Disability & Medical Insurance

Lorraine Johnson, J.D., M.B.A. and Ray Stricker, M.D. recently published "The treatment of Lyme disease: a medicolegal assessment" in Ex. Rev. Anti-Infect. Ther. 2(4),533-557 (2004).  
The authors discuss: a) the medical basis for diagnostic and therapeutic uncertainty in Lyme disease, including variability in clinical presentation, shortcomings in laboratory testing procedures, and design defects in therapeutic trials and b) the issues regarding the legal standard of care that apply to treating physicians and insurers caused by underlying scientific uncertainty in Lyme disease diagnosis and treatment. The authors highlight the role of evidence based medicine, patient autonomy, patient preference and informed consent in Lyme disease. An announcement about the article and how to acquire a copy is posted on the CALDA intranet (  SIGN ON AS A GUEST.
Social Security:
Eligibility for Social Security and SSI Benefits Based on Lyme Disease
by Barbara R. Silverstone, Staff Attorney, National Organization of Social Security Claimants’ Representatives, August 2000 Reprinted from LDA’s Tiny Tick Tales newsletter 2000
Social Security Disability starter kits

If you suffer from a chronic condition such as Lyme disease that seriously limits your ability to work, you may find that your financial situation is deteriorating while you try to devote your energy towards your medical care and your health. If you are disabled and cannot work, you need more information about two disability benefits programs administered by the Social Security Administration (SSA).

If you have worked in jobs covered by Social Security, you may be eligible for Social Security disability benefits; Medicare coverage is available after two years of disability, and additional benefits may be paid to your immediate family members. Even if you haven’t worked outside the home, you may be eligible for Supplemental Security Income (SSI) disability benefits if your income and resources are very limited; Medicaid eligibility begins immediately for SSI recipients. Many people receive benefits under both programs.

Benefits are also available if you never married and your disability began prior to age 22, and continues until your parent is eligible for retirement or disability benefits, or until you are eligible for survivor’s benefits. These Social Security disability benefits are called Disabled Adult Child’s benefits and are intended to support a disabled individual whose parents are no longer able to do so.

Determining Eligibility

Social Security disability benefits are available to disabled workers who meet two conditions: (1) they are too disabled to work at any job, not just the jobs which they held in the past; and (2) through their employment, they have contributed enough FICA tax over the years to be covered. In general, workers who have worked at least five out of the ten years just before the disability began are covered; the rules are different for workers under age 30. Your wage history will determine your monthly benefit amount.

SSI benefits are available to disabled individuals whose income and resources are very limited. Generally, to be eligible for SSI benefits, an individual may have no more than $2,000 in resources ($3,000 for a couple) and income of under $512 per month ($769 for a couple). The income levels change each year. Income and resources from a spouse or the parents of a minor child are deemed to be available to the claimant. The value of a home and certain other assets are not included.

Claimants who are eligible for Social Security disability benefits but whose benefit amount is very low may also be eligible for SSI benefits.

Who is "Disabled"?

Eligibility for disability benefits depends on the limitations you have as a result of both physical and mental impairments. For example, in addition to the physical limitations imposed by Lyme disease, the pain and fatigue may cause mental strain or depression which can affect your ability to function in the work place.

SSA will evaluate you by first determining whether you have been, or expect to be, disabled for at least 12 months. If so, SSA will ask whether or not you are currently working. If you are not working, SSA will then compare your condition to its criteria in its "Listings of Impairments.” Although there is no specific Listing for Lyme disease there are several different listings under which you may be evaluated, and you may show that your symptoms are equivalent to one of the listed impairments. For example, you may experience the same joint pain and fatigue as that described in the listings for arthritis or lupus (listings §§ 1.02 and 14.02).

