How Does the Social Security Administration Decide if I Qualify for Disability Benefits for Crohn’s Disease?
If you have Crohn’s disease, Social Security disability benefits may be available. To determine whether you are disabled by Crohn’s disease, Social Security Administration first considers whether your Crohn’s disease is severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process. See Winning Social Security Disability Benefits for Crohn’s Disease by Meeting a Listing. If you meet or equal a listing because of Crohn’s disease, you are considered disabled.
If your Crohn’s disease is not severe enough to equal or meet a listing, Social Security Administration must assess your residual functional capacity (RFC) (the work you can still do, despite your illness), to determine whether you qualify for benefits at Step 4 and Step 5 of the Sequential Evaluation Process. See Residual Functional Capacity Assessment for Crohn’s Disease.
About Crohn’s Disease and Disability
What Is Crohn’s Disease?
Crohn’s disease is a chronic, inflammatory disease of the gastrointestinal tract (see Figure 1 below) that produces symptoms such as severe abdominal pain, cramping, nausea, fatigue, diarrhea, and insomnia.
With Crohn’s disease, the body’s immune system attacks the gastrointestinal tract, causing inflammation.
Crohn’s disease may involve the entire alimentary tract from the mouth to the anus.
In addition to the common symptoms of abdominal pain, cramping, nausea, fatigue, diarrhea, and insomnia, you may also experience fecal incontinence, rectal bleeding, fever, vomiting, arthralgia (joint pain), abdominal tenderness, palpable abdominal mass (usually inflamed loops of bowel) and perineal disease. You may also have weight loss or other indications of malnutrition.
Figure 1: The human gastrointestinal tract.
When Does it Occur?
Crohn’s disease can occur at any age. However, it is most common for it to begin either when you are in your teens and twenties or between your fifties and seventies.
Cause and Treatment
The cause of Crohn’s disease is unknown, and it is rarely curable. Recurrence may be a lifelong problem even after surgery. Treatment is usually limited to controlling the symptoms.
Crohn’s disease is a form of inflammatory bowel disease (IBD), which includes both Crohn’s disease and ulcerative colitis. The various forms of inflammatory bowel disease share similar symptoms and treatments.
Crohn’s disease affects the small intestine. Ulcerative colitis affects the large intestine (the colon).
Winning Social Security Disability Benefits for Crohn’s Disease by Meeting a Listing
To determine whether you are disabled at Step 3 of the Sequential Evaluation Process, the Social Security Administration will consider whether your Crohn’s disease is severe enough to meet or equal the Crohn’s disease listing. The Social Security Administration has developed rules called Listing of Impairments for most common impairments. The listing for a particular impairment describes a degree of severity that Social Security Administration presumes would prevent a person from performing substantial work. You will be considered disabled if your Crohn’s disease is severe enough to meet or equal the Crohn’s disease listing.
The listing for Crohn’s disease is 5.06, which has two parts: A and B. You will be disabled if you meet either part.
Meeting Social Security Administration Listing 5.06A for Crohn’s Disease
A Social Security disability claimant with Crohn’s disease meets listing 5.06A and is disabled if he or she has had sufficient narrowing of the intestine.
Listing 5.06A requires two hospitalizations for bowel obstruction at least 60 days apart within a six-month period. This hospitalization requirement means that only the most severe chronic cases qualify under listing 5.06A.
If the complications are eliminated by surgery, then you do not qualify under part A. In many instances, surgery does produce long-term benefit when combined with the proper diet and medication.
Meeting Social Security Administration Listing 5.06B for Crohn’s Disease
A Social Security disability claimant with Crohn’s disease meets listing 5.06(B) and is disabled if he or she has two of the following within a consecutive 6-month period while being treated:
- 5.06B.1 Anemia with hemoglobin of less than 10.0 g/dL.
- 5.06B.2. Serum albumin of 3.0 g/dL or less.
- 5.06B.3. Clinically documented tender abdominal mass palpable on physical examination with abdominal pain or cramping that is not completely controlled by prescribed narcotic medication.
- 5.06B.4. Perineal disease with a draining abscess or fistula, with pain that is not completely controlled by prescribed narcotic medication.
- 5.06B.5. Involuntary weight loss of at least 10 percent from baseline.
- 5.06B.6. Need for supplemental daily enteral nutrition via a gastrostomy or daily parenteral nutrition via a central venous catheter.
Residual Functional Capacity Assessment for Crohn’s Disease
What Is RFC?
If your Crohn’s disease is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process. RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Even if your Crohn’s disease is less than the 5.06 listing level your life may be completely disrupted by your impairments. The symptoms often make it difficult to cope with life, let alone work.
One possible symptom is malnutrition that is not severe enough to satisfy listing 5.08, but is enough to affect your strength and stamina.
