a history of your injury or illness, description of your symptoms, a list of medicines taken, doctors who treated you, and the limitations on your ability to work.

There are requirements regarding the doctor’s report as well. For instance, it must include sufficient information to allow the SSA to determine the nature, severity, and duration of your impairment, as well as your ability to perform basic work functions. The report must include your statements about your symptoms, in addition to the doctor’s opinion and observations. In addition, the report must include the results of any lab tests and a list of the work-related activities the doctor concludes.

After the exam, you should make some notes about what happened during the consultative examination. Write down how long the exam lasted, what questions you answered and whether you were given an opportunity to fully explain your symptoms and limitations, what tests the doctor performed and what activities the doctor asked you to do.

Initial Decision and Further Review

If your claim is initially denied, you have 60 days to appeal the decision and request a hearing before an administrative law judge (ALJ). If your appeal is not filed on time, the ALJ will typically dismiss your appeal and you may lose your right to further appeal your case.

The hearing can be held in-person or remotely by video teleconference. In general, a video hearing can be scheduled more quickly than an in-person hearing. You will be notified of the hearing date at least 75 days before the hearing. The SSA will try to schedule the hearing with 75 miles of your home.

At the hearing, you will have the right to submit new evidence and bring witnesses to testify. The ALJ may ask other witnesses to testify at the hearing, include experts like independent doctors and vocational specialist that SSA pays to testify. The recorded hearing is more informal than a court trial. You will receive a written decision after the hearing.

Appeals Council

If your claim is denied after the hearing, you have 60 days after receiving notice of the decision to request a final administrative appeal before the Appeals Council. Your appeal must be in writing and submitted by mail or in person to the SSA. If you fail to appeal on time, your appeal may be dismissed.

The Appeals Council looks at all requests for review to decide whether if it will review the case or not. If the Appeals Council determines the decision after the hearing was correct, it will refuse to review your case. If the Appeals Council agrees to review your case, it will either conduct a review itself or send the case back to the ALJ. If the Appeals Council reviews your case, you will get a written copy of its decision.

If you are dissatisfied with the Appeals Council decision, you can file a civil suit in federal court. You will have 60 days after receiving notice from the Appeals Council denying your request for review to of the decision to file a civil lawsuit in federal court.

Continuing Disability Review Process

If your claim for disability benefits is approved, the SSA will periodically review your case to see if you are still entitled to SSDI or SSI benefits. The Continuing Disability Review (CDR) requires a medical examination every three years or every seven years, depending on the severity of your condition. Children receiving SSI benefits will have their claims reviewed when they turn 18, and then they must meet the requirements for disability as an adult.

The SSA will also schedule a CDR in the following situations:

• You return to work;
• Your medical evidence shows your condition is improved;
• There is a new treatment for your condition;
• A third party informs the SSA that you are not following your treatment; or
• You inform the SSA that your condition has improved.

If your claim is up for review, the SSA will notify you by mail, by sending you a short form to complete. The SSA looks for information about your condition from the prior 12 month. Next, the SSA may send you a long form to complete, if the short form shows your condition could improve. You will be asked to send updated medical evidence to the SSA, but it could also get the evidence on its own.

If the CDR shows that your medical condition has improved enough for you to work, the SSA will terminate your benefits. You have a right to appeal this decision.

Legal Editors: Anselmo Alegria and Wiliam E. Leavitt, February 2018