Social Security Disability Insurance Determination

Approved Social Security Disability Claim Form
Social Security Disability Insurance. Courtney Keating / Getty Images

Definition of Disability

Specific criteria must be met to qualify for Social Security Disability Insurance (SSDI). The Congress of the United States has defined disability, for purposes of entitlement to disabled worker's benefits as the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

A person must not only be unable to do his or her previous work but cannot engage in any other kind of substantial gainful work which exists in the national economy, considering the persons:

  • age
  • education
  • work experience

It is immaterial whether such work exists in the immediate area, or whether a specific job vacancy exists, or whether the worker would be hired if he or she applied for work.

"The worker's impairment or impairment's must be the primary reason for his or her inability to engage in substantial gainful activity although age, education, and work experience are also taken into consideration in determining the worker's ability to do work other than previous work".

5 Step Process to Determine Disability

1--Are you working? If you are and your earnings average more than $860 a month, you generally cannot be considered disabled. Note: This amount increases annually. See: What Is Substantial Gainful Activity (SGA)?

2--Is your condition severe? Your impairments must interfere with basic work-related activities for your claim to be considered.

3--Is your condition found in the list of disabling impairments? Social Security maintains a list of impairments for each major body system which are so severe they automatically mean you are disabled.

If your condition is not on the list, Social Security must decide if it is of equal severity to an impairment on the list, and if so, the claim is approved.

4--Can you do the work you did previously? If your condition is severe but not of same or equal severity with an impairment on the list, Social Security determines if it interferes with your ability to do the work you did in the last 15 years. If it does not, your claim is denied. If it does, further consideration is given.

5--Can you do any other type of work? If you cannot do the type of work you did in the last 15 years, Social Security determines if you can do any other type of work with consideration given to age, education, past work experience, and transferable skills. If you cannot do any other type of work, your claim is approved. If you can, your claim is denied.

What Is Residual Functional Capacity?

Residual Functional Capacity (RFC) is the total of what one is left capable of doing after impairments have taken their toll. Social Security identifies the level of work capability in categories of:

Sedentary work

Sedentary work is defined as "involving lifting no more than 10 pounds at a time and occasionally lifting and carrying articles like docket files, ledgers, and small tools". Although sitting is primarily involved in a sedentary job, walking and standing should be required only occasionally. Standing and walking should total no more than 2 hours per 8-hour workday while sitting would total about 6 hours per 8-hour workday. Most unskilled sedentary jobs demand good manual dexterity for repetitive hand and finger motions.

Light work

Light work is defined as "lifting no more than 20 pounds at one time with frequent lifting or carrying of objects weighing up to 10 pounds". A good amount of standing and walking, approximately 6 hours of an 8-hour workday, is usually required for jobs in this category. Good use of hands and arms for grasping and holding is important also. A seated position which involved extensive pushing and pulling of hand or foot controls would be included in the light work category too.

Maximum RFC

  • In the age group 18-44, the maximum residual functional capacity allowed is "less than sedentary".
  • For literate people of all education levels between age 45-49, the maximum RFC allowed is also "less than sedentary".
  • Above age 50, with consideration given to education, and previous work experience, the maximum RFC increases to sedentary, light, or medium.

The Standard of "Pain"

In 1984, Congress passed the Social Security Disability Benefits Reform Act, which defined the standard of judgment on pain. It stated that:

"An individual's statement as to pain or other symptoms shall not alone be conclusive evidence of disability as defined in this section; there must be medical signs and findings established by medically acceptable clinical or laboratory diagnostic techniques which show the existence of a medical impairment that results from anatomical, physiological or psychological abnormalities which could reasonably be expected to produce the pain or other symptoms alleged".

Though this act had an expiration date of 1986, it became the standard of judgment. In 1988, Social Security ruled there need not be objective evidence of the degree of pain.

Factors Used in the Judgement of Pain

Several factors are used in the standard judgement of pain including:

  • the nature of the pain
  • locations
  • onset
  • duration
  • frequency
  • radiation
  • pain intensity

Other Factors

Other factors which must be considered in determining proof of pain include:

  • what causes the pain and makes it worse
  • name, dosage, effectiveness, and side effects of pain medications
  • treatment for pain relief other than medications
  • functional restrictions
  • daily activities

Other Symptoms and Health Problems

Many other health problems can directly interfere with an individual's ability to work. These effects are also given consideration in the disability determination process. Factors considered can include health problems such as:

Listing of Impairments

The specific list of severe impairments used by the Social Security Administration to decide disability cases from Social Security Disability Determination (The Blue Book).

Arthritis is considered under the Musculoskeletal Body System and has several specific medical listings or categories.

1.00 Musculoskeletal System

1.01 Category of Impairments, Musculoskeletal

1.02 Active rheumatoid arthritis and other inflammatory arthritis

1.03 Arthritis of a major weightbearing joint (due to any cause)

1.04 Arthritis of one major joint in each of the upper extremities (due to any cause)

1.05 Disorders of the spine

1.08 Osteomyelitis or septic arthritis (established by X-ray)

14.00 Immune System

14.01 Category of Impairments, Immune System

14.02 Systemic lupus erythematosus

14.04 Systemic sclerosis and scleroderma

Problems to Overcome in Receiving Social Security Disability Benefits

More than one million people file for disability benefits with the Social Security Administration each year.

Do You Need Representation?

Though initially designed to make it easy for people to represent themselves, it did not take long for representatives to become involved in the disability process. Representation in a Social Security Disability case can be valuable since:

  • learning the details of the system can be difficult.
  • rules are increasingly complex.
  • experts know the details of the process.
  • experts may improve your odds of winning disability benefits.

Sources:

SSA Publication No. 05-10029, 5/1996

How to Apply for and Win SSA Disability Benefits, 1997 3rd Edition, by Frederick A. Johnson

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