Teacher Finally Receives SSD Benefits

I was retained after a federal court remanded this case to ALJ Iris Rothman. The claimant’s prior attorney was ambivalent about representing the claimant because ALJ Rothman inexplicably refused to review the case objectively. Sure enough, ALJ Rothman denied the claim a second time despite overwhelming medical and vocational evidence.

Rather than the usual terse one or two page or two decision, the Appeals Council (the “AC”) remanded this claim a second time in a detailed five page remand order. The AC not only made it clear that ALJ Rothman’s second decision was utterly devoid of any merit, but strongly and repeatedly indicated that the claim met at least one of three listed impairments. If a listing is met, then the claimant is deemed disabled without any further evaluation.

The new ALJ assigned to the case issued a fully favorable decision on the grounds that the claimant’s macular degeneration equaled listing 2.04 as of her February 1, 2005 onset date. If you believe the denial of your SSD benefits was wrong seek a second legal opinion. While the legal process for reversing an erroneous benefits decision may take some time, SSD benefits should be approved as long as there is supporting medical and vocational evidence.

SSA Consultative Examiners

The reason that Administrative Law Judges give the vast majority of the time to deny applications for Social Security Disability (“SSD”) benefits is that the opinions of the state agency consultative examiners (“CEs”) show the claimant can work. Once again, a federal district court has ruled that it was improper for an ALJ to do so.

I was retained to appeal an SSD case to the Eastern District of New York, which was assigned to Judge Nicholas Garaufis. My primary argument was that the ALJ gave more weight to the opinions of the CEs than to the claimant’s treating doctors, and in doing so, failed to apply the treating physician rule properly. In the New York metro area, CEs are usually performed by Industrial Medicine Associates.

The claimant’s treating doctor provided a detailed residual functional capacity (“RFC”) assessment demonstrating the claimant lacked the ability to perform the physical demands of sedentary work. However, the ALJ interpreted the CEs’ vague conclusions as providing for a sedentary RFC, and relied on those opinions to deny the claimant’s SSD application. Judge Garaufis ruled that:

"As Plaintiff correctly notes, the ALJ cannot rely on those RFCs as evidence contradicting the Treating Physician RFC. This is because an inconsistency with a consultative examiner is not sufficient, on its own, to reject the opinion of the treating physician."

It seems that most ALJ SSD denials are based upon the opinions of the CEs, and most of the time the ALJ provides little or no reason for elevating the CEs’ opinion over that of the treating physician. Whether appealing to the Appeals Council or federal court, it is essential to point out the absence of a legitimate or logical basis for the ALJ’s rejecting the treating physician’s opinion.

Child’s Benefits

If you succeed in winning Social Security Disability (“SSD”) benefits, then you may also be entitled to receive additional benefits for your children under 18 years of age. The child’s benefit is usually about half of the SSD benefit. You cannot rely on the Social Security Administration (the “SSA”) to take steps to help you secure the child’s benefits.

I represent a 53 year old press operator whose SSD application was approved after 4 months. The SSA did not notify him about his right to child’s benefits. The claimant did not think he was entitled to child benefits because his son had already graduated from high school. However, the claimant’s SSD benefit onset date was several months before the son graduated. As a result, the claimant will be entitled to receive several additional thousand dollars worth of benefits.

When applying for SSD benefits, always disclose the identities of dependents. The disclosure provides a protective filing date for child’s benefits.

UPS

Aetna administers the United Parcel Service (UPS) long term disability (“LTD”) plan. Fortunately, UPS maintains the right to reverse Aetna’s decisions.

A UPS package supervisor retained me after Aetna terminated his LTD benefits on the grounds that he could do sedentary work based upon an functional capacity examination (“FCE”). In my 74 page appeal to Aetna, which included 46 pages of new medical records, I explained how the FCE actually showed that the claimant could not do sedentary work. Aetna denied the appeal based upon a peer review that rejected the FCE, and conclusorily stated that there was no clinical support showing the claimant was unable to do sedentary work.

Aetna’s final decision was hypocritical. Aetna relied upon the FCE to terminate LTD benefits, but Aetna refused to allow the claimant to rely upon the FCE after admitting that it showed the claimant could not do sedentary work. In other words, Aetna accepts evidence when it thinks the evidence will support its decision, but rejects the identical evidence when it thinks the evidence will not support its decision.

As for the peer review, Aetna provided absolutely no reason why it accepted the opinion of the peer review doctor it paid to review the claimant’s medical records, over the opinions of the claimant’s treating orthopedist, pain management specialist, internist, rheumatologist, physiatrist, and physical therapist, each of whom explained why the claimant could not do sedentary work. I pointed out these and other critical flaws to UPS, which reversed Aetna’s decision.

The claimant went without LTD benefits for nearly a year because of Aetna’s actions. To compound matters, the claimant’s other benefits, such as medical insurance, were terminated when the LTD benefits were terminated. The claimant had to spend thousands of dollars for medical testing, reports, and attorney’s fees to get his benefits reinstated. If UPS employees have any influence at work they should consider persuading management to replace Aetna.