The Social Security Decision-making Process – Overview

While some cases are decided upon early on in the process, it has been my experience that a majority of cases make it all the way to the hearing level before a decision is reached.  Below is a basic outline of the Social Security decision-making process from the initial application stage to the actual hearing before a Judge.  As you may know, this process can be quite lengthy and time-consuming!

Getting a Decision at the Initial Application Stage

When you file your first disability application, your case is initially opened by the Disability Adjudication Section (D.A.S.), which is considered to be a part of the State government.  After you file your application, the D.A.S. adjudicator will interview you and request to review your medical records.  Three months later, the adjudicator will issue their decision.

Even deserving cases may be denied at the initial application stage.  For one, D.A.S. adjudicators are often overworked and unable to spend adequate time in order to develop each and every disability case file, meaning even a compelling case may be overlooked.  Secondly, by law, adjudicators have certain guidelines that they have to follow when analyzing a case.  If their guidelines are not met, then even deserving cases may not be approved.  For example, a case may be initially denied simply because medical records were not returned by physicians or a claimant’s medical record did not include work activity limitations.

The D.A.S. adjudicator’s decision denying your case is mailed to you, briefly stating why you were denied.  This letter will also state that you have 60 days to make an appeal.  Please note: Appeal forms are not mailed out to you.  You must contact Social Security and request an appeal form, also known as a Request for Reconsideration and a Reconsideration Disability report.  Many claimants often give up at this point after discovering how lengthy and difficult it is to fill out all the paperwork.  Clients typically retain me at this point in the process so that I can submit their reconsideration paperwork and continue representation thereafter.

Getting a Decision at Reconsideration

Once your Reconsideration paperwork is complete and sent back to the D.A.S., another adjudicator will review your case.  From my experience (and this is backed up by Social Security statistics), only a few cases are reversed at Reconsideration.  A way of bettering your chances of winning at recon would be to submit medical evidence that was not originally submitted to the adjudicator.  Make sure that you include a cover letter that explains exactly how this evidence shows that your case meets a listing or how the medical evidence shows your work activity limitations.

Keep in mind that the Reconsideration process normally takes about 3 to 4 months and it unfortunately usually results in a denial.  Social Security has been closely observing the value of having a reconsideration review and it is likely that this stage of the game will be taken away at some point in the future.  So, if your case is denied at Reconsideration, the Adjudicator’s decision denying your case will be sent in the mail to you with a reason and a notice that you can appeal by requesting a hearing within a 60-day period.

Getting a Decision at an Administrative Law Judge Hearing

After you request a hearing, you will receive an acknowledgment and a letter instructing you to expect to wait for 1 year.  During the year, your file will be transferred from the D.A.S. to the Social Security hearing office known as the Office of Hearings and Appeals (the O.H.A.).  After a year, you will likely receive a notice from the Judge stating that your file is being worked on and indicating who your case has been assigned to.  Once a hearing is scheduled by the O.H.A., you will receive a hearing notice regarding the time and place of your hearing.

When to Get a Lawyer Involved

I have gotten involved in several cases at all levels of this process – even though the majority of my clients hire me after receiving their initial denial letter.  Many of my clients feel more comfortable having my firm complete and submit the appeal paperwork within the 60-day period.  In addition to sending all the correct paperwork, I make sure that your comprehensive medical record, including recent treatment, is sent to the Adjudicator or the Judge at the accurate address before the hearing.  Most importantly, I identify and develop a strategy to win each case and obtain forms, letters, or other documents from your doctors and others to prove your case.

Obviously, not all cases need to be heard by a Judge. However, from my experience, even many seriously ill claimants will more than likely not be approved at the reconsideration adjudication level.  Thus, I advise all of my clients that they will have to appear before a judge at a disability hearing.