How Are Disability Benefits Calculated?

Realizing that you’ve become disabled to the point where you are no longer able to work can be frightening and stressful. Suddenly you have to balance the costs of normal life with the increased costs of healthcare, but you may not have the income to pay for it. Fortunately, there are resources available for many of those who find themselves unable to work. Social security disability income is one of those resources.

Qualifying Conditions

Not just anyone will qualify for Social Security Disability Income (SSDI). You must have a condition that prevents you from working, and you must meet the Social Security Administration’s definition of being disabled. There are many conditions listed in the Social Security disability blue book that are likely to qualify for disability benefits. Some of these conditions include cancer, some mental disorders, musculoskeletal or cardiovascular disorders, and neurological or respiratory disorders, among others. The conditions listed in the book are far from exclusive. Other conditions may qualify you for assistance, depending on individual factors. On the other hand, having one of the listed conditions is also not a guarantee that your application will be approved. If you are approved, you can start receiving benefits.

Average Indexed Monthly Earnings

Calculating how much you’ll be receiving each month in benefits can be a little complicated. There are benefit prediction calculators that can help you get an idea for what to expect. Keep in mind that all they can do is give you a ballpark answer. The actual amount you receive may be different. Your monthly benefits are based on yoru average indexed monthly earnings (AIME), which is the average amount of income you’ve received over a set period of time. For income to count towards this, it must come from jobs from which you’ve paid into Social Security. Your benefits are calculated by putting your AIME through a formula. The formula is calculated using fixed percentages of portions of your income, though those portions may be adjusted from year to year. In 2020, the formula calculated 90% of your AIME’s first $960, 32% of your income between $960 and $5,785, and 15% of anything over $5,785. The resulting number would be your primary insurance amount, which Social Security then uses to determine what you would receive in benefits.

Payments That Reduce Your Benefits

Just because you qualify for a certain amount based on your AIME doesn’t mean that’s what you’re going to receive. If you are receiving other benefits, the amount of disability income you receive will likely be reduced. Workers compensation, state funded temporary disability benefits, military disability benefits, and disability-based state or local government retirement benefits are all examples of other disability benefits that will reduce the amount of social security disability income that you are entitled to.

Income That Doesn’t Reduce Your Benefits

Other sources of income don’t have an impact on the amount of SSDI income you receive. Private sources, such as private long-term disability insurance, don’t reduce the amount of benefits you receive. Public benefits such as Supplemental Security Income or Veterans Affairs benefits are the exception to the rule that public disability benefits reduce your SSDI benefits. Additionally, there is no limit on the amount of unearned income to qualify for SSDI benefits. As a result, you can still earn income from investments, gifts, inheritances, or interest.

Another thing you should keep in mind is that you technically can still work while receiving benefits. This income doesn’t take away from your disability benefits. It can complicate things a little though. Working part time can make it harder to prove that you are unable to work full time. Since one of the qualifying factors for receiving SSDI is that you are unable to participate in full time work, earning above the substantial gainful activity (SGA) threshold will disqualify you from receiving benefits. This threshold for 2021 is an average monthly income of $1,310 or more.

Receiving Back Pay

Social Security disability claims can take a long time to process. As a result, if your claim is approved, you’ll have been entitled to your SSDI benefits for some time before you actually start receiving those payments. This means you should receive back pay to make up for the missed payments. How much back pay you receive will depend on your monthly benefit, when you filed your claim, and when you became disabled. Because of this, it’s important to file your claim as soon as you can after becoming disabled. Keep in mind that there is a five-month waiting period that is taken away from the beginning of their disability benefits. The clock starts from the established onset of your disability. Any time after that and before you start receiving regular benefits is time you’ll be entitled to receive back pay for.

There is a lot that goes into calculating how much you are entitled to receive for disability benefits. You’ll have to meet the qualifying conditions to start. From there, your average earnings prior to becoming disabled, other sources of disability benefits and income, and the potential for back pay will all impact how much you will receive. Don’t delay filing a claim to start receiving additional income to support you through your disability.

INTERSTITIAL CYSTITIS

Social Security (“SSA”) defines interstitial cystitis as a complex condition that causes pain or discomfort in the bladder and pelvic region that has lasted at least 6 weeks and cannot be explained by another cause, such as a urinary tract infection or kidney stones. Interstitial cystitis is most common in women. It is common for people to have symptoms such as urinary frequency and bladder pain for many years before even being diagnosed.

In Social Security Ruling 15-1p, SSA explains what evidence is needed to establish a medically determinable impairment of interstitial cystitis and how interstitial cystitis will be evaluated. The policy developed by SSA is based largely on guidelines developed by the American Urological Association and the National Institute of Diabetes and Digestive and Kidney Diseases.  SSA will be looking for sufficient objective evidence to support a finding that your interstitial cystitis, or your interstitial cystitis in combination with any other impairments, prevents you from performing substantial gainful activity. Substantial gainful activity is the ability to work full-time, generally 8 hours a day, five days a week.

How do I show Interstitial Cystitis is a medically determinable impairment?

SSA will only find interstitial cystitis is a medically determinable impairment if it has been diagnosed by a physician. However, they will not rely on a diagnosis alone. Your diagnosis must be consistent with the evidence in your case record. This means a diagnosis of interstitial cystitis also requires that supporting testing and ruling out other diseases that can cause your symptoms, such as kidney stones or a urinary tract infection. 

