Your Adult Social Security
Disability or SSI Claim:
The First 15 Minutes (continued)
Diagnosis : Taking a look at the diagnoses that a claimant alleges is
extremely important because there are several diagnoses that will result in a claimant “meeting a listing”. This
means that that particular diagnosis is listed as a condition in the Disability “bible” which will result in an
automatic approval or allowance of benefits, when the diagnosis is confirmed by an acceptable medical
As an example, if
a person is receiving regular weekly or biweekly kidney dialysis, all it will take to get a claims allowance is
a form (usually faxed) from the facility providing the treatment. When a condition meets a listing contained in
the Disability Evaluation under Social Security book, this becomes a claim the examiner can allow and dispose of
in less than a week.
If such a
diagnoses is for a Supplemental Security Income claim, the claimant may also be eligible for immediate benefits
payable under the Presumptive Disability provision of SS disability law. This will allow the immediate
presumptive approval of a claim for payment even before all medical evidence needed to adjudicate the claim has
Disability allowances, a claimant may receive a disability check for up to six months while the examiner gains
medical evidence supporting the claim.
The diagnoses also
tell whether the claimant is alleging just a physical disability or a physical/mental combined disability. As
mentioned previously, when combination impairments are alleged, extra processing forms and collateral contact
information must be obtained in order to further document the extent of the impairments.
The other thing
the diagnoses/allegations section of the application will tell is whether the condition can be expected to
resolve in a year or less.
For example, an
individual may have a broken arm or a broken leg and be seeking temporary benefits until the fracture is healed.
In these instances, unless a non-union of the fracture is subsequently documented by the medical evidence, these
cases will be denied because they are not expected to be disabling for at least one year. And it becomes a
matter of an examiner just waiting for the medical evidence to come in prior to issuing a decision.
conditions that are expected to resolve within one year are easy cases to adjudicate, and are generally put to
the back burner while awaiting medical evidence in favor of working on cases that have more of a chance of being
Claims applications are checked for dates of last medical treatment. If a claimant has not seen a doctor in the
past 3 months and there is no pending appointment listed on the application, this indicates that a “consultative
evaluation” exam, alias a CE, may need to be scheduled for the claimant. This is when Social Security pays a
private contracting physician or psychologist to examine the claimant and document the severity of a any
At this point, a
telephone call may then be made to the claimant to verify that there is no pending appointment with a treating
physician and/or that there are no current medical records that were not listed on the application. If no
current medical documents can be obtained from a treating source, the CE appointment will be scheduled at the
earliest possible date.
[Next: Next Steps in Processing the Claim]