The first part of this article concerns the most basic eligibility requirements for Social Security disability (SSDI) and SSI and the second and third parts concern how disability decisions are rendered.
Basic Eligibility
To be awarded Social Security disability benefits, an applicant must prove the following to be medically eligible:
- They must have a condition, physical or mental, that is considered severe enough to have a significant effect on their ability to do basic work-related tasks.
- The condition must have lasted, by the time a disability determination has been rendered, one full year...or it must possible, based on the medical evidence available, to make a projection that the condition will last one full year.
- The condition must be severe enough that it prevents the claimant from working and earning a monthly amount equal to what is known as SGA, or substantial gainful activity.
An applicant must also be eligible for the SSDI program by virtue of having worked and paid Social Security taxes for many years or for the SSI program by having low income and assets.
Learn more about eligibility guidelines for SSDI and SSI.
The Decision-Making Process
Claims for SSDI and SSI are processed in the following steps.
1. A disability claim is taken by Social Security; typically, this occurs at a Social Security field office.
2. After the disability interview has been conducted, the appropriate paperwork has been completed, and the claim has been entered into the system, it is then transferred to a state agency (Disability Determination Services, or DDS), where it is assigned to a disability examiner.
3. The disability claims examiner has the responsibility of rendering a medical determination on the case. To do this, the examiner will begin the process of gathering the claimant's medical records. This process may take weeks or even months. Once the records have been gathered, the examiner will, in consultation with medical and mental consultants (physicians and psychologists who are assigned to the examiner's work unit), examine the case to determine the following:
- The nature of the claimant's past work.
- The requirements of the claimant's past work.
- The claimant's mental or physical limitations that exist as a result of their condition.
- Whether or not the claimant can return to the past work, based on current mental or physical limitations.
- Whether or not the claimant can perform other types of work.
Claimants who are found to be unable to perform their past work and are also found to be unable to perform some type of other work will typically be determined to be disabled and thus eligible to receive Social Security disability or SSI disability benefits.
How Disability Determinations Are Made
The most important two things in a disability case are a person's work history and medical records.
A person's work history can play a large role in deciding the outcome of a case because whether you can work your prior job depends on what skills and functions it requires. For this reason, claimants should provide full and detailed information regarding their work history when they are asked to complete and return work activity questionnaires. The skills involved in your prior job will also be taken into account when the claims examiner decides whether you can be expected to do another type of job.
Medical records are key to proving a case. Your medical record should contain both objective evidence like test results but also your doctor's subjective opinion on the specific tasks you can and cannot do. Claimants should provide exhaustive detail regarding the history of their medical treatment at the time of the application (and they should also do this when appeals are filed). Additionally, claimants whose cases are being processed and who have obtained recent medical treatment should report this treatment to the claims examiner (or administrative law judge if your case has reached an appeal hearing).
