Obtaining disability benefits for Schizophrenia

Can I qualify for disability benefits if I am suffering from the effects of Schizophrenia?

Author Attorney Greg Reed:
Updated: 1/25/2024

Approximately 3.2 million Americans have schizophrenia, a mental illness that interferes with a person’s ability to think clearly, manage emotions, make decisions, and relate to others.

People with schizophrenia often lose touch with reality and some are totally unaware that they even have the disorder, making it difficult to treat. Schizophrenia commonly affects men and women between the ages of 16 and 30, but is rarely diagnosed before the age of 12.

The Social Security Administration recognizes schizophrenia as an impairment in its Blue Book under Section 12.03 and has strict criteria that must be met.

The first signs of schizophrenia are often a change of friends, sleep problems, and isolating oneself, symptoms that can be confused with depression or other psychosomatic disorders. Other symptoms of schizophrenia vary in severity and include:

•   Hallucinations – hearing voices or seeing things others cannot see
•   Delusions – false beliefs that don’t change even when presented with conflicting facts
•    Unusual or dysfunctional way of thinking
•   Agitated body movements or catatonia
•   Speaking in a flat, disconnected manner
•   Showing little interest in everyday life
•   Reduced expression of emotions
•   Difficulty beginning and sustaining activities
•   Changes in memory or aspects of thinking
•   Inability to understand information and make decisions
•   Difficulty focusing and paying attention
•   Trouble sustaining relationships

These or a combination of these symptoms can cause you to miss work and jeopardize your ability to maintain employment.

Before giving a diagnosis of schizophrenia, a doctor must first rule out other conditions such as a brain tumor or bipolar disorder.

There is no cure for schizophrenia, but the disorder can be managed with anti-psychotic medications, psychotherapy, self-management strategies and education. Learning coping skills can enable a person with schizophrenia to continue a normal routine of attending school or working. Though many people respond well to medication and are able to hold a job, many cannot work. Demonstrating that you are following your doctor’s treatment plan is an important part of qualifying for disability benefits.

Schizophrenia and Qualifying for Disability Benefits.

The Social Security Administration recognizes schizophrenia as an impairment in its Blue Book under Section 12.03 and has strict criteria you must meet:

  Medical documentation of one or more of the following:

1.    Delusions or hallucinations;
2.   Disorganized thinking (speech); or
3.   Grossly disorganized behavior or catatonia.


AND

  Extreme limitation of one, or marked limitation of two, of the following areas of mental functioning:

1.   Understand, remember, or apply information.
2.    Interact with others.
3.   Concentrate, persist, or maintain pace.
4.   Adapt or manage oneself.


OR

  Your mental disorder in this listing category is “serious and persistent;” that is, you have a medically documented history of the existence of the disorder over a period of at least 2 years, and there is evidence of both:

1.   Medical treatment, mental health therapy, psychosocial support(s), or a highly structured setting(s) that is ongoing and that diminishes the symptoms and signs of your mental disorder; and
2.    Marginal adjustment, that is, you have minimal capacity to adapt to changes in your environment or to demands that are not already part of your daily life.

It is important to note that the Social Security Administration realizes that some people cannot satisfy the requirements of the listing because they live in highly protected and supervised situations, such as a hospital or clinic, that make their functional abilities appear better than they would be in real-life situations where the stress and demands of daily life is much greater.

Social Security is more interested in a person’s functional limitations than a specific psychotic diagnosis.

Some applicants who suffer from schizophrenia who do not meet the requirements of the listing are still unable to hold any job.

These applicants may not exhibit the stereotyped symptoms of schizophrenia, such as hearing voices, but they are unable to maintain organized thought patterns or have difficulty with social interactions. If an applicant can prove that their impairment is ongoing and is so severe it prevents them from performing even unskilled labor, they may qualify for SSI or SSDI on the basis of 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.

Most vocational experts will find a person to be unemployable if their condition or the treatment rendered for the condition causes the person to regularly be absent two or more days a month or be “off-task” 15% or more of the workday.

Although most people who apply for Social Security Disability Income under schizophrenia are eventually approved, the process is challenging and best done with the assistance of a qualified disability attorney.

Considering the range of difficulty with concentration, memory, and dysfunctional thought patterns a person with schizophrenia frequently experiences, they may not be capable of representing themselves. An experienced attorney who can obtain medical records and physician statements and handle appeals and hearings is much more likely to achieve a positive result.

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, diabetes or high blood pressure.

One disorder by itself may not match the requirements of an impairment as stated in Social Security’s Blue Book, but if you have more than one medical condition, Social Security must consider how those health issues combined limit your ability to hold a job and perform necessary daily tasks.

Social Security also has basic financial requirements.

Before you are eligible for Social Security disability benefits, you must satisfy some basic financial requirements.

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 $1,550 per month in 2024 for nonblind applicants and $2,590 per month for blind applicants.

What if I don’t qualify for SSDI?

If you haven’t worked long enough to earn enough work credits, or if you earn too much income, 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, you should 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. However, LTD coverage is good only as long as you are employed, 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 also apply for SSDI.

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 initial applications are denied, but 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?

Qualifying for Social Security Disability benefits is problematic because the requirements of Social Security’s impairment listing are very difficult to decipher.

Your chances for approval are increased significantly if you have an experienced disability attorney who can gather your necessary medical evidence and even write a brief explaining why you qualify. 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.

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.