This guide gives a basic summary of the entire claims process for SSI and SSDI cases.
What are the stages?
1. Initial Determination
3. Administrative Law Judge Hearing
4. Appeals Council Review
5. Filing a civil suit in Federal Court
This is the first step in a disability application. After applying for SSI and/or SSDI, your claim is sent to the Disability Determination Services office, or DDS. At DDS, claims examiners review your medical records and other evidence to determine whether you meet SSA's definition of disabled. DDS claims examiners request your medical records and may send out questionnaires to you or other people who may have information on your ability to function at home, school, or work. If DDS needs more medical evidence to make their decision, they may schedule a medical examination for you, called a Consultative Examination, for which they will pay. The claims examiners and doctors on staff at DDS review all of this evidence to decide whether you are disabled under SSA's criteria.
I was denied benefits - What now?
There are four levels of appeal in disability cases - Reconsideration, Administrative Law Judge Hearing, Appeals Council Review, and filing a civil suit in Federal Court. After each denial, you have 60 days from the date you received the denial letter, or 65 days from the date on the letter, to appeal the decision. Even if you were approved for benefits, if you were not granted all of the back benefits you asked for you may be able to file an appeal. If you were receiving benefits while your decision was pending, you will have to appeal within 10 days of the denial if you wish to continue receiving benefits pending your appeal.
At the reconsideration level, your claim will go back to the DDS office that originally denied your claim. Unless you inform SSA and DDS that you have new evidence relevant to the determination, the claims examiner will simply review the evidence already in file and make a decision. With no new information, it is highly unlikely that DDS will approve your claim.
If DDS denies your reconsideration claim, you can request a hearing before an Administrative Law Judge (ALJ).
Administrative Law Judge (ALJ) Hearing
Before your hearing before an ALJ, you can review your file and submit new evidence. You do not need to appear in person at the hearing, however it is important that you do so if at all possible. You may be able to receive financial assistance so that you can attend the hearing, or the hearing may be conducted by video teleconferencing or telephone. If the ALJ requires more evidence before s/he can make a decision, s/he may schedule and pay for additional medical examinations. You and the ALJ may also ask witnesses to come to the hearing, such as medical or vocational experts. At the hearing, you can ask the witnesses questions, and present new evidence to the ALJ.
If the ALJ denies your claim, you may request that the SSA's Appeals Council review your claim.
You will again want to update your file with new or missing evidence, medical treatment, medications, and conditions. When the Appeals Council reviews your case, it can do one of three things: 1) deny your request for review; 2) approve your request for review and send it back to a new ALJ to review your case; or, 3) approve your request for review and decide your claim themselves.
If the Appeals Council denies your request for review, you may file a civil lawsuit with the U.S. District Court in your area. If you do not want to pursue a civil suit in Federal Court, you can start the process over again by filing a new SSI/SSDI application at your local SSA office.
In a civil suit in the United States District Court, the court is limited to reviewing the case for a procedural error. The court will not review your evidence of disability. After its review, the court will do one of three things: 1) affirm the Appeals Council's decision; 2) reverse the Appeals Council's decision, and approve your claim; or, 3) send the case back to the SSA to develop additional evidence and review your claim again.
If the Federal court denies your claim, you may be able to appeal to the next level, the United States Circuit Court of Appeals. However, very few cases reach this level, and an appeal at this level can be exceedingly challenging and lengthy. You should always talk to an attorney to determine whether you should appeal or file a new application.
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