December 18, 2018

My Brain Injury Claim was Denied. Why?

Because so many disability claims are filed each month, Social Security has developed a very structured claims evaluation process.  Unfortunately, every claim has to be run through this process – a claim for disability based on a broken pinkie finger is processed the same way as a claim involving a person with congestive heart failure who needs a heart transplant.

  • Social Security does attempt to identify the most obvious cases for quick approval as “compassionate allowances,” but these medical conditions usually involve terminal diseases or congenital (from birth) conditions that give rise to significant functional limitations.  See this blog post for more about compassionate allowances).  Currently “traumatic brain injury” is not included on the compassionate allowances list.

Another relatively fast track method to win disability based on traumatic brain injury is to demonstrate that you meet the listing at 11.18, or any of the other neurological conditions described at Listing 11. Social Security’s listings describe medical problems that are so inherently severe that SSA will assume overwhelming work performance limitations.

If you review Listing 11.18, for example, you will see that it requires evidence that you cannot balance when standing and walking for at least 3 months after your injury, or that you cannot communicate and understand for at least 3 months after your injury.

While you and your family may believe that you clearly meet the traumatic brain injury listing, that does not mean that the Social Security adjudicator will see things the same way.  In order to meet a listing, you will need one or more physicians (preferably a specialist who has seen you several times since your injury or accident) to either write a narrative report describing how you meet the listing, or to complete a “statement on the listing” showing that you meet each element contained in the language of the listing.

The adjudicator will also have to be convinced that your condition is permanent, or at least likely to impair you for months at a time.

Adjudicators and the medical advisers SSA uses at the administrative level often do not have the training or the time to review hundreds of pages of complex medical records and conclude that you do meet the listing.

Our experience has been that a fair number of traumatic brain injury cases that probably are at listing level end up being denied by the state agency adjudicator who decides to pass the file along.  When your case does get to an administrative law judge (2+ years later), enough time will have passed so that the judge can see how you are functioning – many of these cases are approved.

So what are the reasons that your eligibility for traumatic brain injry SSDI benefits may be denied at the initial application or at the reconsideration appeal? Here are the 5 most common reasons that this happens:

  • the evidence in your file does not convince the adjudicator that your TBI claim meets an SSA neurological system listing
  • your benefits application may conditions other than TBI and it is not obvious to the adjudicator that your neurological issues are your main problem
  • if you have filled a benefits application out prior to this one, some adjudicators will automatically deny your current application
  • if you have worked since the diagnosed onset of your condition, you could be denied
  • if the adjudicator who reviews SSDI cases has stacks of claimant files on his docket, he may just randomly deny several in order to save time

Although some or all of the above reasons may sound petty or unjustifiable, that is just the way the process works and you need to be prepared for the shock of receiving a denial when you can barely function because of your brain injury.

When you do get before a judge, your chances at approval will go up because Social Security judges usually have training, knowledge and common sense to approve a claim involving a significant brain injury.