SSA recognizes that interstitial cystitis will vary from person to person. Sometimes the symptoms will vary in the same person. For example, some symptoms may worsen around the time of menstruation. Symptoms include, but are not limited to:

  1. Chronic bladder and pelvic pain that ranges from mild to extreme. Intensity may worsen as the bladder fills. People with interstitial cystitis may experience vaginal, testicular, penile, low back or thigh pain.
  2. Urinary urgency and/or frequency. This may interfere with sleep.
  3. Suprapubic tenderness on physical exam, sexual dysfunction, sleep dysfunction, and chronic fatigue.

Medical signs that support a diagnosis of interstitial cystitis include:

  1. Bladder-wall stiffening (fibrosis)
  2. Pinpoint bleeding on the bladder wall (diffuse glomerations)
  3. Hunner’s ulcers (patches of broken skin on bladder wall)

SSA will look at whether your medical provider has performed a physical exam and reviewed your medical history. They will evaluate whether your medical provider’s treatment notes are consistent with the diagnosis of interstitial cystitis and consistent with any work-related limitations.

What kind of documentation will SSA be looking for?

  1. Objective medical evidence will be most important. Specific testing that Social Security will look for in evaluating interstitial cystitis includes a) repeated testing showing there is no urinary tract infection despite interstitial cystitis symptoms; b) a positive potassium sensitivity test (Parson’s test); and c) testing showing antiproliferative factor (APF) in the urine. A cystoscopy is often done to visually examine the bladder.
  2. Your report of symptoms will also be evaluated. It is important that your report of symptoms is consistent with the objective medical evidence and supported by the other evidence in the record. Social Security is looking at how interstitial cystitis affects your ability to work. This might be chronic pelvic pain that affects your ability to focus or concentrate, urinary frequency and urgency requiring frequent bathroom breaks, or interrupted sleep leading to daytime drowsiness. Whatever your specific symptoms from interstitial cystitis, they need to be documented in the record both in your statements to Social Security and in the record submitted by your medical providers. Consider keeping a diary to document symptoms like the frequency of urination, pain, and response to treatment.
  3. Evidence from non-medical sources can be helpful. This may be evidence from friends, family members, former employers, or clergy. This kind of evidence cannot be used to establish a diagnosis of interstitial cystitis, but can help SSA determine the severity of your interstitial cystitis and how it impacts your ability to function. 

What can I do now?

  1. If interstitial cystitis is part of your disability claim, we need to have a clear diagnosis. Some people have symptoms of interstitial cystitis for years before they are diagnosed. It is important for you to have a clear diagnosis in the file accompanied by testing or other objective findings. It is not enough that your provider notes that your symptoms might be caused by interstitial cystitis. A diagnosis must be accompanied by testing supportive of an interstitial cystitis diagnosis and tests to exclude other conditions that could cause your interstitial cystitis symptoms. Start talking to your provider now to create a consistent, supportable record.
  2. In addition to having a supported diagnosis in the file, be sure you communicate with your provider and with us any co-occurring conditions you may have.  People with interstitial cystitis may also be diagnosed with disorders such a fibromyalgia, chronic headaches, chronic fatigue syndrome, Sjogren’s syndrome, systemic lupus, depression, and anxiety. 
  3. Stay compliant with medication and treatment. Generally, treatment for interstitial cystitis is directed at symptom control and may include diet changes, physical therapy, home exercise, stress reduction, and medication. If you are not willing to take medications or otherwise comply with your provider’s recommended treatment for your interstitial cystitis, please let us know why. A failure to follow through with recommended treatment can be seen as an indication that your interstitial cystitis is not as severe as you say. We want to make sure SSA understands your specific situation.
  4. If possible, undergo any testing recommended by your provider. Some of the specific testing important to a claim involving interstitial cystitis is discussed above. Treatment for interstitial cystitis may require you to see a specialist. Always let us know if you are unable to undergo any recommended testing due to issues such as finances or insurance issues.
  5. Interstitial cystitis is not always an easy disorder to understand. As mentioned above, it can be helpful to keep a diary tracking how often you are having symptoms, how long symptoms last, symptom severity, and any activities missed due to your interstitial cystitis.

Remember, interstitial cystitis is an impairment that is not always well understood. Not everyone will have the same symptoms or limitations. It is important for us to help SSA understand the specific way you are affected by interstitial cystitis.  

What Does Workers’ Compensation Cover?

Workers’ compensation can seem like the most elusive form of insurance. How does it work? What does it actually cover? And how does the claims process work? This article will go into each of these questions to help you better understand workers’ compensation.

What is Workers’ Compensation?

Workers’ compensation is a form of insurance that provides wage replacement and compensation for medical bills in the case that an employee is injured during the course of their employment. This form of insurance not only protects the worker, but it also protects the employer.

While this insurance assures workers that they will be properly cared for in the case of injury, they are also required to waive the right to sue their employer. What does this mean? Basically, when workers waive the right to sue their employer, they waive the possibility of being awarded a potentially larger sum than they could receive otherwise.

However, the employer in turn waives the employees burden of proving the employer was at fault.. For the employer, waiving the employee’s right to sue ensures that they will not have to deal with costly and painful lawsuits. Practically all states in the United States require employers to have some form of workers’ compensation.

What Does It Cover?

While every state has different laws governing to what extent workers’ compensation is required to cover employees, there are some general guidelines. Typically, workers’ compensation will cover medical expenses, lost wages, and funeral costs. 

When it comes to medical expenses, employers are usually required to reimburse you for any ER visits, check-ups, prescriptions, or surgeries that are directly resulting from the work-related accident. Once the employer accepts the claim they will generally pay for medical services directly.

