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How to Win Social Security Disability Benefits for Spinal Disorders Using Listing 1.04

Published on December 17, 2014 by

Anyone applying for disability benefits from the SSA has two possible ways to prove that they qualify:

  1. They can meet the requirements defined for individual conditions in the SSA’s Listings of Impairments.
  2. They can prove that they are unable to work due to their impairment by using the SSA’s Five Step Sequential Evaluation Process.

Of the two options, meeting one of the listings is by far the preferred method because it’s much more straightforward. What are the Listings of Impairments? These are a list of medical criteria or standards that the SSA has come up with to define a particular condition. Anyone who proves they meet one of these definitions qualifies for disability benefits automatically. All you have to do is show that your condition matches the criteria and that you’ve been without a job because of it for at least 12 months (or that the medical evidence argues you’ll be unable to work for that long or longer).

Naturally, it is not quite that simple though. In order to prove to the SSA that you meet their criteria, you need very specific objective medical documentation. Exactly what do you have to show to receive benefits for Disorders of the Spine?

Standards and Medical Criteria for Listing 1.04

To meet listing 1.04 – Disorders of the Spine, there are several things that you can show to the SSA:

Nerve root compression evidence. Those suffering from this problem show motor loss, limited spinal motion, neuro-anatomic pain distribution, sensory loss, or a loss of reflexes. If the lower back is involved, these people typically have a positive straight-leg raising test.

Spinal arachnoiditis. People with this condition experience severe dysesthesia or painful burning that forces them to move around and change positions frequently (more than once every two hours).

Lumbar spinal stenosis resulting in pseudoclaudication. Sufferers experience chronic nonradicular weakness and pain that prevents them from ambulating effectively.

In order to prove any of these issues, you’ll need objective medical evidence gained from testing. There are many tests the SSA uses to identify spine disorders, including:

  • Plain x-ray of the cervical spine
  • Plain x-ray of the lumbosacral spine
  • Range of Motion (ROM) Tests
  • Straight Leg Raising Test (SLR)
  • Thoracic Gas Volume (TGV)
  • Gaenslen’s Test (sign)
  • Spurling’s Test
  • Human Leukocyte Antigens (HLA)
  • Deep Tendon Reflexes (DTRs)
  • Lung Subdivisions
  • CT Scan (Computerized Tomographic) of the spine
  • General EMG (electromyography)
  • Schoeber Sign
  • MRI of bone
  • MRI of spinal cord and spine
  • Piriformis Compression Test
  • Bone densitometry
  • Magnetic Resonance Neuropathy
  • Flêch sign
  • Spirometry
  • Myelography
  • Patrick’s Test (Fabere Test)
  • Functional Residual Capacity (FRC)
  • Nerve Conduction Studies (NCS)

Testing positive on one or more of these tests can help provide you with the evidence you need to prove to the SSA that you meet the requirements of a disability on their list and automatically qualify you for benefits.

Failing to match something on their Listings of Impairments, though, doesn’t have to be the end. Remember that many can and do go on to receive benefits by going through the Five Step Sequential Evaluation Process. If you can prove that your condition prevents you from working in any job in our country that your experience and education otherwise would qualify you for, the SSA will approve your claim.

It’s not easy though, so you want to ensure you get a knowledgeable Social Security disability attorney on your side as soon as possible. Learn more about the claims process by reading our Social Security Disability eBook for free!

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Winning Social Security Disability Benefits for Weight Bearing Joint Surgery Using Listing 1.03

Published on December 10, 2014 by

 If you are filing a claim for reconstructive surgery or arthrodesis of a major weight-bearing joint, you need to know what the SSA wants to see in order to approve the claim and get the benefits you deserve.

How can you qualify? The most straightforward way is to meet the definition the SSA has laid out in their Listings of Impairments for this specific issue. These listings are the medical standards or set of criteria that the organization has laid out for individual conditions. If someone can prove they meet these criteria, they automatically qualify to receive disability benefits.

Alternatively, someone who doesn’t completely meet the requirements in the Listings of Impairments can still qualify for disability benefits if they can show that their health issue keeps them from being able to work in any position in the nation that meets their education and experience. This is accomplished by going through the SSA’s Five Step Sequential Evaluation Process or proving that medical issue in question is the equivalent of one of the disabilities in the Listings of Impairments.

Ideally, you want to meet a disability listing, but it’s not easy. Precise objective medical documentation is needed, and the SSA won’t even consider a disability based on a listing unless you’ve already been out of work for 12 months – or it is believed that you will be out of work for at least that long – due to your medical condition.

