December, 2015: Stanley’s Case: How An Understanding of Social Security’s Rules Can Result in a Fully Favorable Decision before Hearing

Without the benefit of an experienced lawyer, many Social Security disability claimants fail to realize what needs to be proven in order to succeed with their claim. Stanley’s circumstances make evident that a detailed understanding of the Social Security regulations and rules is essential to knowing what evidence needs to be obtained in order to prevail in one’s disability claim.

Stanley is a forty-eight (48) year old gentleman with a high school education and a strong past work history that includes working as an operations manager in a supply center, which job required him to be on his feet for most of the day (and likewise required a good amount of lifting). Unfortunately, Stanley suffered significant injuries as a result of a motorcycle accident that caused significant damage to one of his legs (requiring reconstructive surgery). Stanley was one of the fortunate few that had the benefit of both short and long term disability plans through his employer that allowed him to collect an ongoing check following the accident. As one of the requirements in his long-term disability plan, Stanley is required to put in an application for Social Security disability benefits. The policy provides, as the vast majority of such long term disability (LTD) policies do, that the LTD insurance carrier gets to reduce the amount that they pay out by the amount of any Social Security disability benefits received in any particular month. The policy standard for paying out is likewise more generous during the initial two years of the policy, providing that Stanley would get a benefit as long as he remained incapable of performing the usual and customary duties of his ordinary occupation. Thus, while we were pursuing Stanley’s Social Security disability application in New Hampshire, whereby we would need to show he has remained or is likely to remain totally disabled from all forms of gainful employment, he could continue to collect a check under the terms of the LTD policy as long as he in essence remained incapable of returning to his former occupation.

Thus, while Stanley was clearly incapable of returning to his former employment which required him to be on his feet for lengths of time, the more difficult prospect was making it evident to the Social Security Administration that he was not capable of performing a sit down (or what is called a sedentary) position. In speaking with Stanley, what became clear about his days is that it was difficult for him to be able to sit at a desk setting, upright, with his feet on the ground, for lengths of time He would have to extend his leg out and lean backwards to take the pressure off from his leg. Likewise, he found that he needed to sit with his legs elevated for periods of time (recline) for the same reasons. Thus, while at first glance it appeared that Stanley was going to be a prime candidate for a sit down position, the above difficulties would make it rather impossible for him to stay seated at a work station, comfortably, for up to 2 hours at a time. Likewise, upon being questioned further, it became clear that Stanley likewise had difficulty getting up from a seated position, which could be required of him at most sit down positions for up to one-third of the day. Just as important was the fact that Stanley was not only going to have difficulty standing and/or walking for up to one-third of the day, but also going to have difficulty getting up and down from a seated position (such as if he had to go to another work station or to a counter to assist a customer).

Some of these very subtle issues such as the distinction between sitting and reclining, and the difficulties of being able to get up from a seated position for up to one-third of the day, made a significant difference in terms of how Stanley’s claim would be evaluated by the SSA based on their rules and regulations. Ultimately, by pursuing these types of arguments by way of a pre-hearing brief presented to the presiding Administrative Law Judge at the Lawrence, Massachusetts Office of Disability Adjudication and Review, and by citing the appropriate rules regulations at issue, it served (as part of other argument made on Stanley’s behalf) to provide him with a fully favorable decision in his case.

By obtaining a favorable decision in his claim, it served to provide a significant offset for the LTD carrier thereby allowing them to pay significantly less money on a monthly basis as now the Federal Government was going to be providing a significant benefit which could be deducted under the coordination of benefits provision of the LTD policy. This made it much less likely that the LTD carrier would consider trying to discontinue the monthly check they were paying Stanley: especially where SSA had determined Stanley to be totally disabled from all forms of gainful employment (which likewise sent a message to the LTD carrier that if SSA had found him totally disabled from working, isn’t that something we should be determining as well: if not, why not).

Stanley was quite happy to see at the end of all of this that he was now more secure in the monthly checks he would be receiving, that he would be obtaining Medicare insurance as part of winning his Social Security disability claim. To top it all off, this was able to be accomplished without the need to go to hearing.