Multiple Disabilities: Social Security Must Consider Combined Effects
If you have multiple impairments or disabilities, Social Security will consider their combined effects when determining if you meet a listing or can't work.
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People applying for Social Security disability benefits often have more than one illness or injury that is causing their disability, making them unable to work a full-time job. Impairments that are not limiting enough on their own to qualify you for disability may still help your application when the combined effects of all of your medical conditions are considered together.
Social Security considers the combined effects of multiple impairments during two steps of the evaluation process: first, when comparing your impairments to the disability listings in the “Blue Book,” and second, during the "residual functional capacity,” or “RFC,” assessment to see whether you qualify for a medical-vocational allowance.
Combined Effects of Multiple Disabilities and the Blue Book
Social Security’s Blue Book is a list of impairments that qualify for disability when the requirements for an impairment detailed in the listing are met; in other words, the impairment listings specify when Social Security will find a medical condition to be disabling. If your medical evidence meets the requirements of an impairment listing, you will automatically be found disabled; Social Security will not need look at how your impairments limit your activities (unless specific functional limitations are requirements of the impairment listing).
Even if you do not meet the requirements of an impairment listing exactly, Social Security is required to consider whether your symptoms are "medically equivalent" to the criteria in the listing (in Social Security lingo, this is called “equaling” the listing). To equal a listing, your symptoms, diagnoses, and test results do not have to exactly match the requirements of the listing. (For more information, see our article on equaling a disability listing.)
Most importantly, Social Security is not allowed to evaluate each of your medical conditions separately to see whether your evidence equals a listing, without considering the combined effects of all your impairments together. For example, one of the ways you can meet the listing requirements for inflammatory arthritis is by showing that you have repeated flareups that limit your activities of daily living, social functioning, or ability to complete tasks, with at least two of the following symptoms: fever, extreme fatigue, malaise, or weight loss. Suppose you have been diagnosed with rheumatoid arthritis and you have repeated, severe flareups that make it very difficult to do much because of pain and stiffness, but you don't have fever, fatigue, malaise, or weight loss, so you cannot meet the listing requirements. Now suppose you also have COPD and and shortness of breath, but your FEV1 value is slightly higher than what the listing for chronic pulmonary insufficiency requires. Social Security must consider whether the combined effects of your arthritis and breathing difficulties add up to an impairment that is just as severe as the arthritis as described in the listing. In that case, Social Security should find that your impairments “medically equal” the Blue Book listing for inflammatory arthritis, and you are eligible for disability benefits
Another example involves diabetes, high blood pressure, and obesity, a trio of conditions that is becoming more common on disability applications. Until last year, the listing for diabetes mellitus required a diagnosis of the disease plus evidence of one of the following complications: neuropathy, acidosis, or retinitis proliferans. Suppose you did not have one of those three listed complications for diabetes, but you did suffer from morbid obesity and hypertension. Social Security had to consider whether the combined effects of your diabetes, obesity, and hypertension added up to an impairment that was just as severe as diabetes plus one of the three listed complications. The disabling effects of both your obesity and hypertension may well be functionally equivalent to one of the listed complications. (For 2012 and on, adult diabetes is no longer the subject of an impairment listing. See our article on getting disability for diabetes for more information.)
For more information on disability for obesity, see our article on disability benefits for morbid obesity and for more information about meeting listing requirements in general, see our section on how Social Security uses the Blue Book.
Combining the Effects of Mental and Physical Impairments
Social Security must consider the combined effects of both physical and mental impairments. The Blue Book requirements for mental impairments require Social Security to consider how limited your activities of daily living and social functioning are and whether you have problems with concentration or finishing tasks in a timely manner. Physical impairments often affect these areas as well. Social Security must consider the effect of your physical impairments when determining whether you meet the listing requirements for a mental impairment.
Likewise, your mental impairments may have effects that increase the severity of your physical impairments. For example, even moderate anxiety and depression can decrease your tolerance for pain. Social Security is required by law to consider the effects of your mental and physical impairments together.
Combined Effects and the RFC Assessment
If the combined effects of your various impairments do not equal any specific listing in the Blue Book, you may still be able to prove that your impairments are so severe that they prevent you from working full time.
Social Security will assess your physical and mental limitations to come up with your "residual functional capacity,” or “RFC.” Your RFC describes what you are able to do despite the combined effects of all your impairments. The RFC assessment indicates whether your exertional (strength-related) restrictions limit you to sedentary work, light work, or medium work, and also includes any specific nonexertional limitations you have. For example, physically you may not be able to reach overhead, bend or stoop, use hand and foot controls, and be exposed to excessive fumes. Mentally, you may be limited in your ability to work with the general public or with supervisors and coworkers, or you may require extra training and supervision.
These additional limitations from your various impairments can be very important in qualifying for disability benefits. Social Security uses your RFC to determine whether there are jobs that you can do despite your impairments, after taking into account your age, education, and work experience. There are many jobs available even for those who are limited to sedentary jobs, but having a lot of extra restrictions can make the pool of available jobs much smaller. If the pool of jobs available to you is too small (see our article on being able to do only a limited range of sedentary work), Social Security will grant you disability benefits via a "medical-vocational allowance."
It's the job of a disability attorney to argue that each additional limitation you have rules out additional jobs. For more information on ruling out jobs, see our article on eliminating jobs on cross-examination, and for more information on how the RFC assessment is used to rule out jobs to qualify you for a medical-vocational allowance, see our section on how Social Security uses your RFC to determine disability.
Social Security must consider all of your impairments to come up with your RFC, even impairments that are not severe and are not listed in the Blue Book. Things like mild anxiety around people or occasional incontinence that requires frequent bathroom breaks must be considered in the RFC assessment even though they would not, standing alone, qualify you for disability, or even get you into the formal disability determination process. For this reason, it's important to include any impairment or medical condition that might affect your ability to work in your application for disability, even those that seem minor. For more information on how Social Security combines severe and non-severe impairments in your RFC to determine whether you can work, see our article on combining severe and non-severe impairments to win a medical-vocational allowance.