In situations where the injury is more enduring, workers’ compensation will also give you more enduring reimbursement. For example, if a construction worker fell from a roof and broke his neck resulting in paralysis and the need for in-home care, workers’ compensation would likely cover the ongoing cost.

In addition to covering medical expenses, workers’ compensation also covers lost wages due to time away from work. The way this compensation works varies by situation. But generally, workers’ compensation ensures that you will receive a fair wage for necessary time off to recover.

Finally, in the rare and painful case of death, workers’ compensation will cover funeral costs and provide death benefits to dependents.. 

How Does a Claim Work?

There are two main steps to putting your claim through the system. First, you will want to report the incident to your employer as soon as you become aware of the injury. And second, you’ll need to file the claim.

 Reporting the incident may look a little different depending on the state that you live in but generally, there is a 30-day window after the accident occurs in which you can report the injury. After that window, you may not be eligible to receive compensation.  

To prove that your injury should be covered under workers compensation you must demonstrate that your injury was connected to work. In legal terms, this means that you have to show both that your injury arose out of your employment and that it occurred during your employment.

These requirements are more straightforward when it comes to on-the-job injuries such as cutting your hand using a tool at on your job..However, it gets a little trickier when it comes to illnesses that develop over time or injuries that occurred outside of an obvious workplace setting. In situations like these, you will want to look up the specific laws for your state that govern when an injury is covered by workers’ compensation and how that compensation works or consult an attorney.

After you’ve gone through the process of reporting your injury, your company will then give you paperwork to fill out to file the claim. After you’ve filled out this paperwork, it will typically be sent to the employer’s insurance company and/or to the state to be filed and processed.

If your employer does not dispute the claim that your injury was work-related, your claim will be processed, and you they will start paying your medical bills and compensating you for time off work. If your employer disputes your claim, you will have to file a claim with the labor commission, most likely with the help of an attorney..

When it comes to workers’ compensation, you want to know that your back is covered. This guide can give you a foundation to better understand how workers’ compensation works. But be sure to do your research regarding your state’s laws as well as the coverage offered by your employer to ensure that you understand what compensation you are entitled to in case of injury.

5 Steps for Applying for Long Term Disability Benefits

People don’t like to think that accidents or injury could happen to them, but unfortunately, the statistics are against them. About 1 in 4 twenty-year olds get seriously injured and are unable to work for a period of time before they retire. Thankfully, many employers provide or make available disability insurance to help in this siutation There are multiple types of disability insurance that kick in if you are ineligible to work for any amount of time. There is short term disability that prevents you from being able to work for shorter periods of time (no longer than 6 months usually) and then there’s long term disability (which can range from 2 years until retirement). Either of these types of insurance may be provided by an employer or purchased individually. This article focuses on how to apply for employer provided long-term disability insurance.  Here’s a step-by-step process of how to apply for long term disability benefits.

Look at Quotes

Long before you need to use it, you will need to purchase long-term disability insurance. Every insurance company is different as is each individual. Different companies have different ways of measuring how an individual qualifies for their insurance, so you want to find a company that fits for you. You also want to look at whether your employer offers disability insurance. Most employers will have short term disability insurance to some degree, but you may have to look on your own to find an insurance company that will give you long term disability benefits. There usually isn’t a lot of choices to make with an employer provided policy. The most important is usually whether you will pay for the policy premium before payroll taxes are deducted or after. Generally speaking, if you pay your premium after taxes are deducted then you will not be required to pay taxes on the benefits if they are awarded. Some employers also offer policies with different maximum payment periods. You will want to consider your age and your various risk factors in determining how long you want the long-term disability benefits to last.

Filing a Claim for Benefits

If the time comes that you need the long-term disability benefits , the application process will require you to fill out paperwork. The details for the paperwork differ depending on the company, but most companies will ask you for your name, date of birth, social security number, contact information, family members, name of your employer, work and education history, when you were last able to work, when you becamesick/disabled, your reason for disability, all medical providers and their contact information, prescribed medication, and any other income you might receive. The form is sometimes called the employee’s statement and requires basic information about you and your health history. The insurance company wants to know as much information about you and your health history as they can so they can make an informed decision about offering you insurance. They will use the information you provide to gather information such as medical records, testing, prescription records, and job descriptions. Then they will review that information often with the help of medical and vocational experts. That means that it is very important that you are thorough and accurate with the information you provide on these forms. Remember, insurance companies do not make money by paying claims so they are not likely to go out of their way to help you no matter how difficult your circumstances or how nice they seem on the phone.

Get a Statement from Your Doctor

You will then need to submit a physician’s statement completed by your doctor. Most insurance companies will provide you with a form that asks the necessary questions. Some may even contact your doctor directly. Some insurance companies will have you complete a medical exam with their medical technician at their expenses. But regardless of what insurance company you are applying to, you will need a doctor to provide your medical history, including diagnosis, treatment, and the doctor’s assessment about your ability to work with the injury or sickness. Your physician’s statement is one of the most crucial aspects of applying for long term disability benefits because the insurance company needs to know that you are disabled and will not be able to work long-term. If your doctor recommends additional testing to strengthen your case you should take that recommendation very seriously and get the testing done. Because long-term disability claims come under such high scrutiny, you want to be as thorough as you can in your application process.

