How does the Social Security Administration decide Who is Disabled?
By Pitt Dickey

This article will discuss the tests the Social Security Administration (SSA) applies to determine whether a person can qualify to receive monthly Disability Insurance Benefit payments from the SSA. There are five basic tests that the claimant must meet to obtain Disability Insurance Benefits from the SSA. The tests will be examined below:

1. Generally, the Claimant must have worked for 10 years to be insured for SSA Disability Insurance benefits

In order to obtain disability insurance benefits the rule of thumb is that the claimant must have worked and paid in sufficient FICA taxes from his employment for a period of ten years prior to his disability beginning. There is a five year grace period after a disabled worker has last worked this ten year period in which s he is still covered by SSA Disability Insurance Benefits. For example, Mary works as a teacher from 1983 to 1993. In 1993 she decides to stop working to care for her small children. In 1997 she develops severe back pain and undergoes a laminectomy which unfortunately leaves her in great pain. She is still eligible for disability benefits up through 1998 because she is under the five year grace period from 1993 to 1998. If she were to have her back problem to occur in 1999 she would no longer be eligible for Disability Insurance benefits because the injury occurred after the 5 year grace period.

There are other rules that can allow very young workers to obtain coverage under the SSA disability insurance benefits program.

If the claimant has less than ten years of quarters of paying taxes then he can still be eligible for SSI benefits for the disabled but these benefits pay less and also are only available for persons who live in households with a very low income.

2. The nature and extent of the claimant’s health problem

The SSA has developed a very elaborate system which categorize various injuries and sicknesses into a system called the “Listings”. For example a person who has a herniated disk will be reviewed according to the Listing which describes what clinical findings and symptoms would justify a finding of disabled by the SSA. Naturally there are a lot more health problems than there are listings and sometimes fitting a particular claimant into a rigid listing is very difficult. The Listings are basically designed to deal with the most common health problems and to set out a standard method of evaluating these health problems.

If the SSA determines that a claimant’s health problem meets a Listing then the claim should be approved within the system without the necessity of having a hearing before an Administrative Law Judge.

Life however seldom fits into neat little boxes and frequently a claimant will come close but not quite meet the listing. This can result in the denial of the claim and an elaborate appeal and review process.

Many people’s claims are approved that do not precisely fit a Listing if their health problems are severe enough to prevent them from being able to maintain full time employment. The Listings primarily seem to help the SSA make favorable decisions on cases that are clearly payable under the Disability Insurance Benefits without the necessity of having a hearing before an Administrative Law Judge.

3. The Claimant’s impairment must have lasted at least twelve months or be expected to last at least twelve months or will result in death.

The SSA Disability Insurance Benefits system is set up to pay monthly benefits to workers who have relatively long term health problems that prevent them from working. To qualify a worker must have a condition that can reasonably be expected to last at least a year or result his death. In other words if you break your leg and are going to be out of work for six months, the SSA is not going to pay you disability insurance benefits during the time that you miss work. Life is uncertain and in many cases it is unclear to the claimant and to his physician if the condition is going to prevent the claimant from going back to work. However, it is very helpful to a claimant’s disability claim if his doctor is willing to write a letter to the effect that in the doctor’s opinion the claimant is disabled.

In situations where a claimant is facing a life threatening disease such as cancer, the claimant’s case can sometimes be expedited to speed up the process of approval of his claim.

4. The Claimant’s impairment must prevent him or her from working at any type of full time job

In this test, the SSA essentially has to decide that not only can the claimant not go back and do his former employment but that as a result of his health problems he is unable to do any other type of work that exists in the American economy. In other words, if a man used to work as a brick layer and he develops diabetes and can no longer perform such hard labor, the SSA must also determine that his diabetic condition prevents him from doing sedentary work such as selling tickets in a movie theater box office.

A claimant cannot continue to work during the process of applying for SSA disability insurance benefits. If the SSA determines the claimant has been performing substantial gainful activity (working for money in SSA jargon) then by definition the claimant is going to be found not disabled. I have frequently found this situation puts the disabled in a catch 22 position, they are faced with the choice of not being able to pay their mortgage and buy medicine or going to work when they really should be at home recuperating in order to pay the bills.

5. The date the Claimant’s disability began determines when the Disability Insurance payments will begin.

The SSA has to decide the onset date of the claimant’s illness. This means when was the claimant so sick that he was unable to work. This date can be either very clear, such as the date of a heart attack, or very murky such as the employee who has congestive obstructive pulmonary disease who continues to work at his job because he needs to maintain his health insurance. The onset date is when the SSA will actually begin to pay disability insurance payments to the claimant.

Pitt Dickey has practiced law in Fayetteville since 1978. He has handled SSA disability claims for over twenty years. He practices with the firm of Smith Dickey Dempster & Carpenter, P.A. at 555 Executive Place, Fayetteville, N.C. He can be reached at 485-8020. Copies of prior Disability Update articles are available on line at www.smithdickey.com.