Other symptoms that may contribute to RFC are feelings of malaise and lack of energy. However, these symptoms are difficult to quantify so it is important to have documentation both through your own symptom diary and through medical records.
You may have psychological impairments that are associated with your Crohn’s disease. These may include malaise or lack of energy that also show up as physical impairments. You may also suffer from poor coping skills in dealing with Crohn’s disease.
These types of symptoms will need to be carefully evaluated and shown in correlation with physical symptoms.
Getting Your Doctor’s Medical Opinion About What You Can Still Do
Your Doctor’s Medical Opinion Can Help You Qualify for Social Security Disability Benefits
The Social Security Administration’s job is to determine if you are disabled, a legal conclusion based on your age, education and work experience and medical evidence. Your doctor’s role is to provide the Social Security Administration with information concerning the degree of your medical impairment. Your doctor’s description of your capacity for work is called a medical source statement and the Social Security Administration’s conclusion about your work capacity is called a residual functional capacity assessment. Residual functional capacity is what you can still do despite your limitations. The Social Security Administration asks that medical source statements include a statement about what you can still do despite your impairments.
The Social Security Administration must consider your treating doctor’s opinion and, under appropriate circumstances, give it controlling weight.
The Social Security Administration evaluates the weight to be given your doctor’s opinion by considering:
- The nature and extent of the treatment relationship between you and your doctor.
- How well your doctor knows you.
- The number of times your doctor has seen you.
- Whether your doctor has obtained a detailed picture over time of your impairment.
- Your doctor’s specialization.
- The kinds and extent of examinations and testing performed by or ordered by your doctor.
- The quality of your doctor’s explanation of your impairment.
- The degree to which your doctor’s opinion is supported by relevant evidence, particularly medically acceptable clinical and laboratory diagnostic techniques.
- How consistent your doctor’s opinion is with other evidence.
When to Ask Your Doctor for an Opinion
If your application for Social Security disability benefits has been denied and you have appealed, you should get a medical source statement (your doctor’s opinion about what you can still do) from your doctor to use as evidence at the hearing.
When is the best time to request an opinion from your doctor? Many disability attorneys wait until they have reviewed the file and the hearing is scheduled before requesting an opinion from the treating doctor. This has two advantages.
- First, by waiting until your attorney has fully reviewed the file, he or she will be able to refine the theory of why you cannot work and will be better able to seek support for this theory from the treating doctor.
- Second, the report will be fresh at the time of the hearing.
But this approach also has some disadvantages.
- When there is a long time between the time your attorney first sees you and the time of the hearing, a lot of things can happen. You can improve and go back to work. Your lawyer can still seek evidence that you were disabled for a certain length of time. But then your lawyer will be asking the doctor to describe your ability to work at some time in the past, something that not all doctors are good at.
- You might change doctors, or worse yet, stop seeing doctors altogether because your medical insurance has run out. When your attorney writes to a doctor who has not seen you recently, your attorney runs the risk that the doctor will be reluctant to complete the form. Doctors seem much more willing to provide opinions about current patients than about patients whom they have not seen for a long time.
Here is an alternative. Suggest that your attorney request your doctor to complete a medical opinion form on the day you retain your attorney. This will provide a snapshot description of your residual functional capacity (RFC) early in the case. If you improve and return to work, the description of your RFC provides a basis for showing that you were disabled for a specific period. If you change doctors, your attorney can get an opinion from the new doctor, too. If you stop seeing doctors, at least your attorney has one treating doctor opinion and can present your testimony at the hearing to establish that you have not improved.
If you continue seeing the doctor but it has been a long time since the doctor’s opinion was obtained, just before the hearing your attorney can send the doctor a copy of the form completed earlier, along with a blank form and a cover letter asking the doctor to complete a new form if your condition has changed significantly. If not, your attorney can ask the doctor to send a one-line letter that says there have been no significant changes since the date the earlier form was completed.
There are times, though, that your attorney needs to consider not requesting a report early in the case.
- First, depending on the impairment, if you have not been disabled for twelve months, it is usually better that your attorney wait until the twelve-month duration requirement is met.
- Second, if you just began seeing a new doctor, it is usually best to wait until the doctor is more familiar with your condition before requesting an opinion.
- Third, if there are competing diagnoses or other diagnostic uncertainties, it is usually best that your attorney wait until the medical issues are resolved before requesting an opinion.
- Fourth, a really difficult judgment is involved if your medical history has many ups and downs, e.g., several acute phases, perhaps including hospitalizations, followed by significant improvement. Your attorney needs to request an opinion at a time when the treating doctor will have the best longitudinal perspective on your impairment.
Medical Opinion Forms
Medical opinion forms can be great time savers for both your attorney and your doctor, but they must be used with care. Forms may not be appropriate at all in complex cases; and they need to be supplemented in many cases so that all issues are addressed. The best forms are clear and complete but not too long.
When the time is right, here is a form for your disability attorney to use: