When applying for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI), most people naturally think about the reasons why they should be granted benefits. You may find it useful, however, to turn the perspective around and understand the reasons why you might be denied SSDI or SSI benefits. In some cases, the reasons are beyond your control. In other instances, though, you may be able to avoid doing something that results in a denial.
For SSDI, which is the benefit program for workers who have paid into the Social Security system over multiple years, one of the most basic reasons you could be denied benefits is that, when you apply, you are working above the limit where it is considered "substantial gainful activity" (SGA). This means you earn too much money to be considered disabled. You are allowed to work a small amount when you're applying for and collecting SSDI, but not over the SGA limit, which is $1,260 per month in 2020 (for nonblind people). The figure is adjusted annually. Income from investments does not count toward the SGA—only work income counts, as it shows your ability to work.
As to SSI, which is the disability benefit for low-income people, when you apply for SSI, you can't be making over the substantial gainful activity level (although after approval you can earn more money than that). But there's a limit on all earned and unearned income for SSI, around $1,600 per month, that applies both when you're applying for benefits and when you're collecting benefits. And any time your income is over $85 per month, your SSI payment will start to be reduced, by a somewhat complicated formula. If you make more than about $1,650, your payment would be reduced to zero; in other words, you won't qualify for SSI.
To qualify for SSDI or SSI benefits, the Social Security Administration (SSA) must believe that your impairment is severe enough to last at least 12 months or result in your death. The only exception to this duration requirement is for blind SSI applicants.
Many claims—like those based on bone fractures resulting from acute trauma, such as automobile or motorcycle accidents—are denied because they are not likely to cause disability for 12 months. Almost all bone fractures heal in less than a year. However, if you have severe bone fractures that aren't healed after six months, the SSA is then likely to think your impairment will last a year. Each case is evaluated on an individual basis.
In addition, your medical condition must cause you severe limitations to qualify for SSDI or SSI. Most claims are denied simply because the applicant's impairment was not severe enough (for more information, see Nolo's article Social Security Disability: How Claims Are Decided).
The SSA and Disability Determination Services (DDS)—the agency that determines your medical eligibility for benefits—must be able to communicate with you regarding your application. If these agencies cannot reach you to schedule examinations or communicate with you about critical matters, your benefits may be denied. If you name a representative (such as an attorney) to handle your paperwork, you may not need to get in touch with the SSA, but be sure to stay in touch with your representative or attorney. If you move while your application is being considered, make sure the SSA knows how to contact you. Claimants (those who are applying for Social Security disability) get denied every day because the SSA cannot find them.
Your medical records are vital to granting your disability. If you refuse to release those records to the SSA, your claim will likely be denied. Similarly, the SSA may need additional information about your impairments, either because your treating doctor's medical records are incomplete or because you have no regular treating doctor. In these instances, the SSA will request that you be examined by an SSA doctor, during something called a consultative examination (CE), at government expense. In some cases, the SSA will require you to attend more than one CE. If you refuse to attend or request that the SSA make a determination based on the medical records already in your file, you may be denied disability because of inadequate medical information or failure to attend the CE.
If you can't make it to a scheduled CE because of the time or location, talk to your claim examiner so the DDS can schedule a CE at a time or place that is convenient for you. If you repeatedly fail to show up for a CE, your claim will most likely be denied.
If you are being treated by a doctor, but fail to follow the doctor's prescribed therapy when you have the ability to do so, you can be denied disability benefits. However, the SSA recognizes certain legitimate excuses for failing to follow the doctor's orders (which can be for taking medicine, going to therapy appointments, or undergoing surgery).
Acceptable medical excuses. Failure to follow prescribed therapy can be excused for reasons beyond your control. Some examples follow.
Acceptable nonmedical excuses. It is possible that you cannot follow a prescribed therapy for a reason that has nothing to do with your medical condition. Acceptable nonmedical excuses for failing to follow prescribed therapy follow.
Additionally, for the SSA to deny your claim for failing to follow therapy, the therapy that you fail to follow must be one that is clearly expected to restore your ability to do substantial gainful activity. If your treating doctor tells the SSA that the prescribed therapy is not likely to result in your ability to work, the SSA won't fault you if you don't follow such therapy.
For more information, see Nolo's article on the impact of failing to follow prescribed treatment.
The SSA will deny benefits to someone whose drug addiction or alcoholism (DAA) is a contributing factor to his or her disability. The key factor a DDS medical consultant must consider when making a DAA determination is whether or not the SSA would still find you disabled if you stopped using drugs or alcohol.
For more information, see Nolo's article on when drugs or alcohol will prevent you from getting disability.
Certain conditions related to conviction of a crime or imprisonment will prevent you from receiving Social Security disability insurance benefits. They are as follows.
However, it's worthwhile to apply for SSDI benefits even if one of the above situations apply to you, because even if you can't get cash benefits, you may be granted a period of benefit-free disability that will "freeze" your earnings record, keeping your eventual disability, retirement, or dependents benefits from decreasing.
Note these situations do not prevent you from receiving SSI disability benefits, although being incarcerated does keep you from collecting SSI benefits.
If you obtain disability benefits by dishonest means, the SSA can terminate your benefits and prosecute you for fraud. If you obtained benefits through fraud on the part of someone working for the SSA, your benefits can also be terminated.
If your claim has been denied for one of these reasons, see Nolo's article Social Security Disability: Deciding Whether to Appeal a Denied Claim. Or, for more information in general about Social Security disability in general—including tips on applying for benefits, appealing a denial of benefits, and understanding detailed medical listings—see Nolo's Guide to Social Security Disability: Getting & Keeping Your Benefits, by David A. Morton III, M.D. (Nolo).