How Do You Qualify Medically for Social Security Disability or SSI?
Here's an overview of how Social Security decides whether you are medically eligible for disability benefits.
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Despite what you might hear, there is an objective system in place at the Social Security Administration (SSA) to qualify individuals for Social Security benefits based on disability. The Social Security field office that receives your application first checks to make sure you are financially eligible for SSDI or SSI benefits and that you aren't doing a substantial amount of work, and then forwards your application to Disability Determination Services (DDS), a state agency. DDS determines whether your medical condition is so severe that you should qualify for benefits.
How Does the Medical Disability Qualification Process Work?
DDS follows a sequential evaluation process to determine if you're medically eligible for benefits. In this order, DDS determines whether your impairment is severe, whether it matches (or is equivalent to) a Social Security disability "listing," whether are are able to do your past job, and whether you can be expected to do any type of job, given your limitations, age, education, and skills.
The SSA and DDS have a book that lists the approval criteria for certain impairments, nicknamed the "Blue Book." Most serious medical impairments have specific approval criteria, or qualifications, listed in the blue book. For example, if you have congestive heart failure (CHF), the DDS disability examiner reviewing your case would check the manual of impairment listings against your medical evidence to see if your condition meets the listed requirements for CHF. Alternatively, you can argue that your symptoms are equivalent to the criteria in a disabilty listing and as such should qualify you for benefits.
Learn more about getting approved based on a disability listing.
What About Conditions Not Listed in the Blue Book?
Not every condition is listed in the blue book. Fibromyalgia, for example, is not in the blue book. Nor is irritable bowel syndrome, adult diabetes, carpal tunnel syndrome, or a variety of other problems. This doesn't mean you can't get disability benefits.
How do you qualify for Social Security disability if your particular problems are not covered in the disability listings? If a child's condition doesn't meet the requirements of a specific medical listing, the child could still be found disabled if his or her condition is considered functionally equivalent to the listings. For more information, see our article on functional equivalence for SSI disability.
If you are an adult and your condition does not meet or equal the requirements of a listing, you can get what is called a med-voc allowance (medical-vocational allowance). A med-voc allowance is how most people get approved for Social Security disability.
This is how a medical-vocational allowance works. DDS looks at your medical records and prepares an RFC (residual functional capacity) assessment, which indicates your exertional limits, such as how long you can stand, how much you can lift, whether you can bend and stoop, and so on. The RFC assessment will indicate whether are you capable of only sedentary work, light work, or medium work.
Can You Do Your Past Job?
After DDS finishes the RFC assessment, the agency will assess whether or not you can return to your past work, based on your RFC limitations. For example, if your RFC says you are capable of no more than light work, and your past work was at the medium exertion level (that is, the job required being able to lift 50 lbs occasionally and 25 lbs frequently), then you can't reasonably be expected to return to your past work.
DDS finds that most people who apply for Social Security benefits based on disability are not to be able to return to their past work. In other words, that's not usually how Social Security denies people. (If you are denied on this basis, see our article on proving you can't do your past jobs.)
Can You Do Your Other Work?
The final step in the process is whether you can do "other work." If you have a physical impairment, the DDS examiner first looks at medical-vocational guidelines, called the "grids," or "grid rules." These rules states whether someone of your age, education, work history, and RFC level is disabled or not.
If the grids say you're disabled. If you are over 50 and your situation matches the particular vocational factors of a what's called a grid rule, you could be found disabled right away. The claims examiner won't even evaluate whether your limitations actually prevent you from doing any type of job. For instance, someone who is 59 years old, has a sedentary or light RFC, and has only done unskilled work will be found automatically disabled. Read about the grid rules to find out whether there is one that applies to your age and work history.
If the grids are silent. If there is no grid rule for your particular situation, the DDS examiner will investigate whether there are other forms of less demanding work that you might be able to switch to. For the DDS to say you can do another type of work, it has to be work that you are exertionally capable of doing, and if it is skilled work, it has to be work which your particular job skills will transfer to. For example, if you used to do a skilled mechanic-type job that required medium exertion, but now, because of your medical condition, the examiner gives you an RFC for only light work, the examiner will try to find other light work to send you to, such as a mechanic job that involves less lifting and is classified as light exertion.
When the claims examiner looks for other jobs you can do, he or she uses a huge volume called the Dictionary of Occupational Titles that lists thousands of jobs, including many that may not exist in your area. The claims examiner might also consult with a vocational analyst for help.
DDS will usually say that there is some other type of job you can do that's within your limitations; that's called "sending you to other work," and is how most people are denied for Social Security. (When DDS "sends you" to an "other work" job, that doesn't mean that DDS actually sends you anywhere. That's just the terminology used to describe the process used to turn you down for benefits by saying that you are capable of doing another job.) It will be up to you to appeal the denial and prove that you can't do "other work." For more information, see our article on proving you can't do other work.
If the grids say you're not disabled. If a grid rule says that you're not disabled, you'll need to show there are reasons why the rule doesn't apply to your situation. For more information, see our section on the grid rules.
People in their fifties usually have an easier time getting approved for this reason: Social Security doesn't commonly expect individuals in their fifties to be able to transfer work skills and learn a new job as easily as a younger person might, especially for older people without much formal education. So, for this kind of disability applicant, it's less likely that they will be "sent" to other work. The grids have different rules that apply to those over age 60, age 55-69, age 50-54, and under age 50, and they direct a finding of disabled much more often in the rules for those over 55 and 60.
Learn more in general about how Social Security decides if you can work.
DDS goes through a similar process when a disability claimant files for disability due to cognitive, emotional, psychiatric, or psychological impairment: that is, first the examiner looks to see if the claimant's condition meets or equals a listing and then the examiner assesses whether the claimant can function well enough to do his or her prior job or any other work. (Read our overview on getting disability for mental, emotional, or psychological impairments.)
For individuals with emotional or mental problems, such as depression, anxiety, or learning problems, the disability examiner will sometimes find that the individual is incapable of performing SRRTs. These are "simple routine repetitive tasks." When an individual is found to be incapable of SRRTs, Disability Determination Services will have trouble sending that person to "other work." So, if you have depression, anxiety, or any other "mental" impairment in addition your physical problems, get this condition documented: Be seen by a psychiatrist or a psychologist. In some instances, this can help you in getting your disability case approved. (Read our article on how moderate depresison or anxiety can help you get disability benefits.)
Return to our series of articles on the Medical Eligibility Rules for Social Security Disability.