The listing for rheumatoid and other inflammatory arthritis, section 1.02, requires a medical showing of a history of persistent joint pain, swelling, and tenderness involving multiple major joints and signs of joint inflammation on current physical examination despite prescribed therapy for at least 3 months, resulting in significant restriction of function of the affected joints, and clinical activity expected to last at least 12 months. There are specific tests which SSA requires to corroborate the diagnosis of arthritis. Under Listing 14.02, for Lupus, SSA requires a showing of constitutional symptoms and signs (e.g., fever, fatigability, malaise, weight loss), multisystem involvement and, frequently, anemia, leukopenia, or thrombocytopenia in combination with severe loss of function in a single organ or body system, such as joints, muscles, or skin, or the ocular, respiratory, cardiovascular, digestive, or renal systems. SSA will also consider neurological or mental involvement.

It is important that you have been properly examined because SSA will rely on the results of medical tests to determine whether you can be found disabled at this step of the evaluation. If your condition, including consideration of your impairments in combination is equivalent to the criteria of these listed impairments, SSA will find that you are disabled. But meeting these criteria is not the only way to qualify for benefits.

SSA will continue to evaluate your claim by considering your vocational factors (age, educational background, and work history) along with your physical and mental residual functional capacities to decide whether you are disabled or whether there are jobs that you can do. Keep in mind that you can base your disability claim on a combination of several impairments that may not be disabling when considered separately, but when evaluated together show that you cannot work.

You can assist your claim by keeping a diary documenting your symptoms and how they affect your ability to function during a typical day, during both flare-ups and remissions. You can also provide the ALJ with medical information about this disease well in advance of the hearing, so the ALJ can be familiar with the debilitating nature of the disease.
Applying for Benefits

You can get the application forms for disability benefits from SSA by calling 1-800-772-1213. You can apply for Social Security and SSI benefits at any Social Security office. It is important to complete the form with as much information as possible. Give the full names and addresses of your doctors, and the dates of any hospitalizations. Make a list of the medications you are taking or other treatments you use and their side effects, and any medications and treatments you have tried but which no longer work for you. Describe your daily activities, and list those chores and activities that you can no longer perform or participate in. Tell your doctors that you are applying for disability benefits, and that they should expect to receive a request for more information from SSA.

The Application and Appeals Process

If your application is initially denied, there are several steps in the appeal process. Only about 30 percent of disability applications will be approved at the first step of the process. Many claimants who receive denials file appeals. Over half of the claimants who request a hearing before an Administrative Law Judge will receive favorable decisions awarding benefits. For those who are turned down again, the next steps of the appeals process are the SSA Appeals Council, and, if necessary, Federal Court. The amount of time and effort it takes to pursue an appeal is definitely daunting. Perseverance and persistence are crucially important.

How Long Will The Application Process Take?

It is not uncommon for a claimant to wait 6 – 12 months for a decision on an application for disability benefits. Claims which must be appealed administratively (to an Administrative Law Judge and the Appeals Council) or to Federal Court will take much longer. To give you some perspective on the program, consider that almost three million applications for disability benefits were filed last year. When a case is finally approved, benefits will be paid to cover the months during which you were waiting for a decision.
Once Approved, Can I Work and Continue to Receive Disability or SSI Benefits?

SSA has many work incentive programs which allow recipients to work for a limited amount of time, or under special circumstances, without losing their benefits. Recipients who are considering trying to work should contact SSA at 1-800-772-1213 or consult an attorney who is familiar with Social Security programs for specific guidance.

How Can I Get Help or Additional Information?

Additional information can be obtained from SSA by calling 1-800-772-1213. Most people apply for benefits on their own, but often want assistance in pursuing an appeal. If you need legal representation to assist you in obtaining Social Security disability or SSI benefits, contact your local legal services program or your local bar association referral office. Or, you can get a referral from the National Organization of Social Security Claimants’ Representatives by calling 1-800-431-2804.

Other Social Security Links
The following link may supply you with free information on how to get social security disability.  You may also find paid services on this link. All information on this social security information site is the opinion of the site.  The  LDA does not endorse or support this site but presents it for informational purposes only.

The following link may supply you with information social security disability. All information on the website is the opinion of the website. The LDA does not endorse or support this site but presents it for informational purposes only.