Disability benefits are designed to provide crucial financial support to individuals who are unable to work due to a medically determinable physical or mental impairment. These impairments must be severe enough to significantly limit the person’s ability to perform substantial gainful activity, meaning they cannot maintain employment or earn sufficient income. The purpose of these benefits is to help cover living expenses and medical costs when an individual’s condition prevents them from supporting themselves through work. Qualification requires thorough medical documentation and often involves a detailed review process to ensure the impairment meets specific legal and medical criteria.
The specific afflictions and conditions that qualify for disability benefits can vary depending on the country and the governing agency; however, most systems, such as the U.S. Social Security Administration (SSA), have established guidelines to determine eligibility based on the severity and impact of the condition.
General Criteria for Disability Qualification
To qualify for disability benefits, an individual must have a condition that significantly limits their ability to perform the basic work activities required for their occupation. This impairment must be expected to last at least 12 months or result in death. Temporary or minor conditions typically do not qualify for coverage. The evaluation usually involves medical evidence, including clinical findings, laboratory results, and documented treatment history.
Common Physical Conditions That Qualify
Musculoskeletal Disorders: Severe arthritis, back injuries, spinal cord injuries, and other disorders affecting joints, bones, muscles, or ligaments that limit movement or cause chronic pain can qualify. For example, herniated discs, spinal stenosis, or severe osteoporosis are often recognized.
Cardiovascular Diseases: Conditions such as congestive heart failure, coronary artery disease, and chronic heart arrhythmias that impair the heart’s ability to function correctly and limit physical activity may qualify.
Respiratory Disorders: Chronic obstructive pulmonary disease (COPD), asthma, cystic fibrosis, and other lung diseases that reduce oxygen intake and cause breathing difficulties can be disabling.
Neurological Disorders: Epilepsy, multiple sclerosis, Parkinson’s disease, cerebral palsy, and stroke-related impairments are common neurological conditions recognized for disability benefits. In cases where families need legal guidance on navigating claims, a cerebral palsy attorney can provide support and help ensure access to the benefits they deserve.
Cancer: Active cancer or residual effects of cancer treatment that limit the ability to work can qualify. This includes cancers in remission if there are lasting impairments.
Diabetes: When diabetes causes complications such as neuropathy, vision loss, or kidney failure, it may qualify as disabling.
Blindness or Vision Loss: Complete or near-complete vision loss that cannot be corrected with glasses or surgery is recognized as a disability.
Hearing Loss: Severe hearing impairment that affects communication and work capability may qualify.
Common Mental Health Conditions That Qualify
Depression and Anxiety Disorders: Severe cases that impair concentration, memory, or social functioning can qualify, especially if they are treatment-resistant.
Bipolar Disorder: Manic and depressive episodes that disrupt daily functioning and work capacity are recognized.
Schizophrenia and Other Psychotic Disorders: These conditions often cause significant impairment in thinking, perception, and social interaction.
Post-Traumatic Stress Disorder (PTSD): When PTSD symptoms are severe and persistent, they can qualify for disability.
Autism Spectrum Disorders and Intellectual Disabilities: When these impairments limit adaptive functioning and employment capability.
Other Conditions
Chronic Fatigue Syndrome (CFS) and Fibromyalgia: These conditions are recognized if symptoms are well-documented and cause significant limitations.
Autoimmune Diseases: Lupus, rheumatoid arthritis, and other autoimmune disorders with systemic effects may qualify.
Kidney Failure: End-stage renal disease requiring dialysis or transplantation.
Liver Disease: Advanced cirrhosis or other severe liver impairments.
HIV/AIDS: When the disease or its complications severely limit functioning.
The key factor in qualifying for disability benefits is the extent to which a medical condition limits an individual's ability to perform substantial gainful activity. Documentation from healthcare providers, including test results, treatment records, and descriptions of functional limitations, is essential. Each case is evaluated on its own merits, and the presence of a qualifying condition does not guarantee benefits unless the severity and impact meet the established criteria.
Why Is My Disability Being Denied?
Disability claims can be denied for various reasons, often related to how the application aligns with the specific criteria set by the reviewing agency, such as the Social Security Administration (SSA) in the United States. Understanding common reasons for denial can help applicants better prepare their cases and improve their chances of approval upon reconsideration or appeal.
1. Insufficient Medical Evidence
One of the most common reasons for denial is a lack of adequate medical documentation to prove the severity of the disability. Disability programs require objective medical evidence—such as clinical tests, imaging studies, doctor’s notes, and treatment records—that clearly demonstrates the impairment and how it limits the applicant’s ability to work. Simply having a diagnosis is not enough; the evidence must show that the condition meets or equals the agency’s criteria for disability.
2. Condition Not Severe Enough
Even if an applicant has a diagnosed condition, the reviewing agency may determine that it is not severe enough to prevent all substantial gainful activity (SGA). For example, some conditions may cause discomfort or occasional limitations, but do not significantly impair the individual’s ability to perform basic work tasks. If the disability examiner concludes the applicant can still work despite the condition, the claim will be denied.
3. Failure to Follow Prescribed Treatment
Disability programs expect applicants to follow prescribed treatments unless there is a valid reason not to do so. If an applicant refuses treatment or does not comply with medical advice without justification, the claim may be denied on the grounds that the condition could improve if properly managed.
4. Non-Medical Issues
Denials can also arise from non-medical factors, such as failing to provide requested documentation, incomplete or inaccurate application forms, or missing deadlines. Administrative errors or a lack of cooperation with the claims process can delay or prevent approval of the claim.
5. Work Activity or Income Above Threshold
If the applicant is earning income above a specific limit or engaging in work activity considered substantial, the agency may conclude that they are not disabled. Even part-time work or sporadic employment can affect eligibility.
6. Mental Health or Subjective Symptoms Not Adequately Documented
Mental health conditions and symptoms, such as pain or fatigue, are often subjective and can be harder to measure objectively. If these symptoms are not well-documented with psychological evaluations or consistent medical records, the claim may be denied.
Contact a Lawyer to Help
Disability denials often stem from insufficient or unclear evidence, the severity of the condition not meeting required standards, or procedural issues. Applicants are encouraged to gather thorough medical documentation, follow prescribed treatments, accurately complete applications, and seek professional assistance if needed to strengthen their case. Yet, this is often difficult to do alone, especially for someone who is struggling with a disability. Appeals are common and can lead to eventual approval if the applicant addresses the reasons for denial.
A Los Angeles social security lawyer can significantly improve your chances of getting disability benefits approved by guiding you through the complex application process, ensuring all necessary medical evidence is documented correctly, and helping you meet strict eligibility criteria. They can also represent you during appeals if your claim is initially denied, advocating on your behalf to address any issues or gaps in your case. Their expertise increases the likelihood of a successful outcome.