Chronic Heart Failure and Qualifying for Disability Benefits

Summary: Can I get disability benefits if I am suffering from the effects of chronic heart failure?

Chronic heart failure, or CHF, is very common, accounting for 8.5% of all heart disease deaths in the United States. The Heart Failure Society of America estimates 6.5 million Americans over the age of 20 have heart failure. Also known as congestive heart failure, chronic heart failure is a potentially lethal condition that affects the pumping power of heart muscles. CHF is the leading cause of hospitalization of people over age 65. If you are suffering from the effects of Chronic heart failure you may qualify for disability benefits.

---

If you are suffering from the effects of Chronic heart failure and have been denied disability don’t give up, almost 70% are denied initially! Just call 512-454-4000 for a free, no obligation consultation to learn what your options are.

Symptoms of chronic heart failure range from mild to severe and can come and go.

Some people experience no symptoms at all, but the most common signs of CHF include:

•    Shortness of breath and/or a dry hacking cough
•    Rapid or irregular heartbeat
•    Swollen ankles, legs, or abdomen
•    Rapid or irregular heartbeat
•    Rapid weight gain
•    Increased need to urinate, especially at night
•    Fatigue, weakness
•    Dizziness, fainting
•    Loss of appetite, nausea
•    Difficulty concentrating
•    Chest pain

Any of these symptoms and conditions, either individually or in combination, can make it difficult to maintain employment and raise the probability of qualifying for disability benefits.

Can I qualify for Social Security Disability Income if I have chronic heart failure?

Heart failure can cause symptoms which make it difficult to perform a job such as shortness of breath, problems concentrating, or swelling in the legs making it difficult to walk.

The Social Security Administration lists chronic heart disease as a disability under Section 4.02 in its Blue Book, a manual listing impairments Social Security considers disabling and may automatically qualify for benefits. To qualify for SSDI under Social Security’s listing, you must be diagnosed with severe heart failure despite being on heart medications. Your medical records must indicate that at some point you experienced fluid retention, but you do not have to have fluid retention at the time your claim is evaluated. Additionally, your medical records must document that you have either systolic or diastolic failure.

For systolic failure, (when the heart has weakened pumping strength) medical evidence must indicate:

•    Ejection fraction (the percentage of blood pumped with each heartbeat) must be 30% or less during a period of stability (not during an episode of acute heart failure); OR
•    The heart’s left ventricular end diastolic dimension is larger than 6.0.

For diastolic failure, (when the heart is unable to fill properly) medical evidence must document ALL of the following:

•    A left atrium of 4.5 cm or larger; and
•    Thickness of left ventricular wall and interventricular septum 2.5 cm or larger on imaging; and
•    Normal or elevated ejection fraction during a stable period.

You must also exhibit one of the following functional limitations:

•    The inability to perform an exercise tolerance test (ETT) at a workload equivalent to 5 METs (metabolic equivalent) or less. MET is the amount of oxygen consumed while sitting at rest; one MET is the energy it takes to sit quietly; or
•    Persistent symptoms of heart failure that severely limit activities of daily living; or
•    At least three episodes of heart failure and fluid retention within the past 12 months requiring emergency room treatment or hospitalization for at least 12 hours.

Before applying for Social Security Disability, you should visit your doctor several times to discuss your heart condition.

Social Security will expect you to provide your complete medical records including:

•    Blood work (BNP test);
•    Electrocardiogram;
•    Echocardiogram;
•    Result of an exercise stress test;
•    Chest x-ray.

Most applicants under age 65 do not qualify under the strict criteria of Social Security’s listing, but another way to qualify for Social Security Disability benefits is to prove that your functional limitations prevent you from working at your old job or any other job.

Social Security is mainly interested in how your functional limitations impact your daily life. Complications from chronic heart failure, such as poor concentration or being unable to lift more than 10 pounds, can affect your ability to do physical work or sedentary work. Social Security will conduct a Residual Functional Capacity (RFC) assessment to evaluate your physical and mental capabilities to determine if there is any job you can do, taking into consideration your age, education and whether or not you can drive. Ask your cardiologist to fill out an RFC form. If Social Security decides you cannot do your old job or don’t have the skills to perform a new job, you may be approved for a Medical-Vocational Allowance.

Once Social Security determines the limitations caused by your condition, they will employ a vocational expert to assess whether a person with these limitations is employable.

If you are 55 or older or have another medical condition you may get approval.

Social Security follows a set of rules to determine when the agency expects an applicant to learn a new job.

Applicants who are 55 or older often fall under a grid rule, which means they are not expected to learn a new job. For example, a 55-year-old applicant with no transferable skills might be found disabled. If you can’t go back to your old job, and you don’t have the skills to learn a new one, Social Security will likely grant you disability benefits.

You may also be eligible for Social Security Disability benefits if you have another medical condition, for example kidney disease or thyroid disease.

Applicants often have more than one illness or injury that prevents them from working full time. By itself one disorder may not meet the requirements of an impairment as stated in Social Security’s Blue Book. However, if you have multiple medical conditions, Social Security must consider how those health issues, combined together, limit your ability to hold a job and perform necessary daily tasks.

Social Security also has basic financial requirements.

You must satisfy some basic financial requirements before you are eligible for Social Security disability benefits.

You must: 1) have a disability that has lasted or is expected to last 12 months; and 2) you must have worked in a job where you paid Social Security taxes long enough and recently enough; and 3) you must not earn more than Substantial Gainful Activity (SGA), which is $1,620 per month in 2025 for nonblind applicants and $2,700 per month for blind applicants.

What if I don’t qualify for SSDI?

