Because of a recent successful Federal Court appeal by Louisiana Social Security disability attorney Matthew D. Lane, Jr., an Administrate Law Judge’s (ALJ) unfavorable decision was reversed and remanded.
In 2011, client applied for Social Security Disability Insurance Benefits and Supplemental Security Income based on prior cervical spine trauma, osteophytes of the cervical spine, chronic headaches, and bilateral hand numbness and weakness. An Administrative Law Judge (ALJ) denied his claim in 2012, and the Appeals Council did not grant review.
In 2013, attorney Matthew Lane filed a civil action in the United States District Court for the Western District of Louisiana on client’s behalf seeking judicial review of the Social Security Administration’s (SSA) decision under 42 U.S.C. § 405(g).
In 2015, the Court issued a Judgment reversing the ALJ’s decision. The Court found that the ALJ did not properly evaluate the claimant’s treating source medical opinion under Myers v. Apfel, 238 F.3d 617 (5th Cir. 2001) because it did not analyze the six factors for evaluation of medical opinions in 20 C.F.R. § 404.1527 (length of treatment, frequency of examination, nature and extent of relationship, support provided by other evidence, consistency of opinion with record, and specialization).
The Court further found that the ALJ did not comply with regulations requiring evaluation of the side effect of claimant’s medications, which included Methadone, Darvocet, Lortab, Neurontin, and Flexeril, on the ability to function despite an opinion from claimant’s treating doctor that he experienced drowsiness, dizziness, and delayed reaction time.
As a result of the successful Federal Court appeal, the client will have another opportunity to prove he was disabled prior to his date last insured (DLI) in 2011. And if successful, the client will be eligible to receive disability insurance benefits and Medicare rather than being restricted to receipt of supplemental security income and Medicaid.
Learn more about representation in the Federal Court appeal process or complete a claim evaluation if you need assistance appealing an unfavorable ALJ decision.
The following article was published in the August 2011 edition of the Promulgator, a publication of the Lafayette Parish Bar Association.
When Should Injured Clients Apply for Social Security Disability Insurance Benefits?
Matthew D. Lane, Jr.
If you represent injured clients in connection with either Workers’ Compensation or personal injury claims, the question of whether and when a client should apply for Social Security Disability Insurance Benefits (“Disability Benefits” or “Benefits”) is sure to arise. This article briefly addresses several significant, albeit relatively obscure, federal statutes and regulations that should be considered in deciding when to file an application for Disability Benefits under Title II of the Social Security Act (the “Act”). The Act provides for payment of Disability Insurance Benefits, and just like an insurance contract, the Act has strict parameters limiting coverage. Failure to consider these parameters can cause an applicant to be time-barred from receipt of Benefits, to sacrifice a period of entitlement to Benefits, or to experience a lengthy delay in Medicare eligibility.
Title II of the Social Security Act, 42 U.S.C. § 401, et seq., provides for payment of Disability Benefits to individuals who are disabled within the meaning of the Act and who are insured under the Act by virtue of their contributions to the Social Security trust fund through Federal Insurance Contributions Act (FICA) taxes. In general, to be found disabled under the Act, a claimant must be unable to perform his or her past work or a significant number of other jobs in the national economy because of medically-determinable mental or physical impairments that will last for at least one year. 42 U.S.C. § 423(d); 20 C.F.R. § 404.1520. If it appears likely that a client’s injuries will keep him or her out of work for a full year, the question then becomes when he or she should file an application for Benefits.
Workers remain eligible for Benefits for only a limited period of time after leaving the workforce. 20 C.F.R. § 404.130. To be eligible for Benefits, a worker must be insured under the Act. Attaining disability insured status for those over 31 years of age requires 20 quarters of coverage out of the 40 calendar quarters before they became disabled. Id. A worker maintains eligibility for Benefits through consistent employment and payment of FICA taxes, but even with consistent employment for the 5 year period prior to being injured, a worker maintains eligibility for Benefits for a maximum of 5 years after leaving the workforce. Id. The eligibility period may be shorter for workers who become disabled under the age of 31, have a previous period of disability, have not maintained consistent employment, or have not consistently paid FICA taxes. If there is any doubt about how long your client remains insured for Benefits, the client can inquire as to the duration of his or her disability insured status at the local Social Security Administration (SSA) office.
Workers who file for Disability Benefits more than 17 months after becoming disabled may sacrifice one or more months of Benefits due to restrictions on retroactive Benefits. Disability Benefits can be paid up for up to one year prior to the application date. 42 U.S.C. § 423(b). In addition, there is a 5-month waiting period following the date of disability during which Disability Benefits are not payable. 42 U.S.C. § 423(c)(2). In other words, for the first 5 months after a worker is deemed disabled, no Benefits are paid. Benefits start in the sixth full month of disability. The 5-month waiting period operates with the one-year retroactivity period to create the 17-month filing benchmark, which can cause unaware applicants to sacrifice benefits to which they would otherwise be entitled. For example, an insured worker who sustains disabling injuries on January 1, 2011, and who files an application for Benefits no later than 17 months thereafter could begin receiving Benefits on June 1, 2011. In contrast, if the same worker files an application 24 months after the injury, or on January 1, 2013, the worker could begin receiving benefits only as of January 1, 2012. In the second example, the worker sacrificed 7 months in Benefits due to the delay in filing.
