Benefits with Commonwealth of Virginia Members

Social Security Disability: Eight Reasons You May Be Denied Benefits

Will your claim for SSDI disability benefits be denied?

When applying for Social Security disability (SSDI), most people naturally think about the reasons why they should be granted benefits. You may find it useful, however, to turn the perspective around and understand the reasons why you might be denied SSDI benefits. In some cases, the reasons are beyond your control. In other instances, though, you may be able to avoid doing something that results in a denial.

1. You Earn Too Much Income

The most basic reason you could be denied benefits is that, when you apply, your income is above the limit where it is considered substantial gainful activity (SGA). This means you earn too much money. The SGA limit for nonblind people is $1000 per month in 2010, and the figure is adjusted annually. To find out the current SGA income limit, go to the SSA's substantial gainful activity page. Income from investments does not count toward the SGA only work income counts.

2. Your Disability Won't Last Long Enough

To qualify for SSI or SSDI benefits, the Social Security Administration (SSA) must believe that your impairment is severe enough to last at least 12 months or result in your death. The only exception to this duration requirement is for blind SSI applicants. Many claims like those based on bone fractures resulting from acute trauma, such as automobile or motorcycle accidents are denied because they are not likely to cause disability for 12 months. Almost all bone fractures heal in less than a year. However, if you have severe bone fractures that aren't healed after six months, the SSA is likely to think your impairment will last a year. Each case is evaluated on an individual basis.

3. The SSA Cannot Find You

The SSA and the Disability Determination Service (DDS) the agency that determines your medical eligibility for benefits must be able to communicate with you regarding your application. If these agencies cannot reach you to schedule examinations or communicate with you about critical matters, your benefits may be denied. If you name a representative (such as an attorney) to handle your paperwork, you may not need to get in touch with the SSA, but be sure to stay in touch with your representative or attorney. If you move while your application is being considered, make sure the SSA knows how to contact you. Claimants get denied every day because the SSA cannot find them.

4. You Refuse to Cooperate

Your medical records are vital to granting your disability. If you refuse to release those records to the SSA, your claim could be denied. Similarly, the SSA may need additional information about your impairments, either because your treating doctor's medical records are incomplete or because you have no treating doctor. In these instances, the SSA will request that you be examined by an SSA doctor in something called a consultative examination (CE), at government expense. In some cases, the SSA will require you to attend more than one CE. If you refuse to attend or request that the SSA make a determination based on the medical records already in your file, you may be denied disability because of inadequate medical information or failure to attend the CE.

If you can't make it to a scheduled CE because of the time or location, talk to your claim examiner so the DDS can schedule a CE at a time or place that is convenient for you. If you repeatedly fail to show up for a CE, your claim will most likely be denied.

5. You Fail to Follow Prescribed Therapy

If you are being treated by a doctor, but fail to follow the doctor's prescribed therapy when you have the ability to do so, you can be denied disability benefits. However, the SSA recognizes certain legitimate excuses for failing to follow prescribed therapy.

Acceptable medical excuses. Failure to follow prescribed therapy can be excused for reasons beyond your control. Some examples follow.

• You have a mental illness so severe that you cannot comply with prescribed therapy.
• You have cataracts from diabetes that prevent you from being able to accurately measure your insulin dose.
• You have below-normal intelligence that makes you unable to complete required therapy.
• You physically cannot follow prescribed therapy without assistance for example, because of paralysis of the arms.
• You have a fear of surgery so intense that surgery would not be appropriate. Your treating doctor must confirm the severity of your fear to the DDS consulting doctor.

Acceptable nonmedical excuses. It is possible that you cannot follow a prescribed therapy for a reason that has nothing to do with your medical condition. Acceptable nonmedical excuses for failing to follow prescribed therapy follow.

• You don't have the money to pay for treatment.
• Your religious beliefs prohibit you from receiving medical therapy.
• Your doctor prescribes incorrect treatment.
• You don't have a treating doctor.

For the SSA to deny your claim for failing to follow therapy, the therapy that you fail to follow must be one that is clearly expected to restore your ability to do substantial gainful activity. If your treating doctor tells the SSA that the prescribed therapy is not likely to result in your ability to work, the SSA won't fault you if you don't follow such therapy. If your treating doctor's statement is clearly contrary to the general medical opinion, however, the SSA is not bound by it. Note that for a child applying for disability benefits, the issue is whether the prescribed therapy will restore the child's ability to function in an age-appropriate manner.

6. Your Disability Is Based on Drug Addiction or Alcoholism

The SSA will deny benefits to someone whose drug addiction or alcoholism (DAA) is a contributing factor to his or her disability. The key factor a DDS medical consultant must consider when making a DAA determination is whether or not the SSA would still find you disabled if you stopped using drugs or alcohol.

7. You Have Been Convicted of a Crime

Certain conditions related to conviction of a crime or imprisonment will prevent you from receiving Social Security benefits. They are:

• You are in prison after being convicted of a felony, unless you are in a court-approved rehabilitation program that is likely to result in your getting a job when you get released, and your release is expected to occur within a reasonable amount of time.
• You were injured while committing a felony and were convicted of the crime. The impairment suffered or the worsening of an existing impairment during the commission of a felony cannot be used as a basis for applying for disability benefits.
• You were injured while in prison. The impairment suffered or the worsening of an existing impairment while you are in prison cannot be used to obtain benefits. But you can generally receive benefits after being released from prison.

8. You Commit Fraud

If you obtain disability benefits by dishonest means, the SSA can terminate your benefits and prosecute you for fraud. If you obtained benefits through fraud on the part of someone working for the SSA, your benefits can also be terminated.

For More Information

Your claim can also be denied because your impairment was not severe enough (for more information, see Nolo's article Social Security Disability: How Claims Are Decided). If your claim has been denied for one of these reasons, see Nolo's article Social Security Disability: Deciding Whether to Appeal a Denied Claim.

For more information in general about Social Security disability including tips on applying for benefits, appealing a denial of benefits, and understanding detailed medical listings see Nolo's Guide to Social Security Disability: Getting & Keeping Your Benefits, by David A. Morton III, M.D. (Nolo).