Getting Approved

After you’ve submitted the proper paperwork, you may have to do a phone interview with the representative of the insurance company. They will talk about your health history, your lifestyle and will likely ask for the contact information of your primary physician. Even after the interview, your approval process is not complete. An insurance company representative that specializes in making disability decision will review all the information including the medical reports and your statements.It can be a long and anxious waiting period, which is why it’s important to be thorough with your application and submit your paperwork on time to the company. While the final approval process is not up to you, and there’s not much more that you can do other than wait. The policy sets the amount of time the insurance company can take to make a decision and there is usually an allowance for at least one extension. When you get the decision, it will come in a letter from the insurance company. Sometimes an insurance company representative will also call you to notify you of the decision..

What to Do If Rejected

Sometimes applications get rejected. This rejection doesn’t necessarily mean that you don’t meet the definition of disability under the policy. Rather, it may mean that there wasn’t enough medical evidence for the insurance company, or that the insurance company simply made the wrong decision. Remember, insurance companies don’t make money by paying claims.. If your application is denied, you generally have 180 days to appeal it, but this can vary by policy so make sure to read your denial letter carefully. The insurance company’s decision does not limit your future or your potential—you can still get the disability benefits that you need to support your family.

Long term disability benefits require a lengthy process to be approved, and even then, it’s not guaranteed. But if you qualify, long term disability benefits can greatly benefit you and your family when you are not able to go into work. 

FIBROMYALGIA

Social Security (“SSA”) defines fibromyalgia as a complex medical condition that is characterized by widespread pain in the joints, muscles, tendons, or soft tissues that has lasted for at least three months. In Social Security Ruling 12-2p, SSA explains what evidence is needed to establish a medically determinable impairment of fibromyalgia and how fibromyalgia will be evaluated. SSA will be looking for sufficient objective evidence to support a finding that your fibromyalgia, or your fibromyalgia in combination with any other impairments prevents you from performing substantial gainful activity. Substantial gainful activity is the ability to work full-time, generally 8 hours a day, five days a week.

How do I show fibromyalgia is a medically determinable impairment?

SSA will only find fibromyalgia is a medically determinable impairment if it has been diagnosed by a physician. However, they will not rely on a diagnosis alone. Your diagnosis must be accompanied by specific evidence.  There are two different criteria that SSA will consider in determining if a fibromyalgia diagnosis is supported by the evidence.  Your evidence should either meet the 1990 ACR Criteria for Classification of Fibromyalgia or the 2010 ACR Preliminary Diagnostic Criteria; you do not need to meet both. 

1990 ACR Criteria for Classification of Fibromyalgia.

  1. A history of widespread pain that has persisted for at least three months.  
  2. At least 11 positive tender points on physical examination. Your provider should do a tender point test or refer you to someone who can.
  3. Evidence that other impairments that could cause your symptoms were excluded. This may include imaging such as x-rays or MRI that are not consistent with your level of pain or laboratory testing ruling out issues such as thyroid function or rheumatoid factor.

 2010 ACR Preliminary Diagnostic Criteria.

  1. A history of widespread pain.
  2. Repeated episodes of six or more fibromyalgia symptoms. The most common symptoms and signs are fatigue, waking unrefreshed, memory or other cognitive problems, depression, anxiety, or irritable bowel syndrome. However, other conditions recognized as often co-occurring with fibromyalgia include interstitial cystitis, irritable bladder disorder, TMJ, migraines, gastric reflux, and restless leg syndrome.
  3. Evidence that other disorders that could cause these symptoms were excluded. Any testing you have had done, is important, even if results were negative. Social Security wants to make sure that diseases like multiple sclerosis, lupus, and rheumatoid arthritis are not the cause of your symptoms.

SSA will look at whether your medical provider has performed a physical exam and reviewed your medical history. They will evaluate whether your medical provider’s treatment notes are consistent with the diagnosis of fibromyalgia and consistent with any work-related limitations.

What kind of documentation will SSA be looking for?

  1. Objective medical evidence will be most important. This will be your diagnosis of fibromyalgia, any testing and any observations from your medical provider supporting this diagnosis and its impact on your ability to function. These findings should cover the time period from the 12-months before your onset date or application date forward. SSA will be looking for consistent and supportable findings.
  2. Evidence from non-medical sources can be helpful. This may be evidence from friends, family members, former employers, or clergy. This kind of evidence cannot be used to establish a diagnosis of fibromyalgia, but can help SSA determine the severity of your fibromyalgia and how it impacts your ability to function. 
  3. Your report of symptoms will also be evaluated. It is important that your report of symptoms is consistent with the objective medical evidence and supported by the other evidence in the record. 

What can I do now?

  1. If fibromyalgia is part of your disability claim, we need to have a current diagnosis. Some people have had fibromyalgia for years before they file a claim. Many times, the diagnosis accompanied by the appropriate tender point testing or other observations and signs discussed above are not part of the current medical record. It is very important for you to have an updated diagnosis in the file accompanied by testing or other objective findings. This testing should include tests to exclude other conditions that could cause your fibromyalgia symptoms. It is not enough that your provider simply notes “fibromyalgia” in your record. This must be accompanied by appropriate testing, observations, and report of symptoms such as pain, fatigue, sleep issues, brain fog, or depression. Start talking to your provider now to create a consistent, supportable record.

2)     In addition to having a supported diagnosis in the file, be sure you communicate with your provider how fibromyalgia affects you and limits your ability to perform work-related functions. The better you communicate to your provider the specific limitations you experience due to fibromyalgia, the more consistent the record will be. Common issues you should discuss with your medical provider include:

–    Pain interfering with your ability to sit, stand, walk, or lift.

–    Pain limiting your ability to kneel, crouch, crawl, stoop, climb, or use your upper extremities.

