Social Security disability benefits are often the ultimate safety net for persons suffering from medical impairments that make it impossible for them to work. For most people, however, struggling through the Social Security Administration’s bureaucracy is frustrating, confusing and slow. For people suffering with Lupus, the requirements of the Act can appear overwhelming. This article briefly explains the essence of the Social Security Disability program and how it applies in claims related to Lupus.
General Description of the Law
The Social Security disability program is designed to pay monthly benefits to people suffering from medical problems causing symptoms so severe that it becomes impossible to function at any type of work. Issues of employability, insurability and location or desirability of alternative work will not be considered, although age and education are often important factors. This is a medical program that focuses upon medically proven symptoms and their impact on the ability to perform work activities.
Therefore, the focus in on function, not on diagnosis; SSA often admits that claimants have medical problems and are “impaired,” however, it denies that they are “totally disabled.” The debate is over what the claimant can “do” despite the medical problems.
The determination of disability focuses on “proof” of both the medical problem and the severity of the symptoms. The difficulty in claims based upon Lupus is in proving the severity of the symptoms – particularly the fatigue that is often the most disabling feature.
What is proof?
The Act and Regulations require an analysis of medical records such as doctors’ office notes, physician reports and medical test results. The written statements of the Claimant, and the testimony of the Claimant at a hearing, are generally given little weight if not supported by the medical evidence. It is important that a Claimant seeking this assistance actively treats with appropriate medical specialists and involves those doctors in the application process.
It is difficult to have a claim approved if the treating doctors report that the Claimant retains the ability to work.
The Medical Standards
Essentially there are two ways to prove disability in Social Security claims. The first requires medical proof that meets certain medical standards contained in Social Security’s Regulations. If the medical proof meets or equals the appropriate standard the Claimant may be presumed disabled and benefits awarded, as long as the non-disability requirements of the law are also met.
The second is used in claims where the medical standards are not met, but the proof establishes that there are not a significant number of jobs the Claimant can perform considering the remaining functional abilities, age, education and work experience.
A. Meeting or Equaling the Listings of Impairments.
The medical standards are known as the “Listings of Impairments.” The standards in the Listings cover many different body systems and illnesses, including Systemic Lupus Erythematososus hereinafter “SLE”).
The Listing for SLE is found at Section 14.02 of the Listings of Impairments. First the Listing discusses proof of the existence of the disease. Second, the Listing contains two different mechanisms for proving the impact of the disease and its symptoms on function.
To establish the diagnosis the Listing notes that the medical evidence will generally show that the patients fulfill the 1982 Revised Criteria for the Classification of Systemic Lupus Erythematosus of the American College of Rheumatology. SSA will review the clinical notes, test results and other medical evidence for proof of the diagnosis of SLE. The Listing acknowledges the various “constitutional symptoms and signs” such as fever, fatigability, malaise and weight loss.” It notes that there is often involvement of several body systems and frequently findings of anemia, leukopenia or thromobocytopenia.
Once the diagnosis is satisfied, the Listing then turns to the impact the disease has on function. There are two ways to meet this issue in the Listing. The first is to demonstrate significant involvement of a major body system. The Listing, unfortunately, is unclear as to the degree of limitation in the secondary system. The second means of proving functional impairment is in subsection (B) which requires lesser involvement of two body systems, along with evidence of significant constitutional symptoms such as severe fatigue, fever, malaise and weight loss.
14.02 Systemic lupus erythematosus. Documented as described in 14.00B1, with:
A. One of the following:
1. Joint involvement, as described under the criteria in 1.00; or
2. Muscle involvement, as described under the criteria in 14.05; or
3. Ocular involvement, as described under the criteria in 2.00ff; or
4. Respiratory involvement, as described under the criteria in 3.00ff; or
5. Cardiovascular involvement, as described under the criteria in 4.00ff or 14.04D; or
6. Digestive involvement, as described under the criteria in 5.00ff; or
7. Renal involvement, as described under the criteria in 6.00ff; or
8. Skin involvement, as described under the criteria in 8.00ff; or
9. Neurological involvement, as described under the criteria in 11.00ff; or
10. Mental involvement, as described under the criteria in 12.00ff.
B. Lesser involvement of two or more organs/body systems listed in paragraph A, with significant, documented, constitutional symptoms and signs of severe fatigue, fever, malaise, and weight loss. At least one of the organs/body systems must be involved to at least a moderate level of severity.
The Listings are intended to be a difficult standard that will not be met by many claims. However, if a Claimant can meet these requirements, benefits will be awarded as long as the other requirements of the program are met. A Claimant with SLE should provide a copy of this Listing to the treating physician to obtain a medical opinion as to whether this standard has been satisfied.
B. Residual Functional Capacity is reduced to extent that no work activity could be performed.
The alternative means of proving a claim for Social Security Disability benefits is to provide medical proof of symptoms from the impairment which are so severe that the person could not function at any type of work. The focus is upon the medical proof as it relates to the ability to perform work activities. The difficulty, however, is in proving the both the symptoms and their severity.
For SLE it is fatigue which most often persuades Social Security Administrative Law Judges to award this assistance. It is critical that patients fully describe this problem, if it exists, every time they visit the doctor’s office. Social Security will obtain and review all of the medical records and search for consistent complaints of severe fatigue. One of the most common problems is the failure of the patient to fully discuss symptoms with the physician creating a lack of evidence relating to severe fatigue in the doctors’ notes.
This article has not attempted to review the application process or any of the applicable Rulings and related caselaw. Nor is this article intended to provide specific legal advice or to create an attorney-client relationship. Hopefully, however, this brief analysis will provide some insight into the disability system and assist Claimants in obtaining this assistance.