Why Would Your SSDI Claim Be Denied?

Before diving into the appeals process, it’s important to understand why your claim may have been denied. Common reasons for denial include:

• Insufficient medical evidence: The Social Security Administration (SSA) may feel that you haven’t provided enough proof of your disability.
• Earnings above the threshold: If you are still earning above the Substantial Gainful Activity (SGA) threshold, the SSA may determine that you are not disabled.
• Failure to follow prescribed treatment: If the SSA believes that you are not following prescribed treatments that could help improve your condition, they may deny your claim.
• Disability not severe enough: The SSA may conclude that your condition is not severe enough to prevent you from working for at least 12 months.

Even if your claim was denied for one of these reasons, it is still possible to successfully appeal.

Steps in the SSDI Appeals Process

If your SSDI claim is denied, you have four levels of appeal to choose from. Each stage offers you a chance to present additional evidence, clarify your situation, and increase your chances of a favorable outcome.

Step 1: Reconsideration

The first step after a denial is to request reconsideration. This means that the SSA will review your case again, but this time it will be handled by a different team of adjudicators. During the reconsideration process, you may have the opportunity to submit new medical records or additional evidence that could support your claim.

• What Happens During Reconsideration?
• Your case will be reviewed by an examiner who was not involved in the initial decision.
• Additional evidence or clarification may be considered.
• In some cases, you may be asked to attend a new consultative medical examination (CME).
• Timeline: The reconsideration process typically takes about 3 to 5 months. If you are denied at this stage, you can move on to the next level of appeal.

Step 2: Hearing Before an Administrative Law Judge (ALJ)

If your reconsideration is denied, your next step is to request a hearing before an Administrative Law Judge (ALJ). This is one of the most critical stages of the appeals process. During the hearing, you and your legal representative (if you have one) will present your case in front of a judge. You will have the opportunity to provide additional evidence, explain your situation, and answer any questions the judge may have.

• What Happens During the Hearing?
• The ALJ will review all the evidence in your case, including medical records and testimonies.
• You will have the chance to speak about how your disability affects your ability to work and daily life.
• Witnesses, such as medical professionals or vocational experts, may be called to testify on your behalf.
• Timeline: It can take a year or more to get a hearing scheduled. However, this stage often offers the best chance to win your case, especially if you have strong supporting evidence.

Step 3: Appeals Council Review

If the ALJ denies your claim, you can request a review by the Appeals Council. The Appeals Council will look at the decision made by the ALJ and determine if any legal errors were made. However, the Appeals Council does not hold hearings or take new evidence. They will either decide to:

• Uphold the ALJ’s decision (if they find no errors),
• Remand the case (send it back to the ALJ for further review), or
• Reverse the decision (in rare cases, they may rule in your favor).
• What Happens During the Appeals Council Review?
• The Appeals Council will review the ALJ's decision and the evidence that was considered.
• They may approve or deny your request for review, and you may be notified of their decision.
• If they deny your request for review, you may have the option to take the case to federal court.
• Timeline: The review process can take several months (6 months or more), but the outcome depends on the details of your case.

Step 4: Federal Court

If the Appeals Council upholds the ALJ’s decision and you still believe the decision was wrong, your final option is to take your case to federal court. This step involves filing a lawsuit in a U.S. District Court. A judge will review your case and decide whether the SSA’s decision was legally correct. At this stage, new evidence cannot be presented, and the judge will base their decision on the existing record.

• What Happens in Federal Court?
• A federal judge will review the SSA’s decision and determine if there were any legal errors.
• The judge may order the SSA to reconsider your case, or they may affirm the denial.
• Timeline: The process can take over a year, and it may be costly. It’s often advisable to have a lawyer or advocate assist with this stage.