If you have suffered a preventable spinal cord injury, it can have catastrophic impacts on you, your family, and your finances. If you have applied for a spinal cord injury disability claim, and it has been denied, you may be able to appeal the decision. However, appealing a spinal cord injury disability insurance claim denial can be a challenging and time-consuming process, so you should speak with an experienced Reno disability insurance attorney.
What Is a Spinal Cord Injury?
The spinal cord transmits signals from the brain to the body’s other functions. It is enclosed and protected by layers of tissue known as the meninges and a column of vertebrae (spinal bones).
Damage to the spinal cord brought on by accident, illness, or degeneration is referred to as a spinal cord injury. In the US, there are over 17,000 new spinal cord injuries annually.
Vehicle accidents (auto, tractor-trailer, motorcycle, and bicycle) currently account for most injuries, followed by falls, violent crimes resulting in gunshot wounds, and sports and recreational activities. The most common cause of spinal cord injury is an abrupt, severe impact to the vertebrae, where the fractured (broken) bones harm the spinal cord and its nerves. While around 90% of spinal cord injuries are due to trauma, there seems to be an increasing percentage of non-traumatic spinal cord injuries.
What Are the Symptoms of a Spinal Cord Injury?
The intensity and location of the injury on the spinal cord determine the symptoms of a spinal cord injury. The systems that control respiration, heart rate, blood pressure, and bowel or bladder function are all impacted by severe spinal cord injuries. The effects of a spinal cord injury can include:
- Paralysis of the breathing muscles
- Paralysis or loss of feeling in the trunk, arms, and legs
- Loss of bowel and bladder control
There are also a variety of secondary conditions, such as respiratory issues, pressure sores, and occasionally fatal blood pressure spikes.
When the spinal cord is injured, its normal motor, sensory, or autonomic functions may be temporarily or permanently altered. People who suffer spinal cord injuries frequently experience substantial neurologic impairments that are permanent and accompanied by disability. Most spinal cord injury victims deal with persistent pain. For people who survive a spinal cord injury, preventing problems from the damage and issues associated with the disability becomes the most crucial aspect of their care.
Types of Spinal Cord Disabilities
Spinal cord injuries can be categorized as incomplete or complete.
One or both sides of the body still have some function after an incomplete injury. The brain can communicate with the body along specific pathways. Incomplete injuries to the spinal cord are more common than complete injuries. Over 60% of all spinal cord injuries are incomplete. Medical professionals tend to understand how to respond to this type of injury without complicating it.
Incomplete spinal injuries are classified into three types: anterior, central, and Brown-Sequard. An anterior injury is found at the front of the spinal cord. The sensory and motor pathways are damaged in this type of injury. A central injury occurs in the center of the cord and involves nerve damage. When one side of the spinal cord is injured, it results in a Brown-Sequard injury.
A complete spinal injury is a total paralysis (loss of function) below the level of the injury, and it affects both sides of the body. A complete injury may cause paralysis of all four limbs or the lower half of the body. Complete spinal cord injuries are not as common, but more severe. Tetraplegia, paraplegia, and triplegia are the three types of complete spinal cord injuries.
Tetraplegia is the most severe type of complete spinal cord injury. It results in paralysis and can affect any limb. The severity of this injury is determined by its location on the cervical spine. Paraplegia occurs when an injured person loses complete movement and sensation of body parts. Triplegia is typically caused by complications arising from a spinal cord injury labeled as incomplete.
Social Security’s Listing for Spinal Disabilities
You may be eligible for Social Security Administration (SSA) disability benefits if you have suffered a spinal cord injury. The SSA provides monthly benefits to people who cannot work for at least 12 months due to a severe disability. The Blue Book is a list of impairments the SSA considers serious enough to prevent someone from working. It describes the medical criteria used by the SSA to determine whether certain conditions are disabling enough to keep someone from working.
The SSA maintains a list of impairments that define the criteria for certain conditions to be automatically approved for disability. There are three ways to meet the listing requirements listed below in order of severity (you need to meet only one).
Complete Loss of Function
Complete loss of function addresses spinal cord disorders that cause a complete loss of motor, sensory, and autonomic function in the affected part(s) of the body, such as paralysis of an arm or leg, persisting for three consecutive months after the disorder.
Paraplegic or quadriplegic individuals are automatically eligible for benefits under this section of the list. Others, however, may also qualify under this section of the listing. Spinal cord injuries can paralyze other muscles, making them eligible for benefits. For instance, spinal cord injuries can result in paralysis of the stomach, intestines, or bladder.
Disorganization of Motor Function in Two Extremities
Disorganization of motor function in two or more extremities is interference with the movement of two extremities – lower or upper (including fingers, wrists, hands, arms, and shoulders). It is caused by your neurological disorder, resulting in an extreme limitation, such as the inability to stand up from a seated position, maintain balance in a standing position and while walking, or use your upper extremities to independently initiate, sustain, and complete work-related activities. It must persist for three consecutive months after the disorder.
