The Social Security disability programs invoke individual property rights protected under the fifth amendment of the United States Constitution. As such, the application and appeals process are quite lengthy with the applicant, or “claimant” as the agency refers to an individual applicant, receiving many “due process” rights. There are multiple opportunities for notice of agency action and the claimant has a right to have their evidence heard and considered.
The disability application process begins with the individual filing a sworn application in which they allege their disabling medical conditions, the treatments they receive, and the physicians who treat them, their work history, and vital statistics information (citizenship, birth, marriages, children, divorces, and pre-deceased parents and spouses). As stated above, they are usually asked to swear to their Social Security earnings record as part of this process—whether they have reviewed the earnings record and whether it is accurate.
At the initial application stage, the agency has the burden of collecting the medical records directly from the applicant’s medical providers and making the disability assessment described above. Applicants are given the opportunity to also submit additional evidence to the agency including evidence regarding their work history, physical and mental functioning in their activities of daily living, and additional medical evidence or doctor’s opinions they have obtained from their treating providers. In Texas, if the applicant is denied, they can petition for a “request for reconsideration”. The agency then reviews for any changes in the reported medical condition, gathers any new medical evidence or reports, and completes another disability assessment. The chances of being approved at this reconsideration stage are statistically low (approximately only 11% of cases are approved at reconsideration, according to the national averages). Once the claimant is denied at reconsideration, they then have the right to petition for a hearing before an Administrative Law Judge (ALJ).
This hearing (prior to COVID-19 social distancing practices) is live and generally in-person with an ALJ, court reporter, vocational expert, and sometimes a medical expert. The federal rules of evidence and procedure do not apply to these hearings as these are informal agency adjudications subject only to Social Security’s published procedural manuals. Also, the ALJ is not limited by the prior determinations of the agency and has the authority to decide the case/make a disability determination de novo.
After the ALJ decision is issued, the claimant-applicant has the right to ask for review of any part of the ALJ decision and can do so by requesting review of the ALJ decision by the agency’s “Appeals Council” (AC). The AC has full authority to review all parts of an ALJ decision including any favorable part and can review and remand even favorable determinations. The AC reviews ALJ decisions mostly based on a “substantial evidence” standard of review—this looks at whether the record contained “substantial evidence” to support the ALJ’s decision. The substantial evidence review is generally favorable/deferential to the agency’s action under current U.S. Supreme Court precedent. If the ALJ committed an error of law, however, the AC will remand the case back to the ALJ for review. Appeals Council action to decline review of the ALJ decision is considered final agency action for purposes of standing to appeal to federal court.
If the claimant does not seek any further review of the ALJ decision, or further review is denied and no federal lawsuit is filed, then the ALJ decision is final and determinative through the date of the ALJ decision, as to any alleged disabilities in the application. In other words, res judicata applies to any subsequent claim or application for disability that includes the same disability allegation for a time period already adjudicated through the date of the ALJ’s decision.
Agency decisions become final after 60 days. That’s because at every appeal level, the applicant has only 60 days to perfect their appeal. Fortunately, appeals can be processed online through the agency’s website.
