How the SSA Decides If You Are Disabled

To decide whether you are disabled, the Social Security Administration uses a step-by-step process involving five questions. They are:

The Social Security Administration (SSA) uses a variety of guidelines and criteria to determine disability. In seeking benefits, a claimant must not simply demonstrate a medical diagnosis. The applicant must also adhere to a rigid set of rules. When applying, a disability claimant will need to go through a complicated process.

Social Security Disability Insurance (SSDI) benefits are delivered on the basis of several criteria. These criteria include a combination of financial, vocational and medical qualities. An applicant for disability will be carefully examined by the SSA. The SSA will only make a determination when all criteria are clearly met.

Social Security Disability Criteria

Eligibility for disability benefits is based on both financial and non financial criteria. When applying for Social Security Disability Insurance (SSDI), an applicant must first show that he or she is insured. This financial eligibility is based on both past earnings and the number of quarters worked immediately prior to the disability beginning.

Firstly, the applicant must demonstrate a certain number of quarters worked while paying Federal Insurance Contributions Act (FICA) contributions. Secondly, the applicant must demonstrate a certain number of quarters worked directly up until disability onset. The Social Security Administration (SSA) also considers a number of demographic variables such as age, family and work status. Many applicants do not realize how complex the application process can be.

Many of the medical criteria for SSDI are not fully medical. These combinations of medical and vocational criteria determine eligibility or ineligibility for benefits. Applicants can even be deemed ineligible on grounds that are unrelated to actual medical results. For example, if a claimant fails to submit to proper medical examinations, the applicant will be denied.

Other refusals of procedures can result in rejection.

The process of disability application is typically two-fold. Initially, an SSA field office evaluates the application. This stage is strictly based on financial, non medical assessments. If the applicant meets these criteria, then the next stage commences.

At the next stage, the disability claimant moves from SSA field offices to Disability Determination Service (DDS) agencies in the state of the application. This is where medical determinations are made. However, many applicants do not pass this stage. If the claimant is denied, there are several options. Following a rejection at this initial DDS level, the applicant can pursue multiple appeal stages.

The first appeal stage includes appealing to the Disability Determination Service (DDS) that offered the denial. This step is called reconsideration. Following reconsideration, the case can be brought before an administrative law judge (ALJ).

If this does not reach a favorable outcome, the claimant may go before the Appeals Council.The final step in the appeals process is federal court. If this court denies the applicant, then the claimant is officially ineligible for disability benefits.

The determination process typically involves 5 steps. These steps are incorporated as a comprehensive evaluation of medical, vocational and financial information.Together, this information helps to determine if the applicant is truly disabled, unable to work gainfully, and in need of continuous disability benefits. The 5-step process begins with the evaluation of substantial gainful activity (SGA) as it pertains to work capacity.

Social Security field offices screen out applicants who both work, and earn income, beyond the benchmark for SGA. This is a measure of work activity. SGA is defined as “work that involves doing significant and productive physical or mental duties and is done (or intended) for pay or profit.”

Applicants who earn beyond the SGA threshold amount are typically denied. This denial is based on the assumption that these individuals already make enough to provide for themselves and others. In other words, these applicants are usually deemed capable. This happens because the SSA looks for total disability.

If an applicant is able to earn beyond the SGA threshold, that applicant is likely not suffering from a total disability. Partial disabilities and temporary disabilities do not garner Social Security disability benefits.

Medical Disability Guidelines

If the applicant is able to show that he or she does not exceed SGA threshold, then the next step begins. In Step 2, the applicant must demonstrate a severe impairment. This impairment requires a medical screening for determination. Whereas Step 1 determines the SGA threshold through a financial assessment, Step 2 determines this threshold through a medical diagnosis.

A condition is considered severe if it is supported by “medical evidence” that said condition is a “physical or mental impairment or combination of impairments” of “sufficient severity.”

If the medical evidence only establishes a slight abnormality or combination of slight abnormalities, then that condition does not qualify as severe. Thus the determination is made that the applicant is “not disabled” because the condition is “not severe.”

