Receiving an unfavorable disability decision from a Social Security judge can be a disappointing and frustrating experience for disability claimants. Adding to the frustration is the fact that claimants often struggle to understand the judge's rationale for the denial of benefits. The standard language and legal jargon found in disability decisions make them nearly impossible to understand fully without the help of a disability attorney. Here are some tips on how to read a decision denying disability benefits.
All unfavorable disability decisions (denials) are structured the same way. A heading states the claimant's name and Social Security number, and whether the claim is for Disability Insurance benefits, Supplemental Security Income, or both. The heading is followed by five sections:
Note that a cover letter should be attached to your decision stating "Notice of Decision - Unfavorable" that explains how and when to appeal your denial.
This section lists several of the important dates associated with your claim, including the date you filed your disability application, the date you requested a hearing, your hearing date, and your alleged onset date of disability. The names of any witnesses, including vocational and medical experts, and your attorney's name, if you have one, are generally found in this paragraph as well.
Here you'll find Social Security's definition of disability, obviously one of the most significant matters in your case. Social Security defines disability as the inability to perform "substantial gainful activity" (full-time work) due to a "medically determinable" (diagnosable) impairment that has lasted or is expected to last for at least a year or end in death.
In claims involving disability insurance benefits, you'll also notice a discussion of your date last insured (DLI), or the last date on which you met the "insured status requirements" of a portion of the Social Security Act. As the decision states, you must establish disability on or before your DLI in order to be eligible for disability insurance benefits.
This section outlines Social Security's five-step evaluation process for deciding disability claims. (Note that cases involving the termination of existing disability benefits use an eight-step process.)
The first step is deciding whether you are already performing productive work, or what the Social Security Administration (SSA) calls "substantial gainful activity" (SGA). If you're working and earning more than a certain threshold ($1,310 in 2021 for non-blind applicants), you will generally be found not disabled no matter how severe your medical issues.
At step two, the SSA determines which of your impairments are "severe," defined as causing significant limits on your ability to perform work-related activities. If you don't have any severe impairments, you're not disabled.
Step three contains an analysis of whether you meet or equal any of Social Security's medical listings. At step four, the SSA determines whether your residual functional capacity (RFC) allows you to return to any of the jobs you've held in the last 15 years. If not, your claim proceeds to the final step, where the SSA decides if there are any other jobs in the U.S. you can perform, taking into account your age, education, work experience, and RFC.
In this section, the administrative law judge (ALJ) applies the law to the facts of your case and makes legal "findings" (states the results). The findings usually stand out because they're printed in bold type.
DLI and SGA. The judge will first make a finding as to your date last insured (in disability insurance cases) and then determine whether you've performed SGA since your alleged onset date.
Severe or not severe. Next, the ALJ will list which of your impairments are severe and non-severe.
Listings. The decision then explains what listings the ALJ considered and why your condition failed to satisfy the criteria. For example, if you suffer from back pain, the ALJ may have considered your condition under listing 1.04 for disorders of the spine. Those with depression, bipolar disorder, or anxiety might be evaluated under listing 12.04 for mood disorders and/or listing 12.06 for anxiety disorders.
RFC. Next comes the ALJ's crucial finding regarding your Residual Functional Capacity. The RFC generally begins with, "After careful consideration of the entire record, the undersigned finds that the claimant has the residual functional capacity to perform..." followed by a description of your maximum physical and mental abilities.
The RFC finding is followed by an in-depth discussion of the medical evidence in your file and your testimony at the hearing, along with reasons why the ALJ believes you are not as limited as you maintain. For instance, the decision might point out that although you claim to suffer from crippling anxiety, you haven't obtained treatment for this condition and your daily activities, such as grocery shopping or socializing with friends, aren't consistent with that diagnosis.
In addition, this section should contain an evaluation of every medical opinion in your file, including those of your own physicians and the state agency (DDS) medical consultants. The ALJ should explain and justify the amount of weight the judge gave to each opinion, backed up by citations to specific exhibits in the file (usually particular medical records).
Credibility. Finally, the ALJ may comment on the credibility of the claimant, and whether certain factors rendered him or her less than fully believable. For example, if the claimant provided vague or evasive answers at the hearing, or has a documented history of dishonest behavior, the ALJ might find his or her answers to be unreliable.
Drug and alcohol abuse. When drug or alcohol abuse is an issue, the ALJ will make a separate finding as to whether the substance abuse is a contributing factor to your disability. In other words, the judge will determine whether you have a disability caused by or made worse by substance abuse. If that's the case, you won't be entitled to benefits. (Read about drug and alcohol abuse determinations for more information.)
Past work or other work. Following the RFC discussion, which makes up the bulk of most decisions, the ALJ will state whether you can perform your past work or other work. If the judge finds that you can't do your past job, the ALJ will state whether you can do any other jobs in the economy based on your age, education, work history, and RFC. Here the decision should list specific jobs you can perform as well as the strength requirements and numbers of those positions in the regional and national economy.
In this section, you'll find a brief conclusion that simply states the final decision of the judge, followed by the judge's signature and the date.
If you've received an unfavorable disability determination and want to appeal your case, call a disability attorney as soon as possible. Consult Nolo's lawyer directory to find a disability attorney in your area.