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The Disability Claims Digest

Volume 16

Copyright 2013

In This Issue
Peruse Our Archived Newsletters
What Would You Like to Know?
Apply for Medicare On Line
Getting Help with Medicare Costs
Electronic Payments Are Mandatory
How Does Social Security Determine a Claim?
Inadequate Medical Evidence
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Getting Help with Medicare Premiums and Out of Pocket Costs
Social Security and the Centers for Medicare & Medicaid Services are working together to get you Extra Help with your Medicare prescription drug plan costs. If you have limited resources and income, you may qualify for Extra Help with the costs-monthly premiums, annual deductibles, and prescription co-payments-related to a Medicare prescription drug plan. The Extra Help is estimated to be worth about $4,000 per year. To find out if you qualify, Social Security will need to know the value of your savings, investments, real estate (other than your home), and your income. If you are married and living with your spouse, Social Security will need information about both of you.



Welcome to the Sixteenth edition of The Disability Claims Digest. 

In this edition, we will be reviewing how the Social Security Administration evaluates and determines a claim.  We will be discussing the Adult Listings and Sequential Analysis.  We will also discuss how Social Security evaluates a claim when there is little or no medical treatment and/or evidence to substantiate the severity of a medical condition.

As always, we have provided very helpful quick links to websites that we believe offer resourceful information and a plethora of support to disabled individuals, their loved ones and their health care providers.

If you have any questions, comments, concerns or require help with any aspect of a Social Security disability claim, please do not hesitate to contact us at:




Please read on....
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Reminder: Electronic Payments of Your Social Security or Retirement Benefits Are Now Mandatory

Just a reminder that electronic payments are not simply the best way to receive Federal benefits - they will soon be the only way. The U.S. Department of the Treasury's new rule phases out paper checks for Federal benefit and non-tax payments by March 1, 2013. In fact, effective May 1, 2011, all new recipients of Federal benefits, including those filing for Social Security and Supplemental Security Income (SSI), must receive their payments electronically unless they meet one of the very limited exceptions.


Electronic payments are safer, easier, more reliable, less costly, and good for the environment. If you have clients who still get Federal benefit checks in the mail, have them visit today to sign up for direct deposit or Direct Express.


How Does Social Security Evaluate a Disability Claim?

Social Security evaluates Title II disability claims (SSD) or Title XVI claims (SSI) in the same manner.  They use what is called a sequential analysis process.  There are five steps to this evaluation and they are as follows:

1.  Is claimant working at substantial gainful activity level? (CFR 404.1520(4i))

A claimant will define the date that they were forced to stop working because of the severity of their medical conditions.  If a person attempts to work again after that date, and/or that work exceeds a certain amount of gross income per month, (for 2013, that would be $1,040 for most claimants or $1,740 for a blind individual), and/or if the work is deemed to be physically and/or mentally demanding, and/or if that person is working what Social Security feels is substantial hours, this can be considered as inconsistent with the claimant's assertion that they cannot work.  If the work is deemed to be substantial gainful activity, the claim can be denied at this level.

2.  Is there a medically determinable impairment that is expected to last at least 12 months or result in death?  (CFR 404.1520(4ii))

It is at this level that Social Security will look at the medical evidence and assess whether or not the claimant's medical condition(s) fall within the severe range of functioning.  They are guided by the Adult and Child Listings which describes the severity criteria that a medical condition must meet.  See link below to review Social Security's Adult Listings.  If Social Security deems that the medical conditions do not meet the severity level they require, the claim can be denied at this level.

3.  Does the medical impairment(s) meet or equal the listings? (CFR 404.1520(4iii))

A claimant's impairment or impairments must meet or equal the listings and must also meets the duration requirement.  This means that not only must the medical condition be deemed as severe, it must also have been severe or is expected to be severe for at least 12 months or longer.

4. Does claimant have the residual functional capacity to do their past work? (CFR 404.1520(4iv))

At this level, Social Security will review all of the jobs that a claimant performed in the previous 15 years.  They will assess whether or not a claimant's medical conditions, symptoms, physical and/or mental restrictions will preclude them from being able to work in any of their past jobs.

5.  Does claimant have the residual functional capacity to perform any other jobs in the general economy?  (CFR 404.1520(4v))

Social Security will consider the residual functional capacity of a claimant, their age, education, and work experience and will decide if a claimant can make an adjustment to other work.  If they deem that a person can make the adjustment and perform other work, the claim will be denied.  If they deem that a person cannot work in any other job in the general economy, then the claim will be awarded.

The links below will take you to the official Social Security Administration website and will provide you with more detailed information concerning this process.


Please visit our website for helpful information and guidance regarding the Social Security claims process.
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What if there is inadequate medical evidence to show the severity and duration of the medical conditions?


Under Social Security's rules, a claimant must undergo medical treatment "as prescribed by your physician if this treatment can restore your ability to work."  20 CFR 404.1530(a) and 416.930(a).  If a claimant does not follow the treatment without a good reason, then the claim can be denied.


Acceptable reasons for not following prescribed treatment are set forth in the rules such as treatment is contrary to religious beliefs, surgery was previously performed but a person had unsuccessful results, or the treatment was very risky or unusual.


If a person has no health insurance, this is taken into consideration.  Social Security takes the position that there may be free or subsidized medical care available, but they do understand that there are regions where this may not be so.  They site charities, clinics, public assistance agencies, etc. as places where a person can seek out medical treatment and these options must be explored.  Such attempts must be documented.


For additional information regarding how Social Security will evaluate a claim which lacks adequate medical evidence, please click the following link:  


CFR 404.1530 


From The President's
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We hope that the information in this edition of our Disability Digest will prove to be beneficial to you or someone you know who is applying for or receiving Social Security disability or Supplemental Security Income benefits.

It is our mission to help as many people as we can to make their way through the frustrating claims process.  We are here to help anyone who is on this journey.  In addition to excellent representation services, we provide all of our clients with guidance, words of comfort, compassion, encouragement and kindness.

If you know of anyone that may benefit from the information contained in our newsletter, please forward it along to them by using the link below.

Until next time, take care and be well.


Sincerely yours,
Lisa S. Wagman, ADR, CP, NJCP 
Founder and President 
Accredited Disability Representative
Certified Paralegal





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Social Security Disability Benefit Consultants is a subdivision of Premier Legal Services, LLC. We are independent benefit consultants authorized by law to represent claimants before the Social Security Administration from the initial application to the Appeals Council level. We are in no way affiliated with the Social Security Administration directly.

We do not provide any legal advice. Our newsletter is a general service that provides legal information. We are not a law firm. The information contained in this newsletter is general legal information and should not be construed as legal advice to be applied to any specific factual information. We do not endorse any content provided by any linked sites, nor do we assume any responsibility for the interpretation or application of any information originating from such content.
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