What is the Number One Reason People Are Denied SSDI Benefits?
For many individuals suffering from disabilities that prevent them from working, Social Security Disability Insurance (SSDI) benefits provide critical financial support. However, the process of applying for and receiving SSDI benefits is often more challenging and lengthy than many people anticipate.
While there are several reasons for SSDI denials, the number one reason people are denied benefits is insufficient medical evidence to prove that their disability meets the SSA’s criteria. Without compelling and thorough medical documentation, even the most legitimate disability claims can fail. Understanding why this happens—and how to avoid it—can make a significant difference in the success of a client’s SSDI application.
The Importance of Medical Evidence in SSDI Claims
When the SSA evaluates an SSDI claim, they are looking for evidence that the claimant’s disability is severe enough to prevent them from engaging in Substantial Gainful Activity (SGA). To make this determination, the SSA requires objective medical evidence that shows the claimant has a medically determinable disability that is expected to last at least one year or result in death.
If the SSA does not have sufficient medical records to support the claim, the applicant may be denied. Medical records are the cornerstone of any SSDI claim.
These records should be comprehensive,
up-to-date, and clearly show:
The cause and severity of the condition.
How the condition limits the person’s ability to perform work.
The expected duration of the disability.
Treatment history and the results of treatments tried so far.
How Insufficient Medical Evidence Leads to Denial
There are several ways in which the lack of solid medical evidence can lead to an SSDI denial:
Lack of Diagnoses or Incomplete Diagnoses
If a client has not been diagnosed with a specific medical condition, or if the diagnosis provided by their physician is vague, the SSA may have difficulty determining whether they qualify for benefits. To qualify, a client must have a detailed diagnosis and treatment history that is comprehensively documented by a qualified healthcare provider.
Inconsistent Medical Records
Gaps in treatment or incomplete medical records are another common cause for SSDI denial. If a claimant has not sought consistent care or has missed medical appointments, the SSA may question whether the condition is truly disabling. The more comprehensive and detailed the treatment history, the stronger the case for SSDI benefits.
Failure to Follow Treatment Plans
If a client has been prescribed a treatment plan or recommended therapy but has not followed it, the SSA may view this as a sign that the condition is not as severe as claimed. The SSA wants to see that claimants are taking steps to manage their condition, and failing to do so may raise doubts about the true severity of the disability.
The Role of Medical Experts in the SSDI Evaluation Process
The SSA may request a consultative examination (CE) if they feel that the claimant’s medical records are insufficient or unclear. The consultative examiner is a healthcare provider who will assess the claimant’s condition and provide a report to the SSA. This means that if the treating physician is not providing clear, detailed reports or fails to support the severity of the condition, it could negatively impact your client’s claim.
How Walker Firm PC, DBA Casa de la Justicia Handles Insufficient Medical Evidence
As specialists in SSDI, we make sure clients understand the importance of maintaining and obtaining thorough medical records. This includes seeing a doctor regularly, following prescribed treatment plans, and ensuring that all visits are documented with details about the diagnosis, symptoms, limitations, and the impact of the disability on their ability to work. We also help clients gather comprehensive documentation of their diagnoses, including test results, lab reports, and imaging studies (such as X-rays, MRIs, or blood work) that support their claims. In addition, since SSA is specifically concerned with the client’s ability to perform Substantial Gainful Activity (SGA), we ask medical providers to detail the functional limitations the client faces, such as an inability to stand or walk for extended periods, difficulty lifting, or cognitive impairments that prevent them from maintaining employment.
How Walker Firm PC, DBA Casa de la Justicia Handles Appeals
If a client is initially denied due to insufficient medical evidence, our experienced attorneys can review the denial and help the clients through the appeals process and help secure the necessary medical evidence to strengthen their case.
Conclusion: Focus on Medical Evidence for Success
The number one reason people are denied SSDI benefits is insufficient medical evidence to support their disability claims. As attorneys, helping our clients gather comprehensive medical documentation, encouraging ongoing treatment, and working with their healthcare providers to clearly outline their disability’s severity can make all the difference. By focusing on creating a strong, evidence-backed case, the likelihood of a successful claim is strengthened.
At Walker Firm PC, DBA Casa de la Justicia, we specialize in guiding clients through the complexities of the SSDI application process. If you need assistance helping your clients prepare their Initial Request or Appeal a Denial, we are here to help with no-out-of pocket-cost to clients. Just call us at 1 800 454 5454.
