Congenital (con-JENN-it-uhl) heart defects are one of the most common kinds of birth defects, affecting up to 44,000 newborns each year. They can be harmless, or they can cause long-term problems that require extensive treatment. If your child has a congenital heart defect that interferes with their growth and development for at least twelve months, they may qualify for Supplemental Security Income (SSI) disability benefits.
Congenital is a medical term meaning "present since birth." When a child is born with an abnormal heart structure, doctors say they have a congenital heart defect.
The most common congenital defects fall into one of these categories, but some defects (such as Tetralogy of Fallot) can involve multiple problems:
Symptoms of congenital heart defects vary depending on the type and severity of the defect. Common symptoms include:
Doctors have a range of options for treating congenital heart defects in children. Mild defects may be managed with medication, while more severe defects may require heart surgery or even transplantation.
Children from low-income families who have severe congenital heart defects may qualify for SSI disability benefits. Because SSI is a needs-based program, if your family has income and assets above the resource threshold ($2,000 per individual and $3,000 per couple), your child won't be able to get disability benefits, no matter how severe their heart condition is.
Once Social Security has determined that your child's family meets the financial requirements for SSI eligibility, the agency will start gathering information about your child's heart defect. This means asking your child's doctors—ideally including at least one cardiologist—for medical evidence that the heart defect is causing significant limitations in your child's functioning.
Some conditions are so serious that when Social Security sees specific evidence of them in the medical records, the agency will automatically approve the application for benefits. Getting awarded benefits this way is called "meeting a listed impairment."
Social Security has several listed impairments for children with congenital heart defects. Each listing has its own set of criteria that need to be present in your child's medical records in order to get automatically approved for benefits.
Several congenital heart diseases are covered by this listing:
For cyanotic disease, doctors can conduct certain tests in order to determine whether your child has chronically low blood oxygen.
Because Listing 104.06 requires specific test results, the language used in the listing is highly technical. Some of the more technical terms are described below. Your child's medical records will need to show evidence of at least one of the following test results or symptoms in order to get disability under Listing 104.06.
Children whose congenital heart defect causes them to have an enlarged heart (cardiomegaly) or ventricular dysfunction can meet the requirements of Listing 104.02 with evidence of one of the following:
The exact heart and breathing rates needed to meet the listing vary by age:
|Heart rate (beats per minute)
|Respiratory rate (per minute)
|Under 1 year
|1 through 3 years
|4 through 9 years
|10 through 15 years
|Over 15 years
Determining whether a child's growth has been significantly delayed is a bit more complicated. Social Security uses a metric known as the body mass index (BMI) to calculate your child's weight-to-weight ratio, and then compares their BMI to the normal developmental range based on how old they are. If your child's BMI is less than the third percentile (meaning they're smaller than 97% of children the same age), Social Security will find that they meet Listing 104.02.
Congenital heart defects can frequently cause irregular heartbeats (arrhythmias). If, despite treatment, your child has recurring abnormal heartbeats, they may qualify for disability under Listing 104.05 when:
As you can see, the above listing requirements are complicated. It can be helpful to speak with your child's cardiologist for their input on whether your child meets the criteria. If the doctor agrees to write a medical source statement that the listing requirements are met, even better—Social Security values the opinions of doctors who regularly treat your child in their area of specialization.
Children with heart defects that don't meet the requirements of the cardiovascular listings can still qualify for benefits if their symptoms are functionally equivalent to the listings.
Social Security determines functional equivalence by looking at medical records, teacher's notes, and standardized test results to determine whether your child has "marked" limitations in two, or an "extreme" limitation in one, of the following functional areas ("domains"):
"Extreme" limitations are worse than "marked" limitations. Domains where your child rarely, if ever, functions independently are likely to be labeled as an extreme limitation—such as hospital stays that keep your child out of school for days at a time. Domains that your child can navigate by themselves, but only with a lot of help, will likely be labeled "marked" limitations. For example, your child might need alternatives to many physical activities, such as playing sports with friends.
The requirements in order for a child with a congenital heart defect to get disability are complicated, and the disability determination process is long and stressful. Having an experienced attorney by your side can go a long way to speed up the process and increase the chance that your child will be awarded benefits.
Find out more in our article on how a disability lawyer will handle your child's Social Security application.
Updated April 13, 2023