–     Sleep issues that cause fatigue or the need to take breaks or naps during the day.

–    Difficulty focusing, concentrating, or remembering due to brain fog or other mental issues such as depression.

–    Any limitations you have in performing your activities of daily living due to your fibromyalgia.

–    Let your provider know if you have good days and bad days. This is not uncommon with fibromyalgia. If you have bad days regularly make sure to discuss your activity level on these days with your doctor. Also discuss with your medical provider if there are activities that make your symptoms worse. Not everyone has the same symptoms and limitations due to fibromyalgia. It is important that your specific experience with fibromyalgia is discussed with your medical provider.  

  1. Stay compliant with medication and treatment. If you are not willing to take medications or otherwise comply with your provider’s recommended treatment for your fibromyalgia, please let us know why. A failure to follow through with recommended treatment can be seen as an indication that your fibromyalgia is not as severe as you say. We want to make sure SSA understands your specific situation.
  1. If possible, undergo any testing recommended by your provider. As discussed above, SSA will be looking to see if your pain is actually due to other conditions. Always let us know if you are unable to undergo any recommended testing due to issues such as finances.

Remember, fibromyalgia is an impairment that affects each individual differently. Not everyone will have the same symptoms or limitations. It is important for us to help SSA understand the specific way you are affected by fibromyalgia.  

SSR-2p – Obesity

Obesity is an impairment that can contribute to disability in a variety of ways depending on the individual and the specific impairments. While obesity alone may be a severe impairment, it also often makes other conditions worse. Examples of this include increased pain and mobility issues with degenerative joint disease or degenerative disc disease. Obesity may make it more difficult to control blood sugar in those with Type II diabetes. Obesity can impact mental impairments. The increased body size with obesity can also make breathing difficulties worse. The Social Security Administration (“SSA”) must consider a claimant’s obesity if it causes or contributes to an inability to work. In 2019, SSA issued Social Security Ruling 19-2p (“Ruling) to clarify how obesity should be evaluated.

How does SSA define obesity?

Obesity is a complex disorder that results from a number of factors including environment, genetics, and behavior. Health care providers will generally diagnose obesity based on your medical history, physical exams, and your body mass index (“BMI”). BMI is a calculation based on your weight and height. In the medical community, a BMI of 30.0 or higher is considered obese. However, as discussed further below, SSA does not just look at a specific weight or BMI to determine if your obesity contributes to your disability.

What kinds of impairments are associated with obesity?

Impairments that are associated with obesity include, but are not limited to:

  1. Endocrine disorders, such as Type II diabetes mellitus
  2. Disease of the heart and blood vessels, such as high blood pressure or heart attacks
  3. Respiratory impairments, such as sleep apnea or asthma
  4. Osteoarthritis
  5. Mental impairments, such as depression or anxiety
  6. Cancers of the esophagus, pancreas, colon, rectum, kidney, endometrium, ovaries, gallbladder, breast, or liver.

How do I show obesity is a medically determinable impairment?

SSA must determine if obesity is a medically determinable impairment. This means the record must contain objective evidence from an acceptable medical source about your height and weight. It is not enough to have a diagnosis of obesity, the record must contain findings from an acceptable medical source such as height and weight, measured waist size, and BMI measurements over time. It is important that your medical provider consistently tracks these kinds of findings as SSA will look at these measurements over time to determine if obesity is a medically determinable impairment. SSA does not rely on a specific BMI, but looks at the entire case record to determine if obesity is a medically determinable impairment. 

How do I show obesity is a severe?

If SSA determines that obesity is a medically determinable impairment, then they evaluate the severity of this impairment. It will be important that your medical records reflect any symptoms associated with your obesity such as fatigue or pain that can affect your ability to function. It is important that the record demonstrate that your obesity, either by itself or in combination with other impairments, significantly limits your ability to perform basic work activities. Examples of ways obesity may impact functioning include limitations in sitting, standing, walking, and lifting, climbing, balancing, stooping, kneeling, or crouching. It increases stress on weight bearing joints. It can also affect a person’s ability to use their hands and fingers in manipulating objects or decrease tolerance to heat and humidity.

Again, no specific weight or BMI establishes that obesity is “severe”. SSA will do an individualized evaluation of the effect of obesity on a person’s functioning. Therefore, consistent and supportable evidence of your weight, BMI, and any related symptoms over time will be key in SSA’s evaluation of your claim.

What can I do right now?

  1. Make sure your provider is consistently taking note of your weight, BMI, and/or waist size. While you will be asked some of this information in the documents you fill out for SSA, they will evaluate obesity based on the findings of a medical provider, not from self-reported measurements.
  2. Communicate with your provider as to any functional limitations you feel your obesity causes or any impairments it exacerbates. As noted above, this includes issues such as pain and fatigue. It is important that any impairment due to obesity is noted in your medical records.
  3. Please be compliant with medication and treatment. If you are not willing to take medications or otherwise comply with your provider’s recommended treatment for your obesity, please let us know why. Medications and surgeries that are sometimes recommended for weight loss may not work for you. We want to make sure SSA understands your specific situation.

Remember, obesity does not impact everyone in the same way. It is important for us to help SSA understand the specific way your obesity contributes to your impairments or your work-related limitations.

SSR-19-4p – Headaches including Migraines

Headaches can be very debilitating and even prevent a person from working full-time. As debilitating as headaches can be, it is difficult to prove to the Social Security Administration (“SSA”) that they make you disabled because there is no way to objectively measure how severe your headaches are or even that you have them. In 2019, SSA issued Social Security Ruling 19-4p (“Ruling) to clarify how headaches should be evaluated.