If your income is too high, or if you haven’t worked long enough to earn enough work credits, you may be eligible for disability benefits through another Social Security program, such as Supplemental Security Income (SSI), or from a long-term disability insurance plan through your employer or a privately purchased policy.

SSI is a program that pays monthly benefits to people with limited income and resources who are disabled, blind, or age 65 or older. SSI is based on income instead of work credits, and is financed by general funds of the U.S. Treasury.

I have long-term disability insurance – should I file a claim?

Yes, file a claim as soon as you become disabled.

Long-term disability insurance (LTD) is coverage that protects your income if you are unable to work due to illness or injury and is purchased as part of a group employment plan or privately through an insurance company. Policies pay between 50-60% of your salary and benefits continue until you return to work or for the number of years stated in the policy. LTD coverage is good only as long as you are employed, however, so do not quit your job before you file a claim, and be sure to check your policy’s definition of “disabled” as each policy will state the definition of “disabled” which is in use. Additionally, be aware that long-term disability insurance companies can require a claimant to apply for SSDI also.

How do I file for Social Security Disability benefits?

You can apply for Social Security Disability benefits online, over the phone, or in person at your local Social Security Administration office.

If your initial application is denied, don’t be discouraged. Approximately 65% of applications are initially denied, and you will have the opportunity to appeal. There are four steps to the Social Security appeal process:

1.    File a Request for Reconsideration with the Social Security Administration to completely review the case.
2.    If you don’t agree with SSA’s response to your Request for Reconsideration, you can request a hearing before an Administrative Law Judge (ALJ). ALJs are attorneys who work for the Social Security Administration; they review SSDI cases and either uphold or overturn decisions to deny SSDI benefits. If you are not represented by an attorney at this point, now is the time to obtain legal counsel. This is a critical point in the process and will raise your chance for success.
3.    If an ALJ does not grant your claim, you can request that the Appeals Council review your case.
4.    Federal Court review. The final step in the appeal process is filing suit in U.S. District Court.

Do I need a disability attorney for SSDI?

If you have chronic heart failure and cannot work, you may be eligible for Social Security Disability benefits, but meeting Social Security’s requirements is difficult and applying for SSDI is a long process that can take several months to years.

Your chances for approval are improved significantly if you have legal representation. At each potential stage of the process, from the initial application stage, the reconsideration stage and the ALJ hearing stage, an attorney can assist you in completing the detailed forms and questionnaires required by Social Security, collecting and submitting relevant medical evidence, and preparing questionnaires for your doctors. At the ALJ hearing phase an attorney will not only continue to assure that the evidence is complete, but prepare you for questioning by the ALJ, prepare an argument on your behalf and question any doctors or vocational experts selected by the ALJ to testify at the hearing. At the Appeals Council and federal court level, a lawyer can present legal arguments to show your case was wrongfully denied. Fees charged by disability attorneys are regulated by federal law and are usually 25% of disability backpay you are owed. There are no out-of-pocket costs, and if you don’t win your case, you won’t be charged anything.

Do I need a disability attorney for a long-term disability insurance claim?

Whether you have a long-term disability insurance policy purchased through a private insurance broker or a group policy purchased with your employer, filing a claim for long-term insurance is a complex process.

The wording of LTD policies can be confusing and the laws and regulations which affect the two types of LTD insurance differ in their procedures for filing claims and appeals. An experienced LTD attorney with thorough knowledge of ERISA laws and regulations will avoid mistakes and increase your chance of success. An attorney will act on your behalf, completing your application and filing your claim in a timely manner. They can also negotiate a settlement or file an appeal for you. If it becomes necessary to file suit, an LTD attorney can prepare your case against an insurer. Most LTD attorneys handle cases on a contingency basis and charge approximately 25%-40% of a claimant’s past due benefits. You do not pay an attorney’s fee unless the attorney wins your case.

Greg Reed, a partner in the Austin law firm Bemis, Roach & Reed, has successfully assisted hundreds of clients including those suffering from Chronic Heart Failure who have been denied long term disability benefits. Give him a call today!

A client of ours from Round Rock had congestive heart failure, uncontrolled arrhythmias, and a surgically implanted pacemaker.

This previous heart condition was later complicated by a paralyzed diaphragm that caused chronic Pulmonary Insufficiency. The client was determined to have a Class 5 physical impairment by her treating physician, a Board Certified Cardiologist. She was similarly certified as suffering a Class 5 physical impairment by a Board Certified Pulmonologist. She satisfied Social Security’s criteria for total disability under at least three separate sections. Her pathology was demonstrated by multiple, objective tests and she had been certified as totally disabled by a cardiologist and a pulmonologist.

The former president of a company in Houston had been receiving disability benefits, and then was denied.

The Social Security Administration concurred with his physicians that he was disabled from any gainful activity, much less his former occupation as president of a multi-national corporation. At the time of denial, over ten years after the initial disability determination, he was placed on a heart transplant list. The physician on whom Hartford allegedly relied to deny benefits stated that the client could not work at any occupation.

Author: Attorney Greg Reed has been practicing law for 29 years. He is Superlawyers rated by Thomson Reuters and is Top AV Preeminent® and Client Champion Gold rated by Martindale Hubbell. Through his extensive litigation Mr. Reed obtained board certification from the Texas Board of Legal Specialization. Greg is admitted to practice in the United States District Court - all Texas Districts and the United States Court of Appeals-Fifth Circuit. Mr. Reed is a member of the Travis County Bar Association, Texas Trial Lawyers Association, past Director of the Capital Area Trial Lawyers Association, and an Associate member of the American Board of Trial Advocates. Mr. Reed and all the members of Bemis, Roach & Reed have been active participants in the Travis County Lawyer referral service.