If an injured worker is receiving Workers’ Compensation (WC) benefits, then Disability Benefits otherwise due for the same period may be offset or reduced. 20 C.F.R. § 404.408. The application of the offset provision is a fact-specific inquiry that depends on the worker’s past earnings and the amount of WC being received. Regardless of whether a worker’s Disability Benefits would be offset by receipt of WC, it remains important to establish the earliest possible disability onset date with SSA to avoid jeopardizing your client’s eligibility for Medicare.
Medicare is government health insurance available to those over 65 years of age or who are disabled under the Act. After receiving Disability Benefits for 24 months, workers are eligible for Medicare. 42 U.S.C. § 426(b)(2)(A). Of course, due to the 5-month waiting period for receipt of Disability Benefits, eligibility for Medicare begins 29 months after the established onset of a worker’s disability. Thus, even if the WC offset may reduce a worker’s monthly Disability Benefits, it is still important to timely file in order to start the clock on the 29-month waiting period for Medicare eligibility.
In conclusion, in advising disabled clients when to apply for Social Security Disability Insurance Benefits, it is important to know when their disability insured status expires, that filing for Benefits more than 17 months after becoming disabled may lead to the loss of a period of Benefits, and that even if subject to offset, establishing eligibility for Disability Benefits commences the lengthy waiting period for Medicare eligibility. If you have questions about a client’s potential eligibility for Benefits or when to apply, feel free to contact the author at [email protected] or (337) 593-4139.
The Social Security Administration has two programs that provide benefits to individuals found to be disabled under the Act: Social Security Disability Insurance Benefits (DIB) and Supplemental Security Income (SSI). For both DIB and SSI, the standard for determining whether a claimant is medically disabled is the same.
Disability Insurance Benefits (DIB) are governed by Title II of the Social Security Act (the “Act”) and consist of payments to individuals who are disabled and who are insured under the Act by virtue of their contributions to the Social Security trust fund through Federal Insurance Contributions Act (FICA) taxes.
There is a five (5) month waiting period for DIB. In other words, no benefits are paid for the first full five months after a claimant’s onset date. DIB can be paid up for up to one year prior to the application date, and DIB can be paid for a closed period of disability that lasts at least one year.
DIB recipients become eligible for Medicare benefits after receipt of 24 months of DIB benefits (or 29 months from onset of disability due to the 5 month waiting period).
To be fully insured, a claimant must have one quarter of coverage for every calendar year after the year in which he or she turned 21. 20 C.F.R. §§ 404.101 and 404.132. In addition, attaining disability insured status for those over 31 years of age requires 20 quarters of coverage out of the 40 calendar quarters before they became disabled. 20 C.F.R. § 404.130. After 1978, to earn a quarter of coverage, a worker must earn the required minimum amount at any point during the calendar year. 20 C.F.R. §§ 404.143 – 146. For example, if the amount needed to earn a quarter of coverage is $500, and a worker earns $2,000 at any point during the calendar year, the worker has earned four quarters of coverage for that calendar year. For those workers who become disabled under the age of 31, there are abbreviated requirements regarding quarters of coverage. 20 C.F.R. § 404.130 and POMS RS 00301.140.
Title II also provides for payment of benefits to auxiliary beneficiaries. To receive auxiliary benefits, the Act requires that you not be entitled to a higher benefit amount based on your own earnings record. Typically, auxiliary benefits are a reduced percentage of what would be paid to the insured worker. Below is a summary of the auxiliary beneficiary requirements.
Child’s benefits. 20 C.F.R. §§ 404.350 – 404.368.
1. You are the insured’s child (natural, legally adopted, stepchild, grandchild, stepgrandchild, or equitably adopted)
2. Dependent on the insured
4. Under age 18 (unless full time student or disabled before age 22)
5. Available whether insured is alive or dead
Spousal benefits. 20 C.F.R. § 404.330.
1. Married for at least one year or natural parents of a child
2. Age 62 or older (or caring for minor or disabled child)
Divorced spousal benefits. 20 C.F.R. § 404.331.
1. Married for at least 10 years
2. Not currently married
3. Age 62 or older
4. Divorced for at least 2 years
Mother’s or father’s benefits. 20 C.F.R. §§ 404.339 – 404.342
1. Married to or divorced from deceased insured
2. Mother or father of insured’s child
4. Insured’s child in your care and under 16
Parent’s benefits. 20 C.F.R. §§ 404.350 – 404.368
1. You are parent of a deceased insured
2. 62 or older
3. You have not married since the insured’s death
4. You were receiving at least one-half of your support from the insured
Widow’s or widower’s benefits. 20 C.F.R. § 404.335 – 404.338
1. Married at least 9 months prior to insured’s death (with exceptions)
2. Unmarried (or meet exceptions)
3. Age 60 or at least 50 and disabled
4. Benefits also available for divorced widows and widowers who were married at least 10 years
Supplemental Security Income (SSI) is governed by Title XVI of the Act and provides for payments to individuals who are disabled and have limited income and resources. SSI may not be paid prior to the date of application; no retroactive benefits are available. Recipients of SSI benefits are concurrently eligible for Medicaid benefits.
The SSI resource guidelines are quite detailed; however, generally speaking, the current asset limit is $2,000 for an individual and $3,000 for a couple. Several assets are excluded, the most significant of which is a home (any value) and one car (any value) if it is used for work or to obtain medical care. 20 C.F.R. §§ 416.1100 – 416.1266. Additional excluded resources are listed at POMS SI 01110.210.
With regard to income, parental income is deemed to disabled children, and a spouse’s income is deemed to the disabled spouse. Generally speaking, if a family’s income from wages or other benefits (for example, VA benefits) puts them over the resource guidelines, then family members are ineligible for SSI. SSI benefits are available to both disabled adults and children.