Claimants must also show that they have endured the disability for a certain duration. The applicant is denied if his or her impairment (1) is not expected to lead to death, and (2) has neither lasted a year nor is expected to last for a year.

Following this determination, the applicant moves to Step 3. This steps involves the assessment of medical evidence to determine if the claimant’s impairments meets the Listing of Impairments. This list has over 100 impairments that are most severe.

If an applicant is suffering from one of these impairments, that applicant is considered disabled strictly on medical grounds. In these cases, the applicant requires no further evaluation. Even if an applicant does not have one of the 100 impairments, that applicant may still qualify.

If the applicant is deemed to “equal the Listings,” that applicant is permitted without further evaluations. If an applicant at Step 3 does not have a listed impairment or “equal” impairment, then the applicant must move on to Step 4.

At Step 4, the DDS considers whether an applicant has a certain level of so-called residual functional capacity (RFC). This term refers to the skills and tasks required to complete past work. The evaluation of RFC also determines the extent to which an applicant can complete basic work-related activities connected to previous jobs performed.

These jobs typically occurred within 15 years of the current application. If an applicant is determined to be capable of performing these past jobs, the applicant is denied. Applicants who are judged incapable of performing these past jobs move onto the next and final step.

The final Step 5 addresses applicants who are determined to be severely impaired. This ultimate evaluation seeks to judge the ability of the applicant to perform any other type of work. Can the applicant perform any other type of work in the national economy?

This step considers the applicant’s residual functional capacity (RFC) as well. The DDS also examines the applicant’s other vocational factors, including age, education and work experience.

In the end, a determination is made as to whether the claimant can perform other work not previously performed.

Step 5 features an assessment of guidelines called the medical-vocational guidelines, or the vocational grid. If the applicant is determined unable to perform these jobs, the applicant is accepted.

Child Disability Criteria

Children also undergo a similar approval and denial process. Except, in the case of disabled children, the family unit is assessed as well. These determinations factor family earnings and income. A child engaged in substantial gainful activity (SGA) will be denied.

Children must also undergo medical screenings just like adults do. The DDS will determine if children are severely impaired, meeting various listings and medical disability criteria. Children must also meet duration  criteria. Again, if a child does not meet the duration criteria, the child is denied.

The child will be denied if the impairment (1) is not expected to lead to death, and (2) has neither lasted a year nor is expected to last for a  year.

Children who are affected by impairments must prove that those impairments are severe. This means that the impairments must align with, or be equal to, those impairments listed. Common listed physical  and mental impairments include asthma, cerebral palsy and  psychological disorders.

Even if children are severely impaired, they may still not meet the criteria for a medically listed impairment. If this is the case, such children will be closely assessed based on six general domains of functioning. These areas help explain what a severely impaired child can and cannot do in normal, everyday life.

The six domains of functioning include:

(1) Acquiring and utilizing information,

(2) Engaging and completing tasks,

(3) Interacting and relating with others,

(4) Moving and manipulating objects,

(5) Caring for oneself, and

(6) Sustaining health and physical well-being.

There are a number of technical terms associated with deficits in these areas. A child’s impairment or grouping of impairments leads to “marked” limitations in three ways. A marked limitation prevents the child from independently starting, continuing and finishing activities in a given domain.

By comparison, an “extreme” limitation in a given domain denotes an impairment that “very seriously” interferes with that domain. If a child shows “marked” limitation in two or more of these domains, or “extreme” limitation in one of these domains, then the child’s impairments are equal to any listing. In this case, it does not matter if the child hasn’t met a formal listing. The child will be determined disabled and approved for benefits.

Overall, the SSA uses a number of criteria to determine eligibility for disability benefits. The SSA will look at vocational and medical qualifications, as well as financial criteria. Both children and adults can benefit from these disability benefits. However, the process of receiving benefits can be difficult.

This is where the best disability advocates can help. A seasoned social security lawyer can help a client finally receive the benefits deserved.