What kind of headaches does this Ruling apply to?

First, the Ruling applies to primary headache disorders. Primary headache disorders are migraines, tension headaches, or trigeminal neuralgia. They are called primary headache disorders because there is no underlying disease or injury causing the headache. There are also secondary headaches disorders. A secondary headache disorder is a headache that is the symptom of another condition like a neck injury or sinus issues. If you have a secondary headache disorder, this Ruling still provides some guidance, but they are not the main focus of this Ruling. It is also possible to have both primary and secondary headaches.

How can I show a diagnosis of a primary headache disorder?

For SSA to consider your headaches a primary headache disorder, they must be diagnosed by a medical provider who has reviewed your medical and headache history. This should include a review of your specific headache symptoms. Your provider may perform a physical and neurological examination. Often with headache disorders, testing such as an MRI or a CT scan of the head is done to see if your headaches are the result of another condition. Even if these tests are negative, they are still important because they rule out other causes for your headaches. The Ruling makes clear that positive imaging is not necessary to diagnose a primary headache disorder. It is important that the treatment notes from your provider are consistent with a primary headache disorder, so they should contain not only your report of symptoms, but any pain behaviors your medical provider may have observed such as difficulty concentrating, need for a dark room, neck stiffness, or tremors. Also, while not required, your case will be stronger if you headaches are evaluated and treated by a specialist such as a neurologist.

How can I show the severity of a primary headache disorder?

Your medical records need to document any symptoms such as difficulty concentrating, light sensitivity, sound sensitivity, or nausea that accompany your headaches. SSA will also want to understand how often you have headaches, how long they last, and how they affect your ability to perform work-related limitations. Particularly with headaches, work-related limitations may include absences from work, difficulty maintaining a schedule, or difficulty focusing and concentrating. We also need to understand if you have sensitivities to noise or light that may make it difficult to work in some environments. It is important that you discuss any limitations related to your headaches not only in your statements to SSA, but also in discussions with your medial provider. A headache journal that documents all of this information can be very helpful, especially if it is shared with your doctor.

When describing your headaches to SSA it is important to discuss issues such as headache frequency, accompanying symptoms, and how long it takes you to recover from a headache. SSA also wants to know what medications you have tried or are currently using for your headaches.  Treatment notes should show if these medications are effective or not.  They should also show if you have any side-effects from the medications. SSA will consider if your headaches improve with medication or if there are reasons you cannot use medications or follow-through with recommended treatment. Consistency and supportability between your reported headache symptoms and the medical evidence will be key in SSA’s evaluation of your claim.

What can I do right now?

  1. Keep a headache diary.  This allows you to help the Agency understand how often you experience headaches, what kind of symptoms your headaches cause, and how long it takes you to recover. A headache diary allows you to also document any activities you had to miss due to your headaches.
  2. Communicate with your provider as to the frequency and severity of your headaches. As is discussed above, SSA will not simply take your word for the frequency and severity of your headaches. They also want to see this reflected in the medical record. Make your doctor aware of not only the frequency of your headaches, but also your accompanying symptoms, and any reactions to medications.
  3. Stay compliant with medication and treatment. If you are not willing to take medications or otherwise comply with your provider’s recommended treatment for your headaches, please let us know why. A failure to follow through with recommended treatment can be seen as an indication that your headaches are not as severe as you say. We want to make sure SSA understands your specific situation.
  4. If possible, undergo any testing recommended by your provider. As discussed above, SSA will be looking to see if your headaches are actually due to other conditions. Always let us know if you are unable to undergo any recommended testing due to issues such as finances.

Remember not everyone experiences headaches the same way or has the same symptoms, it is important for us to help SSA understand the specific way you are affected by your headaches.  SSR 19-4p, helps clarify how a disability claim that includes headaches should be evaluated.

How to Avoid the Common Workers’ Compensation Pitfalls

If you are applying for workers’ compensation, there are some important things you should know. Because workers’ compensation is an insurance program, your employer will often try to pay as little as possible when you file a claim. But if you are careful about following the rules, you’ll be able to avoid the common pitfalls associated with workers’ compensation while receiving all the benefits you deserve.

Notify Your Employer Immediately

One of the most common mistakes employees make when filing a workers’ compensation claim is being denied your benefits because you didn’t make a claim in time. The typical filing period is 30 days from the date of your injury, but it’s better to notify your employer of your injury as soon as possible. If you inform them verbally, make sure to give them a written notice as well.

In most cases, you’ll be given a form and required to fill it out. If your employer doesn’t give you this form, take initiative by typing up the date, time, and details of your injury.

Visit an Approved Doctor

According to workers’ compensation law, your employer or their insurance provider is allowed to choose the doctor who treats your injury after you file a claim. In order for your claim to go through, you must visit this doctor for treatment. This doctor’s reports and assessments will be important information for your claim.

If you don’t visit this appointed doctor, your employer or their insurance provider may dismiss your claim. You can see your own doctor as well, but this must be in addition to visiting the doctor they choose. If for some reason you are uncomfortable visiting the assigned doctor, you are allowed to ask the workers’ comp. insurance carrier for permission to see another doctor.

Be Honest

It is crucial that you are open and honest about your injury when you visit the appointed doctor. Don’t exaggerate your condition, but don’t hide it either. Make sure to explain the whole truth behind your accident, injuries, recovery, and setbacks. Providing false information or withholding true information from your doctor can cause your claim to be denied. 

