How Social Security Determines a Disability Claim

A look at the methods Social Security uses, and the factors they consider, when deciding whether or not to grant disability benefits.

Applications for Social Security disability benefits can be filed in person, over the phone, or online through your local SSA field office. After you've filed your claim, a disability claims examiner, working for a state agency called Disability Determination Services (DDS), will make an initial determination on your case, usually within three to four months. The initial decision is based on your recent medical records, reports from friends and family, and sometimes consultative medical examinations arranged by DDS.

However, only about one-quarter of disability claims are approved at the initial level, although this number is higher for individuals over 50. Instead, most people who are approved for disability benefits receive them on appeal, which consists of a hearing in front of an Administrative Law Judge. (In some states, there is an additional layer of appeals known as the reconsideration stage, which occurs between the initial level and the hearing.) 

Whether your claim is at the initial, reconsideration, or hearing level, Social Security evaluates your case through a five-step process.

Substantial Gainful Activity and Severe Impairments

At the first step, Social Security determines whether you're working, and if so, whether your earnings exceed a threshold amount known as "substantial gainful activity." In 2016, this amount for non-blind individuals is $1,130 per month before taxes. Your claim will be denied at step one if your earnings are over the SGA level, even if your medical condition would otherwise be disabling.

The second stage of the sequential evaluation is to determine which of your physical and mental impairments are "severe." In this context, a severe impairment is one that substantially limits your ability to perform basic work activities. Your condition is more likely to be found "severe" if it is documented by objective medical evidence and supported by the opinion of your doctor. Social Security will consider the combined impact of all your severe impairments in determining whether you're disabled.

Social Security's Blue Book Listing of Impairments

If you're found to have at least one severe impairment, your case proceeds to step three. At this stage, your claim will be approved only if your condition meets or "medically equals" an impairment found in Social Security's "blue book" listing of impairments. The blue book comprises more than 150 very serious medical conditions which automatically qualify a person for disability benefits. While it is relatively rare to get approved based on a listing, because the listings require an illness or disease to be quite severe to get disability, a supporting statement from your treating physician can increase your chances.

Your Residual Functional Capacity

If you don't meet or equal a listing, your case moves to step four, where Social Security determines whether you can perform any of your relevant work from the previous 15 years. This decision is based largely on your Residual Functional Capacity (RFC), an assessment of your physical and mental functional limitations. Your RFC can consist of both physical limitations (related to your ability to sit, stand, walk, lift, carry, push, or pull) and non-physical limitations (on tasks like remembering instructions, maintaining concentration and attention, and adjusting to workplace changes).

If Social Security decides that your RFC prevents you from performing your past work, your case will proceed to the fifth and final stage of the sequential evaluation.

To learn more about this important factor, see our article, What Is Your Residual Functional Capacity?

The Medical-Vocational Guidelines

If you can't do your previous work, Step five is assessing whether there is any less demanding work you can do. The easiest way to get approved for benefits at step five is via the medical-vocational rules, also known as "the grids." The grids consist of a series of tables that dictate when a person is disabled based on his or her age, education, vocational history, and exertional abilities. For example, if you're a 55-year-old individual with a high school education, a history of unskilled work, and you're limited to sedentary or light work, Social Security will find you disabled based on the grids. It is much easier for people over 50 (and especially those over 55) to be approved for benefits based on the grids.

If the grids direct a finding of "not disabled" in your case, you can still be approved for benefits via a medical vocational allowance, the most common way for disability applicants to receive benefits. If Social Security finds that there are full-time jobs that you can do despite your limitations, you will be denied benefits and you will need to appeal to continue your claim. Social Security is not required to show that such jobs are available or hiring, only that they exist. Generally a vocational expert, a person with knowledge of the labor market, assists the Social Security judge or claims examiner in determining whether jobs exist for individuals with the claimant's severe impairments.

If Social Security decides that your condition prevents you from performing any jobs that exist in significant numbers in the national economy, you will be granted a medical vocational allowance. The trick is in being able to show that, for any job Social Security says you can do, your limitations prevent you from doing the tasks required of that job. Doing this successfully usually requires the help of a disability lawyer. 

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