Social Security Disability: How SSDI and SSI Claims Are Decided

The five steps in the disability determination for SSDI or SSI benefit claims.

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When you apply for Social Security disability benefits, one of the first things the Social Security Administration (SSA) will want to know is whether your medical disorder is severe enough to qualify you for benefits. To determine this, the SSA will send your file to the Disability Determination Service (DDS) for a medical review. The DDS is concerned only with determining your medical eligibility for disability benefits (not your legal or financial eligibility).

Any time your claim for disability is evaluated -- whether at the DDS or when you appeal a DDS decision -- SSA procedures require that specific issues be addressed in a specific order. This is done to make sure that everyone gets the same consideration. If at any point in the SSA's five-step analysis, the evaluating agency or court determines that your impairments justify disability, the evaluation ends. This article explains what happens at every step in the disability determination process.

Step 1. Are You Engaged in Substantial Gainful Activity?

If you are working and making a certain amount of money ($1,070 per month or more in 2014), you are probaby doing what's called "substantial gainful activity" (SGA). If you earn more than the SGA level, even if you have an impairment that meets the requirements for disability, you won't qualify for Social Security disability benefits. If you are under the SGA limit, the analysis proceeds to Step 2.

Step 2. How Severe Are Your Impairments?

The second step involves a determination of the severity of your impairments. If your impairments do not (or should not) significantly limit the work you could do, your impairment will be considered not severe (or non-severe, mild, or slight). Your claim will be denied if your impairments (individually or combined) are not severe. Medical conditions cover the range of severity from "not severe" to "incapacitating."

The effect of your impairments on your ability to function mentally or physically is what matters, not just the presence of the impairments. For example, if you have severe hypertension (high blood pressure) that limits the amount of physical work you can safely do, but it is controlled with drugs so that your blood pressure is normal, your impairment would be considered "not severe." Similarly, a seriously nearsighted person whose vision can be made clear with glasses does not have a severe impairment.

On the other hand, if you have retinal disease that blurs your vision, and your condition can't be corrected with glasses, your impairment would be more than "not severe." This same is true for painful arthritis in your spine that cannot be improved surgically. 

If your impairments are determined to be significant -- that is, they are more than "not severe" -- the analysis proceeds to Step 3 for further analysis of the level of severity.

Step 3. Do You Meet the Listing of Impairments?

At the third step of the review, the DDS will compare your disability to an official list -- called the Listing of Impairments -- to see if your impairments are severe enough to meet or equal the SSA requirements. The listings are Federal Regulations (they can be found at 20 C.F.R. Part 404). If you are denied at the DDS level and you appeal the decision, each level of appeal will also use the Listing of Impairments to consider whether the DDS's decision should be overruled.

Each impairment in the listing specifies a degree of medical severity which, if the applicant's condition meets or exceeds it, presumes that any type of substantial work can't be performed. The listings cover most common impairments. If any of your impairments exactly match the criteria of a listing, you will be considered disabled and granted disability benefits regardless of your age, education, or work experience. The listings differ for adults and for children.

If none of your impairments match an impairment listing, the reviewer must determine if your impairments are equivalent to a similar impairment in terms of medical severity (this is called an "equal"). Allowing benefits based on the "equal" standard recognizes that it is impossible for the SSA to include all impairments in the listings. If the SSA says your impairments are equally as severe as those in the listings, you will be granted disability benefits.

For your impairments to be considered equal to a listing, the reviewer must find one of the following to be true.

  • Your impairment is not listed, but it is of the same medical severity as a listed impairment.
  • You don't meet the criteria of a listing, but your medical findings have the same meaning as the listing criteria. For example, you might have a laboratory test that, while not specifically mentioned in the listing, shows the same results as a test that is included in the listing.
  • You have a combination of impairments where none alone is severe enough to meet a listing, but together they are equal to the severity of a listed impairment. For example, you have heart disease and lung disease, which together cause much greater medical severity than either would alone.
  • For a child applying for SSI, the impairment is considered a "functional equal" of those that satisfy the listings. The "functional equal" standard gives benefits to children who don't quite have the medical severity needed to meet one of the above three points, but whose impairments cause the same amount of functional loss. Relatively few children have impairments that qualify as functional equals.

If your impairments or combination of impairments do not meet or equal any listing -- or combination of listings -- the analysis proceeds to Step 4.

Step 4. Can You Do Your Prior Job?

If your impairments do not meet or equal any listing, the reviewer will consider whether, despite your not meeting a listing, the impairments are severe enough to prevent you from doing the kind of work (if any) you've done in the past. If your impairments are not severe enough to prevent you from doing work you've done in the past, your claim will be denied with the rationale that you can return to your prior line of work.

If the DDS finds you cannot perform your prior work, the analysis proceeds to Step 5.

Step 5. Can You Do Any Other Job?

If your impairments prevent you from doing your prior work, the reviewer will consider whether or not there are other jobs in the national economy that you can do depsite your limitations. If so, your claim will be denied on the basis that there are jobs that you can perform. However, if you are are of a certain age and have limited education and job skills, the SSA may not expect you to be able to adjust to other work and may not deny you benefits on this basis. But be clear about this: The SSA does not have to find you a particular job, or a job with pay equal to what you used to make, or a job of equal skill, or a job near where you live, in order to deny your claim. It just needs to determine that there is work out there in sufficient numbers that you could be doing.

For More Information

If you are denied benefits, see Nolo's articles Social Security Disability: Eight Reasons You Could Be Denied Benefits and Social Security Disability: Deciding Whether to Appeal a Denied Claim.

For more information about Social Security disability in general -- including tips on applying for benefits and understanding medical listings -- see Nolo's Guide to Social Security Disability: Getting & Keeping Your Benefits, by David A. Morton III, M.D. (Nolo).

by: David Morton

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