Case Study: Systemic Lupus Erythematosus in Younger Individuals

Case Background

At only 39 years old, Ms. Doe became disabled due to systemic lupus erythematosus (“SLE”). Despite clear and overwhelming evidence in support of her severe condition, Ms. Doe was denied benefits twice by the Social Security Administration before seeing a judge. Lupus is often misunderstood. Even the most favorable judges can have trouble understanding how the symptoms of this condition, particularly with young applicants, interfere with the ability to hold a job.

Social Security uses a 5-step process sometimes called the “sequential process” to evaluate disability cases.  We will explore the process in detail in another post. In this case we proved to a Social Security Disability judge that Ms. Doe was disabled under “Step 3’ of the process.  Under “Step 3”  the Administration must grant disability if a claimant meets or equals a “Social Security Listing.” The “Listings” will be explained further in another post.  In this case, we showed that the claimant meets the Social Security Listing for Lupus.

Briefly, SSA maintains a listing of medical conditions that are so severe that if your condition and symptoms meet or equal the “listing” criteria, it will determine that you are disabled.  To be found disabled under the listings, it is not enough to prove that you suffer from the condition; you must also experience specific, severe symptoms related to it. The requirements can be exacting, so it is important to be familiar with the listings to prove your case.  Know that a disability adjudicator (decision maker) can grant a case if you meet a listing, but they cannot deny your case if you do not meet or equal a listing.  If you do not meet a listing, the decision maker will continue to evaluate your disability under steps 4 and 5 of the process.

Listing 14.02 – Systemic Lupus Erythematosus

To meet the listing, first you must show that you have the condition.  As a general rule, the medical evidence must show that your symptoms satisfy the  “Criteria for the Classification of Systemic Lupus Erythematosus” established by the American College of Rheumatology. 

After proving that your condition meets the diagnostic criteria, you must show that it meets the severity criteria as outlined below. As you see, this can get complicated. 

The Lupus listing is as follows:

A. Involvement of two or more organs/body systems, with:

1. One of the organs/body systems involved to at least a moderate level of severity; and
2. At least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss).

OR

B. Repeated manifestations of SLE, with at least two of the constitutional symptoms or signs (severe fatigue, fever, malaise, or involuntary weight loss) and one of the following at the marked level:

1. Limitation of activities of daily living.
2. Limitation in maintaining social functioning.
3. Limitation in completing tasks in a timely manner due to deficiencies in concentration, persistence, or pace.

Outcome

In Ms. Doe’s case, we secured all her medical records from her treating doctors, and we convinced those doctors, with the help of our client, to provide narratives and assessments to prove that she met the criteria for the Lupus listing.  Social Security decision makers are not doctors and they may not always see and understand the critical evidence that establishes that a listing is met. By putting the evidence together, assisted by the treating experts and showing exactly how Ms. Doe met the listing, we proved to the Social Security Judge that she was disabled. 

Take-Aways

• Get in treatment: If you are not in treatment, get in treatment and make sure you communicate with your doctors everything that you are experiencing so that they understand how your condition impacts you and how best to help you.
• Understand that your doctors are a crucial resource for helping Social Security evaluate your condition.
• Investigate whether a “Listing” exists for the condition that afflicts you.  Review the “Listing” and become familiar with the criteria that Social Security uses to evaluate it.
• Understand that if you do not meet a “Listing,” do not give up; the administration must continue evaluating your claim under steps 4 and 5.
• Representation Matters:  Every case is unique and presents its own challenges.  Some cases are tougher because of the nature of the person’s disability.  Our team knows what specific medical evidence is needed to prove a case of disability, and we know the rules and regulations concerning impairments.
• The Right Representation Matters More: Binder & Binder® is experienced in handling the most complex cases, and we work to resolve them as early as we can for our clients.  Social Security rules can be complicated, but we have successfully represented thousands of claimants over the years. Experience matters.

If you have a disability and the prognosis is that your disability is expected to last a year or more (or one that has lasted that long) and your doctor says you cannot work anymore, you may be able to apply for Social Security Disability benefits. And Binder & Binder® can help. Our advocates represent tens of thousands of people each year throughout the United States, Puerto Rico, the Virgin Islands and all U.S. territories. The people we help are affected by many different types of accidents, injuries and pain that prevent them from working. If you’re suffering from a disabling condition, contact us to talk about getting the benefits you need.