Overview of Social Security Disability Claims in Pennsylvania

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Many people with disabilities seek to consult with an attorney for Disability benefits. We offer you this brief overview because Prince Law Offices often assists their clients claim disability benefits in Pennsylvania. Social Security disability benefits provide financial support to individuals who are unable to work due to a long-term disability. In Pennsylvania, the Social Security Administration (SSA) oversees two main disability programs: Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). While both programs aim to assist individuals with disabilities, they differ in eligibility requirements and funding sources. Here is a general overview of these programs, the application process, and the appeals process, including timeframes for each stage.

1. Distinguishing SSDI and SSI

The two primary programs administered by the SSA—SSDI and SSI—serve individuals with disabilities but have different eligibility criteria:

  • Social Security Disability Insurance (SSDI): This program provides benefits to individuals who have worked and paid Social Security taxes (FICA) for a sufficient number of years to be “insured” under the program. Typically, applicants need to have earned enough “work credits” within a specific timeframe. The number of work credits required depends on the applicant’s age and recent work history. To qualify for SSDI, an applicant must be considered disabled by the SSA’s definition, which involves proving an inability to engage in substantial gainful activity (SGA) due to a medically determinable impairment expected to last at least 12 months or result in death.
  • Supplemental Security Income (SSI): This program provides financial assistance to disabled individuals with limited income and resources. Unlike SSDI, SSI is not based on work history but rather on financial need. SSI is primarily funded by general tax revenues, and applicants must meet strict income and asset limits to qualify. SSI benefits are available to individuals of all ages, including children, provided they meet the financial requirements and can prove they are disabled or blind according to SSA criteria.

In Pennsylvania, residents can apply for both SSDI and SSI if they meet the respective eligibility requirements. Many individuals who have worked in the past but now have limited income may qualify for both programs.

2. Application Process and Initial Determination

The application process for both SSDI and SSI begins with submitting an application to the SSA. Individuals can apply online, by phone, or in person at a local Social Security office. The application process involves several key steps:

  • Initial Application: Applicants must provide detailed information about their medical condition, work history, education, and financial status. Medical evidence, such as records from doctors, hospitals, and other healthcare providers, is essential for supporting the claim. It is crucial for applicants to include as much relevant medical documentation as possible to support their disability.
  • Processing and Review: After submitting an application, the SSA reviews the claim and forwards it to the Pennsylvania Bureau of Disability Determination (BDD), which is responsible for making the initial disability decision. The BDD may request additional medical records or arrange for a consultative examination to gather more information. This stage can take anywhere from three to six months, depending on the complexity of the case and the availability of medical records.
  • Initial Determination: Once the BDD completes its evaluation, the applicant receives an initial determination. If approved, the applicant begins receiving benefits based on the established onset date of the disability. If denied, the applicant has 60 days to appeal the decision. Unfortunately, most initial claims are denied—around 65% on average—making it likely that many applicants will need to go through the appeals process to obtain benefits.

3. Appeals Process and Timeframes

If an applicant’s initial claim is denied, they have the right to appeal. The appeals process consists of four levels, each with specific steps and associated timeframes:

  • Reconsideration: The first step in the appeals process is requesting a reconsideration. The applicant has 60 days from the date of denial to file this request. During reconsideration, a different claims examiner at the BDD reviews the case, including any new medical evidence submitted. This stage generally takes between three and five months to complete. Unfortunately, the approval rate at the reconsideration level is low, with approximately 85% of already-denied cases still resulting in a denial.
  • Administrative Law Judge (ALJ) Hearing: If the reconsideration is denied, the applicant can request a hearing before an Administrative Law Judge (ALJ). Again, this request must be filed within 60 days of the reconsideration denial. The ALJ hearing is a crucial part of the appeals process, as it provides the applicant an opportunity to present their case in person and submit additional evidence. Applicants can also bring witnesses, such as medical experts, to support their claim. The wait time for a hearing varies widely by location but generally is 12 or more months in Pennsylvania. The ALJ will issue a written decision, typically within two to three months after the hearing.
  • Appeals Council Review: If the ALJ denies the claim, the applicant can request a review by the SSA Appeals Council. This request must be made within 60 days of the ALJ decision. The Appeals Council has discretion to grant or deny the request for review. If the Appeals Council accepts the case, it may either decide the case itself or return it to an ALJ for further review. The process at the Appeals Council level can take anywhere from six months to a year or longer.
  • Federal Court Review: If the Appeals Council denies the request for review or upholds the ALJ’s decision, the final step is filing a lawsuit in federal district court. Applicants have 60 days to file a complaint in federal court, where a judge will review the SSA’s decision for legal errors. The federal court process can take up to a year or more, depending on the court’s schedule and the specifics of the case.

Each level of the appeals process provides a new opportunity to present additional evidence and argue the merits of the disability claim. It is not uncommon for individuals to be denied at the initial stages and ultimately win their case at the ALJ hearing level or beyond. Therefore, persistence is often essential for obtaining benefits.

4. Expedited Programs and Compassionate Allowances

For certain severe conditions, the SSA has expedited processes to speed up disability determinations:

  • Compassionate Allowances (CAL): This program fast-tracks claims for applicants with specific severe medical conditions, such as certain cancers, ALS, and advanced-stage diseases. CAL claims are generally approved quickly, often within weeks, based on the medical evidence provided.
  • Quick Disability Determinations (QDD): The SSA uses predictive software to identify claims that are highly likely to be approved based on initial evidence, such as diagnoses with a high likelihood of disability. These claims are given priority processing and can be approved faster than traditional claims.

5. Considerations for Pennsylvania Applicants

Navigating the Social Security disability system can be complex, and many applicants benefit from seeking assistance from a qualified attorney or advocate who can help them understand the process, gather necessary documentation, and represent their interests at hearings. In Pennsylvania, residents may also seek assistance from local Disability Determination Services (DDS) offices, which provide resources and guidance.

Conclusion

The Social Security disability claims process in Pennsylvania can be lengthy and challenging, often taking several months or even years to resolve. However, understanding the distinctions between SSDI and SSI, as well as the step-by-step process from application to appeal, can help applicants prepare for each stage. While initial denials are common, the appeals process offers multiple opportunities for applicants to present their case, ultimately ensuring that those who qualify receive the financial support they need.

by Karl Voigt

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