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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).

Return to:  Social Security Disability Resource Center, or read answers to Questions

Related pages:

Filing for disability with graves disease
Decision process for disability
How to win disability without a hearing
Disability benefit help
How to file for disability in Nebraska
Degenerative disc disease and applying for disability
How do you Apply for SSI?
What medical records have to say for you to get disability
What happened at a Social Security Disability Psychological Exam
What If You Miss Your Social Security Disability Hearing?
How to File for SSI
If you appeal a disability denial, how long to receive a decision?
How long does it take for an examiner to review a disability case?
How to file for disability in Iowa
Eligible for Social Security Disability or SSI?

Information on the following topics can be found here: Social Security Disability Questions and in these subsections:

Frequently asked questions about getting Denied for Disability Benefits | FAQ on Disability Claim Representation | Info about Social Security Disability Approvals and Being Approved | FAQ on Social Security Disability SSI decisions | The SSD SSI Decision Process and what gets taken into consideration | Disability hearings before Judges | Medical exams for disability claims | Applying for Disability in various states | Selecting and hiring Disability Lawyers | Applying for Disability in North Carolina | Recent articles and answers to questions about SSD and SSI

These pages provide answers to basic questions about pursuing disability benefits

Social Security Disability attorneys and representatives
What is the status of your social security disability or SSI case
Rules and requirements to apply for disability
Will I qualify for disability?
Apply for disability for any medical condition
Steps and Tips for requesting a disability hearing
If your disability claim is approved or denied
Social Security Award letter for SSD, SSI
Temporary Social Security Disability SSI
Social Security Disability SSI reviews
How social security evaluates attention deficit
Filing for disability with Post polio syndrome
Tips for Getting Disability Approved
How far back Social Security will pay SSDI or SSI
SSI award notices are received by approved claimants
Winning and getting disability with a mental condition
Getting disability for rheumatoid arthritis
Can you work if you get Disability?
Who qualifies for SSI and how
How to file for disability and where to apply
Conditions that may qualify as disability
Denied on a disability application
Answering questions at a Social Security Disability hearing