When Are Disability Benefits Available for Congenital Heart Disease?

You can get disability benefits if you have congenital heart disease that causes cyanosis or severe functional limitations on your ability to work.

By , J.D. · University of Baltimore School of Law
Updated by Diana Chaikin, Attorney · Seattle University School of Law

Congenital heart disease is the medical term for a wide range of heart abnormalities ("defects") that have been present since birth. Congenital heart disease is the most common type of birth defect and comes in many forms. Some heart defects don't affect your quality of life, while others can cause significant functional limitations.

If you have a kind of congenital heart disease that limits you so much that you're unable to work full time, you may qualify for Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).

What Is Congenital Heart Disease?

Any problems with the structure of the heart that develop before birth are referred to as "congenital." Doctors classify congenital heart disease into two categories: cyanotic or acyanotic.

Cyanotic Heart Diseases

Cyanotic heart diseases cause the skin to turn blue ("cyan" is a shade of blue) the heart isn't able to provide enough oxygen-rich blood through the body. Here are some examples of cyanotic heart diseases:

  • Tetralogy of Fallot ("FAL-oh") is a combination of four defects that involve multiple malformations of the heart structure, causing reduced blood flow.
  • Pulmonary atresia occurs when the valve that controls blood flow from the heart to the lungs doesn't form at all.
  • Tricuspid atresia (also called Ebstein's anomaly) is a missing or misplaced valve between the upper and lower heart chambers.
  • Dextro-transposition of the great arteries (d-TGA) happens when the two main blood vessels (arteries) of the heart are switched in position from where they should be.
  • Total anomalous pulmonary vein connections (TAPVC) occur when the veins that bring blood back to the heart don't connect to the heart in the right spot.
  • Truncus arteriosus is when the aorta and pulmonary artery fail to divide, causing one blood vessel to come out of the heart instead of the usual two.
  • Hypoplastic left heart syndrome occurs when the entire left side of the heart is too small.

Acyanotic Heart Diseases

Acyanotic heart diseases don't cause the bluish tint to the skin characteristic of cyanotic heart defects. Some acyanotic defects include the following:

  • Ventricular or atrial septal defects are holes in the walls dividing the ventricles (lower chambers of the heart) or the atria (upper chambers).
  • Patent ductus arteriosus (PDA) is an opening between the two major blood vessels leading from the heart.
  • Aortic or pulmonic valve stenosis occurs when the major blood vessels of the heart are narrowed, restricting blood flow.
  • Coarctation of the aorta is the narrowing of a part of the aorta, the body's main artery.
  • Endocardial cushion defects compose a range of malformations of the heart walls or atrioventricular valves.

Can I Get Disability for Congenital Heart Disease?

In order to get disability benefits, the Social Security Administration (SSA) first needs to see that you meet the non-medical eligibility requirements for the type of benefit you're applying for. For example, qualifying for SSDI requires that you've earned enough work credits, while SSI is needs-based and depends on how much money you have in certain assets.

Once the SSA is satisfied that you're eligible for at least one of the disability benefit programs, the agency will need to see that your congenital heart disease keeps you from working at the level of substantial gainful activity for at least twelve months. If you haven't (or aren't expected to be) working for a year and you qualify for SSDI or SSI, Social Security can decide that you're disabled if you either meet a listed impairment or if you aren't able to work at any jobs.

Congenital Heart Disease Listing Requirements

A listed impairment is a condition that the SSA considers exceptionally severe. Each listing has several requirements that need to be documented in your medical records. If you meet or equal the criteria of a listing, you'll be automatically approved for disability.

Social Security evaluates both cyanotic and acyanotic congenital heart diseases under listing 4.06. In order to be approved under listing 4.06, you'll need to have a doctor diagnose you with congenital heart disease—usually after you've had a cardiac catheterization.

