Tag Archives: Disability

What is the Role of Disability Determination Services (DDS) in Social Security Disability Claims?

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Social Security disability claims usually begin at the local Social Security Administration (SSA) field office where the applicant lives. The SSA field office collects and processes applications for disability benefits through various channels, including in-person, mail-in and online applications. SSA field offices first verify non-medical eligibility requirements, such whether the applicant has acquired enough prior work credits to receive SSDI benefits or whether an applicant’s current earnings exceed the threshold for gainful employment.

Once non-medical eligibility is verified, the SSA field office forwards the case to a separate Disability Determination Service office (DDS) for medical evaluation of disability. Though federally funded, DDSs operate as State agencies. In Virginia, Virginia Disability Determination Services partners with SSA and the Virginia Department of Social Services to review and make initial decisions on eligibility for SSDI, SSI, and Medicaid programs. Local DDS offices serve as critical gatekeepers in the disability evaluation process. Their primary responsibility is to assess medical evidence and make the initial determination as to whether a claimant is disabled or blind under the law.

At the initial application stage, DDSs seek and acquire evidence from the claimant’s identified medical providers, relieving the applicant of the burden and expense of ordering their own medical records. If that evidence is insufficient, DDS may order and require a consultative examination (CE) to obtain additional medical assessments and opinions. DDS then forwards the cumulative file information to reviewing physicians to evaluate the evidence and make recommendations regarding the severity of the applicant’s condition and their residual functional capacity. After making a final determination, DDS returns the case to the local SSA field office for appropriate administrative action.

If DDS determines that the claimant is disabled, SSA proceeds to compute and pay-out the subject benefits. If the DDS finds the claimant not disabled, the claimant may appeal the adverse decision though several stages. Following the first appeal, DDS will reevaluate the claim on Reconsideration. If DDS upholds its denial, a claimant may appeal again and then receive an evidentiary hearing before an SSA Administrative Law Judge.

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How to Appeal a Denial of Long-Term Disability Benefits

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What Should You Do if an Insurance Company Denies Your Claim for Long-Term Disability Benefits?

Suffering from a long-term disability can be an incredibly challenging and life-altering experience. Thankfully, many employer’s offer individuals long-term disability (LTD) insurance benefit to provide financial support during these difficult times. In some cases, these plans may provide initial benefits to persons who are not immediately eligible for Social Security Disability Benefits.


Understanding Long-Term Disability Policies and ERISA:

If your LTD plan is issued through your employer, the policy most likely is governed by the Employee Retirement Income Security Act (ERISA), which can present a unique set of challenges. ERISA is a federal law that establishes minimum standards for retirement, health, and other welfare benefit plans offered by employers. ERISA also impacts the rules and regulations surrounding your claim process and subsequent appeals. ERISA provides protection for both the plan participants and the insurance companies, aiming to ensure fairness in the administration of benefits.


ERISA imposes certain requirements on insurance companies, such as providing participants with plan information, a clear explanation of the claim denial, and a fair appeals process. However, it also sets deadlines and limitations on the claimant’s ability to present evidence, making the claim process complex and challenging to navigate without a proper understanding of it’s procedure. Importantly, ERISA mandates that claimants must exhaust an insurance company’s internal appeals process before pursuing any legal action. Your first objective should be to familiarize yourself with the specific requirements and deadlines for submitting an appeal, which are usually spelled out at the end of the denial letter. While plans may vary, in most cases you have only 180 days to submit your initial denial appeal. However, filing an immediate appeal also can be a mistake. You must use this 180 day window to properly develop an appeal if you are to expect a different result. For this reason, you should contact an attorney immediately after receiving the denial letter.


Steps to Take if Your Long-Term Disability Claim Is Denied:

1. Carefully read the denial letter from the insurance company, as it should outline the reasons for the denial and the procedures for submitting an appeal. Understanding the insurance company’s rationale is crucial in preparing your appeal. For example, did they rely upon the opinion of an outside medical consultant or did they just not receive all of your medical information in a timely manner?

2. Request a copy of the insurer’s file, including any adverse medical opinions upon which they relied to deny your claim.

3. Collect all relevant medical records, test results, and other evidence that support your disability claim.

4. Consult with your healthcare providers to ensure you have a comprehensive and up-to-date record of your condition. If the insurance company lists the opinion of an outside medical consultant, ask your own provider whether they agree or disagree with those conclusions. Your doctor’s can play a crucial role in responding to a denial, but a short letter stating you are disabled may not be sufficient. It is important to ask the right questions.

5. Eventually, you must submit an appeal letter that addresses the reasons for the denial and provides additional evidence to support your disability claim. Prior to sending in your appeal, consider seeking assistance from an experienced attorney who specializes in disability and ERISA claims.

6. In cases where all other options have been exhausted, filing a lawsuit may be the final course of action. Understand that ERISA lawsuits usually are limited to a review of the administrative record. Do not assume that you will be able to introduce new and additional evidence to a neutral jury, which is why the proper development of the initial administrative appeal is often the key to a successful claim.

SSDI: What Is My Last Insured Date?

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When applying for Social Security Disability benefits, your “last insured date” is a key factor that initially dictates whether you are eligible to apply for benefits. The last insured date is the date on which your eligibility for Social Security Disability Insurance (SSDI) benefits ends. When you apply for SSDI benefits, the Social Security Administration (SSA) will look at your work history to determine your last insured date. To receive SSDI benefits, you must prove that your disability onset date occurred before your last insured date.