Return to Work at the Right Time

Many employees are anxious to return to work, so they skimp on following their doctor’s treatment plan. While this behavior might be tempting, it can cause your claim to be denied because your workers’ comp claim administrator can decide you’re not trying, or that you’re faking your injury.

To avoid this pitfall, make sure to obey your treatment plan to the very letter: go to all appointments, do your physical therapy, and follow any other instructions your doctor gives you.

Remember that you have a right to your medical safety. If you and your doctor disagree about your treatment, or on your timeline for returning back to work, you are allowed to appeal to the Worker’s Compensation Commission.

Get a Second Opinion

Although you are required to visit the doctor assigned to you by your employer, you can (and should) get a second opinion on your treatment. If your own doctor’s treatment plan varies significantly from the insurance company’s doctor, you should notify the Worker’s Compensation Commission. A disagreement such as this could impact your claim statement.

When your health, safety, and livelihood are on the line, it’s worth the time and effort it takes to go get a second professional opinion about your injury.

Work with a Trusted Legal Professional

Unfortunately, complications often arise when you file a workers’ compensation claim. Your claim may be denied, your employer could deny that your injury is work-related, or your company might claim you’re not an employee. You could be accused of faking your injury, or your paperwork could slip through the cracks. You may have requirements that seem unreasonable placed on you in order to qualify. You may run into other complications as well.

If you feel your claim was wrongly denied, you should stand up for yourself and fight the committee’s decision. In order to avoid having to pay out of pocket for your treatment, you should work with a trusted legal professional who can help you receive your benefits and be treated fairly. It can be difficult to go through this process all on your own. Surround yourself with a support network who can speak on your behalf and be a strong advocate for you. Going it alone can be a costly mistake.

Even though all the rules surrounding workers’ compensation can seem complicated and overwhelming, it’s important to do the work to obey them. Doing your due diligence when it comes to all the paperwork and doctor’s appointments will pay off when you’re able to receive the benefits you deserve. Make sure to keep copies of all your medical records and compensation applications. Work with trusted professionals when necessary and be open about communicating with your employer. And above all, take care of yourself and your body.

SSI vs SSDI — What’s the Difference?

Social Security Disability (SSDI) and Supplemental Security Income (SSI) seem very similar on the surface, but they are actually quite different. They function like two sides of the same coin, helping those who need help most in the areas where they are most vulnerable. If you are considering applying for SSI or SSDI benefits, make sure to read this article so you know which program or programs you should apply for. Applying for the correct program or programs makes sure you will get all the benefits you are eligible for.

What is Social Security Disability (SSDI)?

Social Security Disability Insurance is funded via payroll taxes, and as the name suggests, it’s considered a form of insurance. This insurance is automatically earned by people who have worked for five of the ten years preceding disability, and by so doing, have contributed to the national Social Security trust fund. Aside from the work requirement, to qualify for SSDI disability benefits, candidates must be between 18 years old and full retirement age. Once an insured person reaches full-retirement age they become eligible for retirement benefits instead of disability benefits.

The Social Security Administration does not pay SSDI benefits for the first five months after a person becomes disabled, which is why it’s very important to apply as soon as it becomes clear that the benefits will be needed. Those who reach retirement age while on SSDI will have their disability benefits converted to retirement benefits.

Spouses and children of people who receive SSDI benefits may be able to receive dependent benefits (auxiliary benefits) while they are still in high school or under the age of 18 for children or while they are caring for a child under the age of 16 for spouses. After receiving SSDI for two years, beneficiaries become eligible for coverage under Medicare.

What is Supplemental Security Income (SSI)?

Supplemental Security Income is a need-based program that is funded by general fund taxes. To qualify for SSI, candidates must have less than $2,000 in assets for individuals or $3,000 for couples. Their income must also be very limited. 

SSI benefits begin on the first of the month when after the month application was first submitted. These benefits come in the form of monthly cash payments. People who receive SSI benefits are also eligible for Medicaid, food stamps, and often times housing assistance or other similar programs.

What’s the Difference?

Aside from the differences in definition outlined above, SSI and SSDI have several distinctions.

Approval Rates

Approval rates for SSDI are generally higher than they are for SSI. This is likely because judges and claims examiners tend to give more credibility to applicants with a long work history, and because SSDI applicants have higher incomes and insurance coverage which allows them to see a doctor on a regular basis. 

Taxes

The majority of SSDI and SSI benefits are not taxable, but SSI is less likely to be taxed than SSDI due to differences in average income. If total income is less than $25,000 for an individual or $32,000 for a married couple filing jointly, then benefits are not subject to income tax. Total income above that threshold becomes subject to tax. If a married couple filing jointly receives SSDI benefits as well as another source of income, taxation is more likely. 

Qualifications

SSI is for people who haven’t worked five out of the last ten years and have limited income and resources. SSI can apply to citizens and nationals of the United States, as well as aliens who meet certain requirements, and the recipient must live in the U.S. or Northern Mariana Islands unless they are living abroad for education or military reasons. Marital status also affects eligibility for SSI because a spouses income and resources can be deemed family resources. People who are older than full retirement age can qualify for SSI if they meet the income and resource limits regardless of whether they meet the disability requirements. Otherwise, the test for disability with SSI and SSDI is the same.

Means Testing

Means testing looks at the annual income of Social Security beneficiaries and uses that data to determine what kind of benefit check they should receive, if at all. The theory behind means testing is that it should help ensure that benefits are going to people who really need them, which is how the program was originally designed in the mid-1930s. This will help save the program money in the long run, delaying asset reserve depletion.

