Is It the Disability Examiner's Fault That I Got Denied for Disability?

When your initial disability interview is completed, all of your information is sent in a disability claims folder to a state agency for a medical determination, known in most states as disability determination services, or DDS.

DDS agencies are federally funded state agencies that develop medical evidence for social security cases and make initial and reconsideration appeal determinations as to whether or not a claimant is disabled under the rules and regulations of Social Security Disability.

Once at DDS, a disability examiner is assigned to obtain medical evidence from the sources that you listed during your disability interview first. If the disability examiner ascertains that there is medical evidence that is not available, or that the medical evidence exists but is obtainable, or is insufficient to make a medical disability claim determination, the examiner will schedule a consultative examination to obtain medical information.

Most disability determinations can thought of being made by a two person team (i.e. disability examiner and unit consultant, who may be a medical consultant, an M.D., or a psychological consultant, a Ph.D.).

But, some disability examiners have been qualified to make their disability determinations without the review of the second person. The SDM, or single decision maker disability examiners, usually make determinations that are relatively clearcut, i.e. likely to result in a denial of disability or are clearly an approval of disability. Single decision makers, however, must get a second review for all disability claims that have allegations of mental impairments, or complex medical vocational situations.

Disability examiners are bound by the SSD and SSI criteria set forth in the bluebook (Disability Evaluation Under Social Security) which contains a listing of physical and mental impairments and the disability medical criteria that are used to determine if an individual is medically disabled.

Although disability examiners are bound by the above mentioned criteria as far as the medical determination is concerned, disability examiners have some latitude as to how an individual's medical information is interpreted, as well as how much an individual's impairment limits their ability to perform substantial work activity.

Residual functional capacity is primarily determined by a claimant's medical records. However, a person's remaining level of function despite their condition or conditions, is determined, in part, through activities of daily living questionaires (claimants are typically asked to provide information regarding their ADLs, but usually an attempt is made to obtain third-party ADLs from someone who knows the claimant well enough to be able to comment on their daily activities, functionality, and limitation).

Questionaires of this sort, of course, are wholly subjective, both in the claimant's reporting of their daily activities, the examiner's recording of this information, and, yes, even in the manner in which a disability examiner may choose to "guide" the ADL questioning.

However, back to the topic of this post. As a disability examiner, I experienced numerous instances in which I determined that an individual was disabled, only to have my decision overturned by a unit case consultant, unit manager, or medical professional. Consequently, I would not say that it is necessarily the disability examiners fault when a claimant is denied disability benefits.

There are many reasons why a claim may have been denied. It is very often true that a case simply did not have objective medical information attached to it that indicated the claimant was disabled under Social Security disability guidelines.

In other situations, as I indicated a moment ago, a case consultant (translation: assistant unit supervisor in a DDS case processing unit) or a higher-level adjudicative person may have determined that a disability examiner's decision to approve a disability claim was incorrect. Or, in yet another type of scenario, a disability examiner may have marked a case for approval, only to have an external quality control specialist (at something known as DQB, or disability quality branch) review the case and reverse the decision.

Having said all this, however, even though it is typically--in an average case--not the disability examiner's fault that a particular Social Security Disability claim was denied, I cannot deny what I believe to be an indisputable fact: many claims at the state disability processing agencies are denied because the examiner conformed to one of the following scenarios:

1. The examiner had a built-in bias toward the case because it involved a mental impairment such as depression or a the condition bipolar disorder.

2. The examiner had a built-in bias toward the case because it involved an impairment for which disability determination services seems to have a general agency-wide bias against.

3. The examiner worked in a unit whose general decisional policy leaned heavily toward denying certain case profiles (DDS unit supervisors often wield more influence than the actual medical doctors who work in these agencies).

4. The examiner simply did not understand the functional impact of the information presented in the medical records (in other words, the examiner was poorly trained).

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

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