Disability benefits for a chronic medical condition or a chronic condition that has become worse?

Social security disability benefits are available for a chronic medical condition.  While there are several requirements for social security disability insurance benefits, your medical condition must indeed be a chronic condition that, despite ongoing medical treatment, keeps you from performing work-related activities.   The “chronic” nature of your condition or conditions is, in fact, key to winning your disability case.

12-month duration requirement

Social security law requires that your inability to work due to a physical or mental condition has either lasted, or is expected to last, at least 12 months.  There is, however, an exception to this 12 month requirement for conditions that are expected to end in death.  

This so-called “duration” requirement means that your disabling conditions have to be chronic.  Only a long-standing condition that does not respond, or merely partially responds, to medical treatment – i.e., a chronic condition – can last or be expected to last at least 12 months.

Chronic condition v acute condition

Medical professionals often speak of a condition being either “chronic” or “acute” in nature, and this distinction is important in understanding what medical conditions can qualify for social security disability.  Wikipedia defines an “acute” illness as follows:

“In medicine, describing a disease as acute denotes that it is of short duration and, as a corollary of that, of recent onset. The quantification of how much time constitutes “short” and “recent” varies by disease and by context.”

Wikipedia defines a “chronic” illness was follows:

“A chronic condition is a human health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months.”

The chronic/acute disease distinction has nothing to do with how serious the illness is.   Claimant’s are often understandably surprised when their acute and life threatening condition does not qualify for disability benefits due to the 12-month duration requirement.  Here some examples that may clarify the issue:

 

ILLNESS/SITUATION	TREATMENT UNDER SOCIAL SECURITY DISABILITY LAW
John collapses at work and is rushed to the hospital where he is diagnosed to be in congestive heart failure with a heart ejection fraction of less than 30%.  He has no history of heart disease.	If John’s ejection fracture does not improve by much more than 30% over a 12-month period, he will probably earn disability benefits.  However, since he has no history of heart disease and, therefore, has not received medical treatment from a cardiologist, his heart function is likely to improve with medical care.  Over the next 12 months, his heart ejection fraction will not remain in the low 30% level, possibly improving enough for him to return to work.  John can get disability benefits if despite good medical care his heart function does not improve enough to return to work.
Alfredo presents to the emergency room with difficulty breathing, and tests positive for COVID-19.  His condition declines rapidly, and within days he is on a ventilator.	COVID-19, obviously, is serious and life-threatening.  However, it would be difficult for the Social Security Administration to approve Alfredo’s disability claim upon finding that his COVID-19 “is expected to result in death” since the disease is not uniformly fatal.  If Alfredo is older, obese and suffers from many other medical problems, his doctor could support his disability claim by submitting an opinion letter stating that he expects Alfredo to die.
Elesa falls over a steep cliff during a backpacking trip.   By the time she arrives at the emergency room she is near death.  She has to be placed in an induced coma due to brain swelling.	Even if Elesa does not survive, as in the COVID-19 case above, it is not likely that a physician would opine that she is expected to die.  If she does survive, it will certainly be clear within 12 months.  It is likely that, once she survives the initial injury, she will recover enough to return to work in 12 months. In other words, her medical condition is “acute.”     However, you may be eligible for social security disability if you have suffered a brain injury so severe that you are unable to return to work within 12 months.

What about Conditions that Fluctuate?

We know social security law clearly requires medical conditions that are disabling for a consecutive  12 months, but so diseases seldom follow a precise pattern.  People get worse, then better, than maybe worse again: the severity of the conditions can fluctuate.  

Consider a person who ruptures a disc, requires surgery and undergoes post surgery physical therapy. But what if this person improved in 6 months, was discharged by their doctor, and resumed normal activities for 2 months until falling and re-injured their back, causing them to stop most activities for over 7 months.  Could this person be denied social security disability benefits because of the 2 month she returned to normal activity?  

Unfortunately, yes.  But if an administrative law judge’s only concern in granting this claim was the 2 month period, most will examine the 2 month period very carefully to be sure it was, in fact, not a break in the disability.  For example, the ALJ might find that during the 2 month period this person was still not able to return to work due to continued medical rehabilitation and recovery.

Multiple Conditions, Different Durations

Disability claimants seldom have just one medical problem.  What if you have several  conditions, and no one condition lasts for at least 12 months, but taken together, your conditions keep you from working for over 12 months?  Consider this example:

• Larry contracted COVID-19 and is hospitalized for 2 months, recovering from the disease 4 months after the sudden onset of the disease.  1 month after being hospitalized, however, Larry developed severe diabetes and neuropathy. Larry’s diabetes improved with treatment, but continued to keep him from working for over 11 months.  The combination of Larry’s COVID-19 and diabetes with neuropathy meets the 12-month duration requirement.

Other Requirements.

We have focused on the critical requirement that the disabling condition be chronic and of a duration exceeding 12 months, but there are others that should be mentioned:

Legitimate chronic condition diagnosed via acceptable medical standards.

Even if your condition is chronic, you cannot get disability benefits for conditions that the medical community does not recognize.  You also cannot get disability benefits for a chronic condition that – even though a well-recognized medical condition – was not diagnosed with the proper medical standards.   Some examples:

• Freida’s chiropractor has diagnosed her to have fibromyalgia solely based upon her complaint’s of widespread pain.

Fibromyalgia is a recognized and legitimate medical condition.  Freida’s fibromyalgia, however, was not diagnosed by the appropriate medical specialist – a rheumatologist.  More importantly, fibromyalgia is not diagnosed solely on subjective complaints of pain.

•  Emile is a 24 year old man who claims he cannot work due to multiple chemical sensitivity, diagnosed by a naturopath. 

Multiple chemical sensitivity may turn out to be a legitimate medical condition, but to date it is not accepted in the medical community.  Emile is unlikely to win disability benefits.

Impact of chronic condition on ability to perform work-related activities

Merely having chronic conditions for more than 12 months is not enough: the conditions must result in symptoms that impact the ability to do work-like activities to such a significant extent that you cannot do any work.

Quarters of coverage

Social security disability insurance benefits require that you have “insured status” as of the date of your disability.  Workers with a continuous work record and payment of FICA taxes will have no trouble with insured status.  In general, you need to have work and paid FICA taxes for at least 5 of the prior 10 years.

Not working. 

It does not matter how serious, chronic and continuous your disabilities are.  If you are working, you cannot win disability benefits.