To be eligible for SSDI benefits, you must have earned a predetermined number of quarterly work quarters. Once you have earned enough credits to qualify for SSDI, you become “insured” for disability benefits. To earn credit for a work quarter, an individual must have earned a minimum amount of money during that quarter. For example, the amount of earnings required for a quarter of coverage in 2023 is $1,640.

Generally, an individual over 31 years of age needs to have earned 40 work quarters in total. Also, 20 of the work quarters must have been earned in a 10 year look-back period immediately before the onset of your disability. (i.e. did you work in 20 of the past 40 quarters?). Based on this math, if you have not worked for more than 5 years (20 quarters) then you likely will no longer be insured for SSDI purposes. You still can apply for benefits, but you must prove that your disability began prior to the last insured date.

Younger individuals may be eligible with fewer work quarters. If you are under 24, you only need to earn 6 credits in the 3 year period before the onset of disability. If you are between ages 24 and 31, you need to earn credits for working half the quarters between age 21 and the onset of disability.

Based on these formulas, if you no longer are able to work due to a permanent disability, it is important to initiate your application for SSDI benefits in a timely manner.

Can Your Employer Require You to Undergo a Fitness for Duty Examination?

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The Americans with Disabilities Act (ADA) considers that employers may request fitness-for-duty examinations under limited circumstances. The legality of such exam requests sometimes can be complicated.

Generally, the ADA requires Employers to provide reasonable accommodations to individuals with disabilities unless doing so would impose an undue hardship. However, the ADA also permits employers to establish qualification standards that are job-related and consistent with business necessity. In some instances, a fitness-for-duty exam may be necessary to determine whether an employee can perform their job duties, with or without accommodations.

To require a fitness for duty examination, the employer must have a reasonable belief that (1) the employee’s ability to perform his or her essential job functions is impaired by a medical condition or (2) the employee poses a direct threat to safety of others due to a medical condition. The reasonable belief must be based on objective evidence, such as observations of the employee’s job performance or medical documentation. If properly supported, an Employee’s refusal to submit to a reasonable fitness for duty examination can be a basis for disciplinary action. However, if the request is not supported by objective evidence or overbroad in scope, an Employer’s termination of an employee based on an overreaching exam or refusal to submit to such an exam may lead to claims of ADA violations.

Under the ADA, a fitness-for-duty exam must be job-related and consistent with business necessity. In other words, the exam must be necessary to ensure that an employee remains capable of performing the essential functions of their job. The exam must be tailored to the employee’s specific job duties and cannot be overly broad or intrusive.

A fitness for duty exam also should not be abused as a means of discovery into an Employees entire medical history, especially if unrelated to the asserted impairment. The EEOC takes the position that an Employer’s request for medical records must be narrowly tailored to an employee’s job requirements. An overbroad release for medical records or a questionnaire seeking a detailed medical history could be improper, as it might allow the Employer to inquire about unrelated medical conditions or genetic information in violation of the Genetic Information Non-Discrimination Act.

In some limited circumstances, however, a fitness for duty exam may be required without having to articulate evidence of impairment or threat. For example, Employees out of work on worker’s compensation or FMLA leave may be required to submit a fitness for duty certification to return to work. Also, an employee requesting accommodation under the ADA may have to provide medical documentation to substantiate the medical condition requiring accommodation.

When Can You Request Work Accommodations Under the Americans With Disabilities Act (ADA)?

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Under the Americans with Disabilities Act (ADA), employers with 15 or more employees are required to provide reasonable accommodations to qualified employees with disabilities. Reasonable accommodations are adjustments or modifications to a job or work environment that enable an employee to perform the essential functions of the employment position. A reasonable accommodation may include job restructuring, part-time or modified work schedules, reassignment to a vacant position, or acquiring or modifying equipment. It does not typically require the elimination of an essential function of a job, the displacement of other employees, or the creation of a new light-duty job.

The ADA does not require employers to provide accommodations that would cause an undue hardship, which is defined as an action that requires significant difficulty or an unsustainable expense. Additionally, the ADA does not require employers to provide accommodations that would pose a direct threat to the health or safety of others in the workplace.

The purpose and intent of reasonable accommodations is to provide employees with disabilities an equal opportunity to enjoy the privileges of employment when they are capable of performing the essential functions of a position. Some specific examples of reasonable accommodations might include:

• Installing a ramp to make a workplace wheelchair-accessible
• Modifying a restroom so a worker with disabilities can use it
• Allowing a flexible work schedule
• Reassigning a qualified employee to a vacant position

The exact procedure for requesting accommodations under the ADA may vary by employer, but the burden is upon the employee to initiate the request. Employees must request accommodations by informing their employer of their basic disability and the need for an accommodation. The request should be made in writing and should include a description of the accommodation needed.

Upon notice of the request, employers must engage in an “interactive process.” The interactive process involves a discussion between the employer and employee to identify the employee’s limitations and how they impact the employee’s ability to perform the job. If needed, the employer may request additional information from the employee’s healthcare provider to determine the medical and job related conditions. Although healthcare providers might suggest specific accommodations, employers are not required to provide the exact accommodation requested by the employee if there are other effective accommodations that also meet the employee’s needs.