Although individuals who become disabled in New Mexico and are unable to work may be entitled to disability benefits, the majority of claims are denied. In fact, about two-thirds of initial claims are denied; however, having the assistance of a knowledgeable disability benefits attorney increases the likelihood of obtaining benefits. Meanwhile, this article is a brief overview of the eligibility requirements for disability benefits and the reasons why so many claims are denied.

Eligibility for Disability Benefits

In order to qualify for benefits under the Social Security Disability Insurance program, applicants must have an injury or illness that prevents them from performing their job duties or any other type of work. The Social Security Administration refers to this as substantial gainful activity. This does not mean that an applicant cannot work at all, but rather that he or she cannot earn more than a certain amount each month.

Additionally, the SSA maintains a list of qualifying medical conditions known as the Blue Book, and considers certain factors when making a disability benefits determination. The first is that the impairment must have lasted, or be expected to last at least one year or result in death. It is also necessary to have paid into the Social Security system through income tax withholdings and acquiring the necessary amount of work credits.

Although the number of work credits is determined by the applicant’s age, and more credits are needed as an applicant grows older, it is necessary to have worked at least 5 of the 10 years preceding the illness of injury.

Disability Benefit Denials

It is worth noting that only about 30 percent of initials disability benefit claims are approved. One of the leading reasons of claim denials is that the applicant did not acquire sufficient work credits. However, claims can be denied for many other reasons.

First, the application must be completed accurately and honestly, and must contain all the required information. This includes medical records from a treating physician, notes of treatment and the prognosis for recovery. If there are any mistakes or omissions, the claim will likely be denied.

Moreover, the SSA may require an applicant to undergo an examination by an independent physician. If this exam does not concur with the conclusions of the treating physician, the claim may be denied. Similarly, the SSA may determine that the impairment is not included in the Blue Book. In this situation, the condition must be medically equal to a listed impairment.

Finally, the applicant must actually be disabled when submitting a benefits claim, and cannot undertake any physical activity. It is also necessary to follow a doctor’s orders for prescribed medical treatments and rehabilitative care. Failing to do so will also likely result in a claim denial.

The Takeaway

If the SSA denies a benefit claim, there is an appeals process, which starts with a Request for Reconsideration. However, it is important to act quickly by submitting the request within 60 days of receiving a notice of denial from the SSA. At the same time, navigating the appeals process is complicated, which makes having an experienced disability benefits attorney invaluable.