A claim for Social Security disability benefits starts with the initial application. If the claim is denied, the appeal called Request for Reconsideration is handled in a very similar manner. The claimant completes a Request for Reconsideration form and a Reconsideration Disability Report which updates the medical record and disability. The file is sent to the same State agency that determined eligibility of the application. This agency is known as the Disability Determination Service. Each state contracts with SSA to provide disability determinations through one of their agency such as the Department of Rehabilitation. This avoids the necessity for SSA to make disability determinations centrally.
Because the case goes through the same process, a very small percent of the Requests for Reconsideration are reversed and benefits granted. At these two stages, the claimants are never seen or examined by the doctor who is responsible for the determination. The claimant may have the opportunity to speak with a disability adjudicator. The disability adjudicator is not the decision maker, however. Their job is to collect the medical records from the sources provided by the claimant on the forms completed by the claimant. The adjudicator also collect other information from the claimant concerning symptoms and limitations. This information is provided by the claimant by completing "pain questionnaires" or "daily activity forms".
Once the medical records and forms are collected, the adjudicator hands the case off to a State Agency Physician for review of the claim file. Although, the adjudicator may have sent the claimant to an examination by a doctor or “consultative examination”, the examining doctor does not provide an opinion of disability. This is reserved for the State Agency Physician based on review of the paper file.
The Administrative Hearing is the only time the decision-maker has the opportunity to personally see the claimant and inquire into the issue of their disability. This is the only opportunity for the claimant to describe the day to day impact of their medical condition directly to the person solely responsible for determining eligibility for benefits. This personal appearance makes a big difference. The judge is responsible for making a credibility determination about the testimony. Since the testimony is taken under oath, the judge has a burden of finding that testimony credible unless contradicted by the medical evidence of record. The Administrative Law Judge is required by law to accept the findings and opinions of the claimant's treating physicians over that of non-examining physicians (such as the State Agency physician). The "treating physician rule" requires that the judge give greater weight to the treating doctor than "consultative examiners" who may have examined the claimant at SSA's request.
The national average indicates that over 75% of the claims before Administrative Law Judges are granted. It is of the utmost importance to pursue the case to the hearing level.
Many people are intimidated at the prospect of appearing before a judge to obtain benefits. It is not nearly as stressful as some may believe. It is the right of the individual who is dissatisfied with the first two decision to present their case to the Administrative Law Judge. As SSA's own statistics show, it pays to be persistent.
Federal Benefits Advisory Group