The SSI program is means-tested. The SSDI program is not means-tested, but beneficiaries are subject to losing eligibility if their work-related income rises over a certain threshold called substantial gainful activity.

Can I Apply for Both SSDI and SSI?

Yes. It is possible for you to qualify for both. As long as your SSDI monthly benefit is lower than the maximum payment for SSI then you can get both types of benefits. This means you can also qualify for both Medicare and Medicaid too. If you have worked five of the 10 years prior to your disability but your work was minimal you should consider applying for both types of disability.

Knowing whether you qualify for SSI or SSDI or both makes you more likely get all the benefits you may be entitled to. If you are trying to decide what type of benefit to apply for, it also helps to get advice and assistance from a disability lawyer or disability attorney throughout the process. Barnes Disability has an experienced team of professionals that can assist you through every part of the disability process, so contact us today for a free consultation.

What Is the Americans With Disabilities Act (ADA)?

The Americans with Disabilities Act (ADA) is a civil rights law that generally prohibits discrimination against people with disabilities, with the goal of giving people with disabilities the same rights and opportunities as everyone else. The original disability law was passed in 1990, but in 2008 it was revised via the Americans with Disabilities Act Amendments Act (ADAAA). These amendments made significant changes to the definition of “disability” as well as narrowed down the requirements for certain cases, such as with small businesses.

The 5 Titles

ADA disability law is divided into five titles (sections) that apply to different aspects of public life:

Title I deals with employment. It helps people with disabilities access employment opportunities and benefits, and applies to employers with 15 or more employees. Employers are required to provide reasonable accommodations which enable those with disabilities to be able to do the job effectively. This title defines disability, establishes guidelines for “reasonable accommodation,” and addresses the subject of medical examinations and inquiries.

Title II deals with public entities, prohibiting discrimination based on disability by state and local government agencies. Title IIrequires public entities to make their programs, services, and activities accessible to people with disabilities. This involves identifying architectural barriers and communicating effectively with those who have related disabilities.

Title III deals with public accommodations, which includes privately owned, leased or operated facilities like hotels, restaurants, retail stores, schools, health clubs, sports stadiums, movie theaters, etc. Title II requires businessesto make reasonable accommodations to serve and communicate with people with disabilities.

Title IV deals with telecommunications. Telephone and Internet companies are required to provide a nationwide system of interstate and intrastate telecommunications relay services that enable people with hearing or speech disabilities to communicate over the telephone. Title IValso requires federally-funded public service announcements to have closed captioning available.

Title V deals with other provisions that don’t fit under the other titles. 

Who Does it Cover?

The ADA only covers people with disabilities. Disability is defined by the ADA as a physical or mental impairment that substantially limits one or more major life activities. These life activities include seeing, walking, communicating, sitting, and reading.

The ADA does not specify all disabilities that may be covered, but as of 2020, it is likely to cover 

  • Back injuries
  • Heart failure
  • Coronary artery disease
  • Vision loss
  • Hearing loss
  • COPD
  • Asthma
  • Multiple Sclerosis
  • Cerebral palsy
  • Parkinson’s disease
  • Epilepsy
  • Depression
  • Anxiety
  • Autism
  • HIV/AIDS
  • Lupus
  • Rheumatoid arthritis
  • Sjogren’s Syndrome
  • Marfan Syndrome
  • Dermatitis
  • Liver disease
  • IBD
  • Kidney disease
  • Cancer
  • Hemolytic anemia
  • Bone marrow failure
  • Bi-Polar Disorder
  • PTSD
  • Schizophrenia
  • Diabetes
  • Migraines

Conditions of short duration, such as sprains, infections, and broken limbs, are unlikely to be covered. Depression and stress (ex: anxiety) may also not be covered if they are the result of personal life or job pressures.

Being qualified for accommodations under the ADA does not mean that you qualify for disability benefits under Social Security. The opposite is also true. The definitions of disability for the two programs and their purposes are different. While the ADA is meant to help people participate fully in most aspects of public life, Social Security disability is meant to provide some minimal income when you are not able to work because of a disability.

It’s not easy to get SSDI or SSI benefits, and to be honest, Social Security denies most applications. In one survey, only 42% of respondents were approved for benefits. However, there are ways to increase the likelihood of a successful application:

People who have been disabled by a life event should apply as soon as possible. This is because the approval process can take a significant amount of time; at best about six months and in many cases 2-3 years or more.

Strong medical evidence is a major factor in the success of a claim. People with disabilities should get the help of a doctor or other medical professional to create the needed evidence for their application. Social Security will not believe anything you say about your condition unless it is backed up by strong medical support. Those who apply without the help of a medical professional are much less likely to receive benefits.

If you are still working when you file your SSDI or SSI application, that can also hurt your chances of getting approved. Applicants who are working over the limit that Social Security allows are immediately denied regardless of their medical conditions. , Working at the time of application can make it much more difficult to prove that you are sufficiently disabled to qualify for benefits because for many Social Security decision makers, doing any work is evidence that you are capable of working full time. If you are working, it is very helpful to get a note from your doctor explaining what your limitations in doing that work are, especially if your limitations include working less than full time hours. 

If your application is approved, disability benefits will continue until you are able to work again on a regular basis or until you reach full retirement age. Special rules, called “work incentives,” help those affected make the transition back to work by providing continued benefits and health care coverage during the transition period.

When you’re applying for protection under the Social Security Act, it can be extremely helpful to seek aid from a disability lawyer to streamline the process, answer your questions, and increase your chances of getting your claim approved on the first try. Contact us today to see how we can help with your case.