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PTSD & Related Medical Conditions: Obtaining the Proper Compensation

A few months ago, I wrote a post about Post Traumatic Stress Disorder (PTSD). Specifically what it is and how a veteran can find out if he or she suffers from it.  In this post, I will discuss the link between PTSD and other medical conditions, as well as ways a veteran can pursue service connected benefits for any related conditions.

Once a veteran has been officially diagnosed with PTSD, it is important for the veteran to be aware of a few scenarios. One such scenario involves the veteran exploring whether or not the PTSD was caused by a condition that is already service connected.  For example, let’s assume that a veteran is service connected for coronary artery disease, and as a result, has a heart attack.  After the heart attack, the veteran begins to experience symptoms such as frequent intrusive thoughts, anxiety, nightmares about the heart attack or dying, sleep problems, etc.  The veteran’s doctor then tells him that he is suffering from PTSD as a result of the heart attack.

Using the above example, the veteran should file a claim for service connection for the PTSD.  The reason is because even if the PTSD is not the result of military service itself, the veteran can still make a case for “secondary” service connection.  Secondary service connection is when a service connected condition causes a new disability or aggravates a non-service connected disability. In this example, because the coronary artery disease that caused the heart attack was already service connected, and the heart condition was the cause of the PTSD, the veteran can argue that the PTSD is secondary to the service-connected heart condition.  The veteran in this example would have medical research on his side, because recent studies have estimated that 1 in 8 heart attack survivors will develop PTSD after suffering from the emotional stress of surviving a heart attack.

Another scenario that veterans should explore is whether or not their PTSD has caused or aggravated any other medical problems. Along these lines, there are medical studies indicating that in some cases, PTSD may be a contributing factor, if not the cause, of many other conditions such as heart problems, sleep apnea, and the development of unhealthy behaviors leading to other conditions such as diabetes and obesity.

To illustrate this point, if a veteran has service-connected PTSD and the PTSD causes or aggravates another condition, the veteran can argue that the secondary condition should also be service connected. For example, assume that a veteran has PTSD and later develops sleep apnea. If the veteran can prove that the PTSD caused the sleep apnea, he can be service-connected for the sleep disorder. The same would be true even if the veteran had sleep apnea prior to being diagnosed with PTSD, if he can prove that the sleep apnea is now being aggravated or worsened by the PTSD (e.g. the sleep apnea now requires a CPAP, whereas before the PTSD, no CPAP was necessary).

Oftentimes, it has been my experience that in order to win cases like these, the veteran will need expert medical opinions from qualified physicians and/or medical researchers, providing the medical the necessary nexus.

The take away is that discovering that one has PTSD is only the beginning when dealing with the VA disability process and determining the appropriate ratings.

For Questions About Your Disability Claim... Contact Us

by Attorney Leslie Gaines
October 26, 2012

Decompensation and SSDI Evaluations

People whose ability to work is impaired by mental illness or a psychiatric disorder may be entitled to Social Security Disability Insurance (SSDI) benefits, if the condition makes them totally disabled from working. SSDI benefits can be awarded to those suffering illnesses such as anxiety, depression, bipolar disorder (manic-depressive disorder), schizophrenia, agoraphobia (fear of public or open places), or post-traumatic stress disorder (PTSD), among others.

One common problem with proving total disability based on mental disorders is the up and down nature of some illnesses, which may not appear at first to prevent working, because a person may function relatively well for periods of time or in lower-stress situations. However, the SSA recognizes that these same individuals can experience sudden, extreme downturns known as “decompensation episodes,” which make it impossible for them to maintain employment.

“Decompensation” is a term used by mental health professionals to refer to episodes during which a person’s existing mental-health or psychiatric disorder deteriorates, for a time, to include symptoms that are unusually severe. Crippling panic attacks are a common example, but decompensation symptoms vary for different mental disorders.

Mental Illness Disability and Decompensation

The SSA defines disability as a proven medical condition that is expected to last a year or more (or result in death) and that prevents the sufferer from engaging in “substantial gainful activity” (currently, this means working enough to earn a little over $1,000/month). When the claimant has a mental illness or psychiatric disorder with symptoms that fluctuate in severity, proving the existence of decompensation episodes can be crucial to winning disability benefits.

While a sufferer might not seem fully disabled from working during better periods, the fact that decompensation episodes can produce sudden and marked changes in ability can provide additional proof necessary to show that a claimant meets the SSA’s definition of disability.