Marked Limitation in Physical and Mental Functioning
This is when you have marked limitation in physical functioning and in one of the following categories of mental functioning, both of which persisted for three months after the disorder:
- Understanding, recalling, or applying information – This refers to the ability to learn, recollect, and apply information to perform work tasks
- Interacting with others – This means the ability to relate to and work with supervisors, coworkers, and the public
- Concentrating, persevering, or keeping pace – This signifies the ability to focus attention on work activities and to stay on task for an extended period
- Adapting or managing oneself – This refers to the ability to regulate emotions, control behavior, and maintain well-being in the workplace
Marked would be the fourth of a five-point scale comprised of no limitation, mild limitation, moderate limitation, marked limitation, and extreme limitation. The term marked does not require you to be confined to bed, hospitalized, or in a nursing home.
Spinal Cord Disability Claims
Filing a spinal cord disability insurance claim with the Social Security Administration is a complex matter with a unique appeals process; it can be daunting. A qualified and experienced Reno disability insurance attorney can use his or her knowledge about the SSA’s decision-making process to fill out the required information about your spinal injury, on your behalf, on the application. The attorney can make this time-consuming task much more manageable by ensuring that all evidence required to support your spinal injury claim is accurate and complete.
When filing your own SSA claim, you must be sure that your disability has persisted or is expected to last at least 12 months. If you fail to meet this requirement, you will not be eligible for benefits. If you qualify, the next step is to look up spinal injuries in the Blue Book. This will assist you in determining whether your spinal injury will likely qualify you for disability benefits.
Criteria for Spinal Cord Injuries
In the Blue Book, spinal cord injuries are listed in Section 1.04 —Disorders of the Spine. To be eligible for disability benefits under this listing, you must provide medical evidence that your spinal cord has been damaged. You will also need to demonstrate that your injury caused nerve root compression, resulting in pain, weakness, and an inability to move around easily. This must be demonstrated by providing medical images, doctor statements about your injury, and medical records from previous surgeries and treatments.
Your Application For Spinal Injury Disability Benefits
You can apply for disability benefits online, over the phone, or in person at your local Social Security Administration office. You must ensure that you have all the necessary evidence to include with your application, which you should obtain from the doctor treating you. The following items should be included:
- Imaging scans indicating the location of the spinal injury
- The progression of the spinal injury
- The symptoms of the spinal injury and how they affect your ability to perform daily activities
- Treatments you’ve received and their outcomes
- Prediction for future outcomes
- Records demonstrating your hospital admissions and, if applicable, surgical and lab reports
Try not to leave out any vital medical evidence because it takes too long to obtain. If you do so, your application may be delayed. You may be told that you require a Residual Functional Capacity (RFC) evaluation. Your doctor can fill out this form for you because he or she has the most knowledge about your disability and what tasks you are unable to do. The outcome of your claim may be determined by the SSA’s evaluation of your RFC.
What to Do After a Spinal Cord Injury Disability Insurance Claim Denial
Most people applying for benefits for the first time from the SSA end up receiving disability insurance claim denials, but they can appeal those decisions. The length and complexity of the appeals process are why you should strongly consider hiring an experienced Reno disability insurance lawyer to handle your appeals case.
If you decide to appeal a decision denying social security benefits, there are four levels of appeal:
- Appeals Council
- Federal Court
In the reconsideration, which you must request within 60 days from the date of your denial, a new claims examiner will review your application. He or she will take into account any new evidence discovered by you or your attorney to support your claim for disability benefits. If your reconsideration appeal fails, you can file for a hearing before an administrative law judge who only handles SSA cases, where your lawyer can argue your case and subpoena witnesses and experts.
If it’s determined in your hearing that you are still ineligible for benefits, you may appeal a third time to the Social Security Appeals Council. Should the council deny your claim, you can appeal by filing a lawsuit in a federal district court. There are also circumstances where you might consider filing an entirely new claim.
Private or Group Insurance
Suppose you have been denied benefits under a group or a private disability insurance policy. In that case, it’s sometimes a result of you not having the necessary medical evidence to prove the disability in the manner dictated by the policy. Sometimes, the activities you post on social media can ruin your case. And sometimes, your disability claim is denied because insurance companies just don’t like paying monthly benefit checks.
Insurance companies are in the business of creating reasons to deny disability claims. They will purposely twist policy language, use company-paid doctors, and blatantly ignore credible evidence in issuing a spinal cord injury disability insurance claim denial in some cases. Such wrongful denials are an example of disability insurance bad faith. It is not legal, but unethical insurers are betting that some percentage of their policyholders won’t make an effort to sue them. Don’t fall into that group. Hire an experienced Reno disability insurance lawyer to receive the compensation you’re entitled to be paid by your insurance company or the SSA.