In 1965, Medicaid was created to provide health insurance to low-income and asset-poor individuals. The state…
Before spending time and energy on the application process for Supplemental Security Income (SSI) or Social Security Disability Income (SSDI), review some of the major disqualifiers. Eligible individuals can benefit from both programs though they have distinct differences. The major difference is SSI eligibility qualification relies on age, disability, and limited resources and income, while SSDI eligibility determination relies on disability and work credits. In most states, SSI recipients automatically qualify for Medicaid health care coverage, which could result in additional supplementary benefits through your state’s Medicaid program. However, both programs have some common reasons that can disqualify your claim.
Typically, most people think about the reasons they should receive benefits without ever considering why they may be denied. Some of the reasons are beyond your control, while other reasons are missteps you can avoid that result in denial. Things to consider include:
Your Income Earnings are Too High
In the case of SSI, the disability benefit for low-income individuals, you cannot exceed the substantial gainful activity (SGA) threshold. However, it is permissible to earn more money after your approval. Still, there is a limit of about $1,767 a month for a single person and $2,607 a month for couple on all earned and unearned income for SSI in 2022. A maximum Federal payment of $841 per single person and $1,261 per couple may be paid monthly (with a supplement from New York State’s Office of Temporary and Disability Assistance (OTDA)). This dollar amount applies to both application for and collection of benefits. Any time your monthly income exceeds a certain threshold, your SSI payment will receive a reduction based on a complex formula.
When you apply for SSDI (the benefits program for workers who paid into the Social Security tax base over multiple years), your claim may be denied if you work above the threshold considered substantial gainful activity. Going over this amount means you earn too much money to be considered disabled. It is permissible to earn a small amount during your application and collecting of SSDI but not over the SGA limit. This limit (for non-blind individuals) was $1,310 per month in 2021, and the figure is adjusted annually. It is worth noting income from investments does not count toward the SGA; only work income determines your ability to work.
Your Disability is Not Considered Severe or Won’t Last Long Enough
Qualification for both SSI and SSDI benefits means the Social Security Administration (SSA) must believe your impairment is severe enough to continue for at least 12 months or result in your death. Blind SSI applicants are the only exception to the duration requirement.
Many claims based on bone fractures resulting from acute trauma from accidents are commonly denied since the disability is unlikely to last 12 months. Nearly all bone fractures heal in under a year. If your bone fractures are severe enough and have not healed after six months, you may resubmit your claim as the SSA will likely believe your impairment will last a year. Each case receives an individual evaluation.
If your medical condition is not trauma-related, it must still cause severe limitations of disability to qualify for SSI or SSDI. Most denied claims are due to the applicant’s impairment not being severe enough. You can learn about the disability determination for benefit claims here.
The Social Security Administration Can’t Reach You
Both the SSA and Disability Determination Services (DDS) agencies need to be able to communicate with you regarding your application. If they cannot reach you, schedule examinations, appointments, or communicate about critical matters, you will likely be denied benefits. Every day claimants are denied because the SSA cannot locate them. If you opt to name a representative (such as a disability lawyer) to handle your application, you may not have to contact the SSA. However, you most certainly must maintain contact with your disability attorney.
Your Refusal to Cooperate
The SSA requires medical information about your impairment, and if you refuse to release these records, your claim of disability will likely be denied. If you provide medical records, but the SSA deems them incomplete, or you lack a regular doctor for treatment, they will schedule a consultative examination (CE) with an SSA doctor. Refusal to accept this exam(s) and requesting a determination of eligibility be based on existing medical records may be cause for denial due to inadequate medical data or failure to comply with a CE. Your attorney also helps you gather the correct medical information according to the requirements.
Your Failure to Follow Prescribed Therapy
If you receive medical treatment, failure to adhere to the doctor’s prescribed therapy when you are able to may cause a denial of disability benefits. Some acceptable medical excuses include:
- The severity of your mental illness precludes your ability to comply with the prescribed therapy.
- You elicit intense fears regarding surgery, making the procedure inappropriate. Your treating doctor will confirm the severity of your fears to the consulting DDS doctor.
- You are physically unable to follow the prescribed therapy without assistance due to paralysis, cataracts, or other physical limitation.
Some acceptable non-medical excuses include:
- You lack the money to pay for the treatment.
- You have religious beliefs that prohibit receiving the proposed medical therapy.
- Your doctor prescribes a treatment with which a second opinion doctor disagrees.
- The proposed therapy will not result in the restoration of your ability to do substantial gainful activity.
Your attorney can review the details of your situation to see if any exclusions apply and collect the necessary documentation.
Your Disability is a Result of a Drug Addiction or Alcoholism (DAA)
If a contributing factor to your disability is DAA, the SSA will deny your claim for benefits. The DDS medical consultant will determine whether you would still be disabled if you ceased using drugs or alcohol. You can read more about DAA determining factors here.
You have a Criminal Conviction
Certain conditions relating to criminal conviction or imprisonment will prevent approval of SSDI.
- You are in prison after your felony conviction without a court-approved rehabilitation program likely to result in employment upon release. That release expectation is within a reasonable amount of time.
- You received an injury while committing a felony and are convicted of the crime. The resulting impairment, or worsening of an existing one, suffered during a felony crime is ineligible to use as a basis for disability benefits.
- You became injured while in prison. The resulting impairment, or worsening of an existing one, suffered while incarcerated can’t be used to get benefits. However, you can likely receive benefits after your prison release.
If these conditions apply to your situation, it is still worth the effort to apply for SSDI benefits. Although you will not receive cash benefits, you may still be granted a benefit-free disability period that freezes your earnings record, preventing the decrease of eventual disability, retirement, or dependents benefits. Talk to a disability attorney if your claim is complicated by these circumstances.
The above conditions do not prevent your receiving SSI disability benefits, although you will be unable to collect them while incarcerated.
You Commit Fraud
Always apply for disability benefits honestly. If you receive them by dishonest means, the SSA may terminate your benefits and choose to prosecute you for fraud. Benefits obtained through fraudulent methods by your representative or someone working for the SSA also may cause the termination of your benefits.
These common reasons stop you from legally obtaining SSI and SSDI benefits. Before you become too involved in applying, be certain you meet the minimum standards for approval. A disability lawyer can help you sort out any issues, avoid missteps, and properly present your case for disability approval.
For assistance, please contact our office at (212) 920-6371.