Your medical records also need to contain certain kinds of symptoms and test results that demonstrate that your heart isn't working effectively. You'll need to provide evidence of at least one of the following:

  • Cyanosis (blue skin) at rest and test results showing poorly oxygenated blood. (You can show this with either a hematocrit—a measure of the percentage of oxygenated cells in your blood—of at least 55%, arterial oxygen saturation of less than 90%, or resting plasma oxygenation of 60 Torr (a unit of measurement) or less.)
  • Occasional abnormal blood flow of a type called "right-to-left shunting" that causes cyanosis with physical effort (also known as Eisenmenger's physiology), and test results showing measured arterial plasma oxygenation of 60 Torr or less with brisk movement.
  • Secondary pulmonary vascular obstructive disease that causes your pulmonary blood pressure to make up 70% or more of your overall blood pressure.

Because these listing requirements are particularly technical, you should ask your doctor or cardiologist for advice on whether you meet these criteria. Your doctor might even agree to submit a medical source statement to Social Security that explains in plain language why you meet (or "equal") listing 4.06.

What If My Condition Doesn't Meet the Listing?

Even if your congenital heart disease doesn't meet the criteria of Listing 4.06, you can still qualify for disability if you can show that your congenital heart disease causes too many work limitations for you to be able to work full-time. Social Security considers your medically documented limitations by assessing your residual functional capacity (RFC).

What Your RFC Should Include

Your RFC is a set of restrictions on your ability to perform work-related activities as a result of your congenital heart disease, as well as any other medical conditions you're being treated for. For example, if you get out of breath easily, your RFC will state how long you can walk, sit, or stand, and how much weight you can lift and carry.

The more severe your symptoms are, the more restrictions you'll have in your RFC. And the more restrictions you have in your RFC, the more unlikely you'll be able to work at any job.

People with very severe congenital heart disease might need frequent and unscheduled rest breaks or might miss work on a regular basis if they're too fatigued. They can also be found disabled if they'd rack up too many absences or spend too much time "off-task" for employers to hire them.

What Medical Evidence Supports Your RFC

Social Security looks at all medical evidence when determining what restrictions your RFC should contain. The agency will be on the lookout for the following:

  • blood tests
  • electrocardiograms (ECGs or EKGs)
  • catheterizations
  • imaging results (such as ultrasounds, X-rays, or MRIs)
  • surgeries
  • hospitalizations, and
  • medication lists, including side effects.

Probably most importantly, the SSA will review your doctors' progress notes in order to get a sense of how severe your condition is and how well you've responded to treatment. Having consistent medical treatment is one of the biggest factors that determine whether Social Security finds you disabled, so if you haven't seen a doctor in a while, you should consider finding one in your area and price range.

How Social Security Uses Your RFC to Determine Disability

The agency will compare the limitations contained in your RFC with the requirements of your prior jobs to determine whether you can do your past work. If Social Security thinks that you can do your past work despite your congenital heart disease, you won't qualify for benefits.

But if the SSA doesn't think you can return to your past work, the agency then has to determine whether any other jobs exist that you can do.

When deciding whether you can do other jobs, Social Security considers how old you are, how far you went in school, and whether you have any transferable work skills. If you're over the age of 50, you might be able to qualify for disability under the medical-vocational grid rules even if you could do other work with your RFC. But most people under the age of 50 have to show that they can't do even basic sit-down jobs to qualify. In Social Security lingo, this is called having a "less-than-sedentary" RFC.

Additional Information for Heart Disorders

Many people with congenital heart disease are successfully treated as children and thrive into adulthood with little or no residual concerns. But complications or comorbid (occurring at the same time) conditions can make it harder to function, especially as we age. For more information, see our page with more details on specific cardiovascular impairments.

Children with serious heart disorders may be entitled to SSI under slightly different rules than those for adults. If you're seeking disability benefits on behalf of a child, you can earn more in our article on getting SSI benefits for a child with a congenital heart defect.

Updated August 1, 2023

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