SSA Rules on Decompensation Episodes

To help prove SSDI disability, the medical records of treatment for decompensation episodes must include the kind of evidence that the SSA considers important. When the SSA considers an SSDI application based on mental disorder, it first looks to see whether a claimant is diagnosed with an illness contained in SSA’s list of disabling conditions (often called the “blue book”) or equal in severity to one that is on the list, which includes 9 categories:

• Organic mental disorders
• Schizophrenic, paranoid, and other psychotic disorders
• Affective disorders
• Mental retardation
• Anxiety-related disorders
• Somatoform disorders
• Personality disorders
• Substance disorders
• Autistic and other pervasive developmental disorders

Each category is divided into parts (usually Parts A, B, and sometimes C or D) that describe what must be proven if a claimant is to be found legally disabled for SSDI purposes, including (1) the symptoms that must be present for diagnosis of the illness; and (2) the disabling results, or functional limitations, that the illness must cause, in order to be considered legally disabling for purposes of SSDI.
In many of the SSA mental disorder listings, “repeated episodes of decompensation, each of extended duration” is one factor that can be used to show evidence of disability. To qualify for SSDI on this basis, the claimant’s evidence usually must show the SSA that decompensation episodes:

• Occur at least 3 times within a year (or an average of once every 4 months) and last at least 2 weeks each time; and
• Limit functional abilities in these areas:

o Daily living activities;
o Social activities; or
o Activities that require concentration, persistence, or pace.

However, a claimant might be able to show a condition “as severe as” one on the list, with evidence of decompensation episodes that happen more often, but endure for shorter periods of time, or vice-versa. There are also other ways that decompensation episodes can be used to help prove total disability in SSDI cases.

Proving Decompensation Episodes

The claimant must be sure to seek the right kind of medical help and provide the right details to doctors or psychiatrists. Claimants or family members should give medical providers detailed descriptions of how often the episodes occur, how long they last, and the types and degree of limitation that they place on the claimant’s ability to function.

Seeking treatment during decompensation episodes can be crucial to an SSDI benefits claim. In SSDI cases, the key to proving the existence and impact of decompensation episodes is to compile detailed medical records. To get medical records with the right kind of detail, the claimant must get proper treatment during these downturns.

For many people seeking SSDI benefits based on a mental or emotional disability, it can be difficult to seek medical attention during periods when symptoms suddenly worsen. In fact, decompensation can often make it hard for sufferers to cope with the prospect of a trip to the doctor, causing them to cancel or reschedule appointments; but making it to the doctor can be critical to a disability case for SSDI benefits.

Proving decompensation episodes to get SSDI benefits can be a complex process. Other evidence, combined with good medical records, can also demonstrate the impact that decompensation episodes have on a person’s life. These include disability journals, which record the details of episodes as they happen, and testimony from family members, co-workers, and friends with first-hand knowledge of the limits that a mental illness places on the claimant. Every case is different, and an experienced Social Security Disability Attorney can help assess an individual case and determine the best methods of proving disability in each one.

For Questions About Your Disability Claim... Contact Us

by Matthew Hill
October 15, 2012

Social Security: Getting More Than One Type of Benefit

The Social Security Disability Insurance (SSDI) program provides benefits to a person with a disability so severe that they would be unable to do their past work or any other substantial gainful work which exists in the national economy.  

In a Social Security Disability claim, the amount received under this program is based on the worker’s earning record. In general, a worker’s monthly Social Security benefit is based on his or her 35 highest-paid years of earnings in Social Security covered employment. 

You must have worked and met the disability insured status to be eligible for benefits. The general rule is that an individual must have accrued sufficient quarters of coverage, based upon age, to meet the insured status. If the claim is approved medically, then there will be a five month waiting period before entitlement begins—five full months from the date of onset. Medicare is the medical coverage for SSD and there is a 24 month waiting period before entitlement begins. 

Unlike the Social Security Disability program, there is no work requirement for the Supplemental Security Income program (SSI). SSI is a federal welfare program for individuals that are either disabled, blind and over the age of 65. It makes monthly payments to people who are disabled with low income. There are asset/resources and income limitations for single and married couples. The amounts you can receive from SSI may vary depending on your living arrangement. Medicaid is the medical coverage for SSI claims. 

Another benefit under the Social Security Disability Program is a claim for Disabled Adult Child (DAC). Here, an individual may obtain benefits on the work record of a retired, disabled or deceased parent. These individuals must be unmarried and must have become disabled before age 22. 

Under these programs medical evidence is the cornerstone for deciding a disability claim. But before social security will make a determination on your disability, they will first determine whether or not you meet the technical/non-medical requirements discussed above. Once it is established that you meet the insurance requirements and/or income requirements, social security reviews the medical component of the case. A disability, as defined by Social Security, is a physical and/or mental impairment that affects a person’s ability to engage in sustained work activity; and the disability has lasted 12 consecutive months or is expected to last 12 consecutive months, or result in death.   

SSA administers a five-step procedure that embodies a set of presumptions about disabilities:
Step One: Are you presently working?
Step Two: How Severe is the condition?
Step Three: Does the Impairment meet or equal the Listing of Impairments?
Step Four: Can the person return to their Past Relevant Work?
Step Five: Can the person perform other jobs that exist in significant numbers in the national economy? 

Moreover, in determining whether someone is disabled, the regulations consider a person’s chronological age in combination with their education, work experience and the residual functional capacity. Age is an important factor in a social security claim. Social Security has several steps and procedures—their laws are complex.  For this reason, if you have been denied benefits and need assistance from an attorney, call us for a free consultation.

For Questions About Your Disability Claim... Contact Us

by Attorney Wendy Rivera
October 12, 2012

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