Deciding Whether to Appeal a Denied Disability Claim

When you submit an application for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), a claims examiner will review your file to determine whether you qualify for benefits. You'll receive a denial letter if you don't meet the preliminary financial requirements to receive either SSDI or SSI, your medical condition isn't expected to last for at least one year, or the agency thinks that you're still able to work full-time despite your limitations.

If you don't agree with the decision from the Social Security Administration (SSA), you have 60 days to appeal the denial of benefits. Before you decide to appeal, you should become familiar with the agency's appellate review levels and the five-step sequential evaluation used to decide disability claims.

Disability Appeal Process for SSDI or SSI Denials

Your original denial is made at the "initial level" by examiners at Disability Determination Services, a state agency that helps make decisions on Social Security claims. Once you choose to move forward on that same application (instead of abandoning it), you've officially begun the appeal process.

Disability Reconsideration Review

The first appeal of an initial denial is called "requesting reconsideration." When you request reconsideration, you're asking another claims examiner at the state disability agency to review your file again and come to a different decision.

Winning SSDI or SSI at reconsideration isn't easy. Most people at this stage haven't fixed the "flaws" in their application that resulted in the initial denial, and there isn't usually much in the way of new medical evidence available to sway examiners. The odds are good that you'll need to appeal again and request a hearing with an administrative law judge.

Appealing a Disability Denial to the Hearing Level

If you're denied again after reconsideration, you have the opportunity to ask for a hearing where you can explain to a judge why you're disabled. Judges aren't "bound" by the earlier determinations on your claim, meaning they can review the medical evidence with fresh eyes and come to their own conclusions despite the state disability agency's findings. Most people who receive SSDI or SSI are awarded benefits at the hearing level.

Should I Appeal My SSDI or SSI Denial?

Before you file an appeal, closely review your denial notice. The notice will explain why your claim was denied with reference to the medical conditions and records that were considered. You can (and generally should) request your file from the SSA so that you can review the more detailed "technical rationale" for denying you benefits.

When reviewing your decision, look for incorrect statements or opinions that you can challenge on appeal. For example, does the agency have your correct age, education, and work history? Were any important medical records not included when making the denial decision? If you can find any material mistakes made by the SSA, your chances of winning an appeal go up.

In most cases it makes sense to appeal your denial. Filing doesn't cost you anything, and you have your best shot at getting benefits after you've appealed to the hearing level. However, there may be other factors to consider when deciding if it's in your best interest to appeal.

Is Your Impairment Severe Enough to Be Disabling?

The SSA needs to see that your medical condition is severe enough to keep you from working full-time for at least twelve months. Many disability denials are issued because the agency doesn't think that your condition will last for a year or that it will interfere with your ability to perform any job.

If you expect to completely recover from your illness or injury within one year or you think you'll be able to work despite your impairment, SSDI or SSI might not be the kind of benefits you need. Consider applying for workers' compensation or file a claim with a private disability insurer instead.

Do You Have a Favorable Vocational Profile?

Applicants 50 years of age or older can find it easier to qualify for disability under the medical-vocational grid rules. Using the "grid," the SSA can award you benefits if you have a residual functional capacity that prevents you from returning to your past jobs and you don't have the education or skill set required to move into another line of work.

Many claims are wrongly denied under the grid rules because the SSA thinks that the applicant has transferable skills that they can use at a different job. Often, it takes the testimony of a vocational expert at a disability hearing to clear up the misunderstanding. If you're at least 50 years old and your denial letter discusses transferability of skills, it's probably a good idea to appeal.

How Strong Are Your Medical Records?

Disability determinations are made mainly based on the information contained in your medical records. If your doctor says you have significant functional limitations or you have objective medical evidence that satisfies the requirements of a listed impairment, you should qualify for benefits. But if those records are missing—either because you didn't notify the SSA about your treating providers or you haven't visited a doctor—the agency will likely deny your claim.

When deciding whether or not to appeal, make an honest assessment of your medical records. For example, if you're applying for disability based on back pain, do you have an X-ray or MRI showing an abnormal spinal condition? If you're applying for benefits because you have major depression, can you provide progress notes from a psychologist or counselor? You should establish a solid background of treatment for your condition before you appeal, or you're probably facing another denial.

What Are My Chances of Winning a Social Security Appeal?

According to the SSA's Annual Statistical Reports, your chances at each level of review broadly follow a "35-15-50" pattern. This means that, generally speaking, you have about a 35% chance of getting benefits on your initial attempt, a 15% chance of approval at the reconsideration level, and a 50% chance of winning with a favorable decision from a disability judge.

What If I Was Denied For SSDI but Approved for SSI?

Even though the medical definition of disability is the same for SSDI and SSI, the financial eligibility requirements for the benefits differ. SSDI eligibility is based on your wage and employment history, while SSI is a needs-based benefit for people with limited income and assets. Because the application process is the same for both, it's quite possible to be denied for SSDI while being approved for SSI (and vice versa).

SSDI is essentially an insurance program. You pay "premiums" in the form of payroll taxes while you're working. When you stop working and paying these "premiums," your insurance will lapse, just as it would if you stopped paying your car insurance. Unlike an auto insurance policy, SSDI covers you for several years into the future instead of cutting you off immediately. However, eventually you'll stop being covered by SSDI if you don't return to work. The date that you're no longer eligible to receive SSDI benefits is called your date last insured.

If you were denied for SSDI but approved for SSI, it means that you either don't have enough work credits to become insured under SSDI in the first place or that you didn't become disabled until after your date last insured. Because SSDI eligibility is based on your earnings history—which you can't go back and change—it's generally not worth it to appeal this type of denial (also known as a "technical denial"). But if you've worked until very recently and you think the agency made a mistake about your eligibility for SSDI, you should contact your local Social Security field office to see if their calculations are correct.

Social Security Disability Appeal Time Frame

The Social Security disability appeals process can be lengthy and at times very frustrating. A final consideration when deciding whether it's worth it to appeal is your personal tolerance for dealing with bureaucracy. Can you physically and mentally do the paperwork that an appeal requires? Are you willing to get involved in reviewing your file and meeting deadlines? Do you feel comfortable communicating with the SSA? Can you handle long stretches of inaction?

It's important to ask yourself these questions because it may be quite a while before you're approved for benefits. The typical time frame for each level of disability appeal is as follows:

All in all, you're potentially looking at several years from the time you first submit your application until you receive an approval letter. If you receive an unfavorable decision from an administrative law judge and you choose to take your claim to the Appeals Council, that could add another year or more to your wait.

Get Legal Help With Your Disability Appeal

Ultimately, your decision to appeal shouldn't be based solely on any one of the above factors, but after consideration of all of them combined. Finding an experienced disability attorney to help you weigh the pros and cons of appealing your denial is a smart idea. Most disability lawyers offer free consultations, so you can search around until you've found one who is a good match for you.