HCFS - CASE HISTORIES

CASE HISTORY DETAIL

Claimant: John
Disability: A severe medically determinable physical impairment (which does not meet or equal a disability listing). The individual is not engaging in substantial gainful activity and the individual's impairment prevents the performance of his vocationally relevant past work.
Mental Problems: None
Drugs: Yes (current use of cocaine and alcohol)
Age: 50
Education: High school graduate or more. Does not provide for direct entry into skilled work.
Previous Work Experience: Unskilled or none, as to job skills learned in the 15 years prior to the ALJ hearing.

The Claimant currently used illegal drugs and had lost at the Initial Application and Reconsideration levels.

To win this case, HCFS had to prove that his Severe Impairment would remain even if he stopped using drugs - because removing the drug use would not remove the factors giving rise to his Severe Impairment.

The burden of proof is on the SSA, and in response to our questions, the SSA's expert could not testify that removing the drugs would cause the Severe Impairment to disappear.

The unsavory Claimant thus became eligible for SSI, and the resulting Medicaid paid his eligible hospital bills.

Key:
Current drug or alcohol abuse (DAA) is a contributing factor material in the determination of disability, and can defeat an otherwise disabled claimant's SSI eligibility.

However, the SSA must prove its case.

Representing the claimant at the ALJ hearing, HCFS forces the SSA to prove the DAA by posing the following questions to the ALJ's medical expert.

Would you still find the individual disabled if he/she stopped using drugs or alcohol?
Which of the current physical and mental limitations, upon which you based the current disability determination, would remain if the individual stopped using drugs or alcohol for 30 days?
Would any or all these remaining limitations be disabling?

Result:
Claimant determined to be disabled. Rule 201.12 of the mandatory "grid" regulations mandates a finding of disability on the Residual Functional Capacity: Maximum Sustained Work Capability Limited to Sedentary Work as a Result of s Severe Medically Determinable Impairment Table.