Standards and Medical Criteria for Listing 1.03

To meet listing 1.03 – Reconstructive Surgery or Arthrodesis of a Major Weight-Bearing Joint, you need to show a couple of things to the SSA:

  • That reconstructive surgery or arthrodesis occurred
  • That there is an inability to ambulate effectively in knee, hip, or ankle joints after surgery
  • That this inability has gone on (or will continue) for 12 months or longer

Of course, it is not enough for your doctor to simply write a letter to the SSA stating that your inability to ambulate will last for longer than a year. Objective proof is required, and some of the tests that can help in this regard include x-rays, the Apley grinding test, Arthrocentesis, Arthrography, Drawer sign (anterior and posterior), Magnetic Resonance Imaging (MRI) of bone, McMurray’s Test, Patrick’s Test (Fabere Test), and Range of Motion (ROM) tests. If you can show positive results on one or several of these tests, it will go a long way towards helping your cause.

Don’t lose heart if you aren’t able to match something on their Listings of Impairments. You can still use the Five Step Sequential Evaluation Process we mentioned above to show that your condition keeps you from working. If you want the best chance at getting the benefits you deserve, talk with an experienced Social Security disability lawyer today. Learn more about the claims process by reading our Social Security Disability eBook for free!


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Treating Docs May Hurt Your Long Term Disability Insurance Claim

Published on December 3, 2014 by

As far as most people are concerned, when their doctor tells them something their word is final. After all, they have years of medical training and know what they’re talking about. So if your doctor tells you that you suffer from a disability and should be able to receive long term disability benefits, then that is the end of the argument, right? Wrong.

Insurers have been pitting doctors against each other for years by asking claimants to have an independent medical evaluation with a physician that they choose. Supposedly, the idea is just to get a second opinion and see if another medical professional will objectively agree or disagree with the original findings. More and more, though, these independent examiners end up “reviewing” the work of the treating physician and searching for ways to call it into question.

While this might seem like an obvious tactic on the part of the insurers who are paying these independent examiners and have no desire to pay out on claims if they don’t have to, in recent years it appears to be working.

Courts Now Skeptical of Doctors – Period

Not too long ago, courts gave deference to the findings of treating physicians and looked upon the work of “insurance doctors” with more suspicion. Since 2003, though, this deference has disappeared as courts pay more and more attention to “reviewing” doctors who are able to comment on the work of the treating physician and point out any supposed deficiencies in addition to conducting their own tests and examinations.

This doesn’t mean that they now trust doctors who are hired by insurers more – it just means that medical opinions as a whole are given less weight unless they are thoroughly backed up by objective evidence. If you want to have the best chance of winning your claim, you need to make sure that your doctor takes detailed notes and explains any changes in opinion that occur when they are seeing you.

These are the kinds of things that insurers love and “reviewing” doctors pounce on as a way to show that your doctor didn’t do a thorough job and was instead trying to act as your advocate instead of providing an objective analysis. Additionally, you may wish to have your doctor respond to the findings of the independent examiner so that he or she doesn’t get the last word and they have a chance to explain themselves.

An experienced medical disability attorney will be able to tell you in greater detail the kinds of things that your doctor should include in their reports, but you can also get a better overall sense of disability policies by reading our free eBook.

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Long Term Disability Insurance Claims: How Insurers Fight The NAIC Model Act

Published on November 28, 2014 by

Last time, we talked in-depth about the 2004 NAIC Model Act, which was created as a way to ban discretionary clauses from health and long term disability insurance policies. As we noted, these clauses help insurance providers to deny claims to people that otherwise appear to be covered under the policy. More than half the states in our country have acknowledged the unfairness of discretionary clauses and enacted either a version of the NAIC Model Act or another ban to do away with them, but insurers still attempt to get around these bans.

Here are just a few arguments that you might end up having to fight against if your claim is denied and you fight the decision in court:

Ban took effect after policy was issued. Discretionary clause bans only take effect after the date they are signed into law, and they’re not retroactive. Because of this, insurers will often argue that the ban doesn’t apply to your policy because it was issued before the ban started. However, many states have gotten around this argument by including language stating that the ban applies for policies that are renewed after it takes effect. In short, even if you’ve had your policy for years, it can no longer have discretionary clauses when you renew it if the ban is in effect in your state.

Discretionary clause isn’t in policy – it’s in the plan. Insurance policies are individual, and bans modeled after the NAIC one say they can’t include discretionary clauses. However, these say nothing about insurance plans (such as those under ERISA) having similar clauses in their Summary Plan Documents. A good disability attorney, though, will know to argue that statements in the SPD aren’t necessarily part of the plan unless they are also included in governing plan documents.

Policy wasn’t issued in a state with a ban. Often, insurers will argue that their policy was “issued” or “delivered” in a state that doesn’t include a ban and therefore isn’t subject to one. This becomes problematic when the policy is issued to someone who lives in a state that does have a ban. The solution that states like California have come up with is basically to say “we side with the claimant” by including language in their law saying it doesn’t matter where the policy was created – California residents are covered.

More problematic for workers disability claims is the argument that ERISA preempts all state bans, but this is something that is still being played out in courts and bears watching. Stay up to date with all the latest news by following this blog, and learn as much as you can by reading our free disability policy eBook.

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