Overview of Disability
Disability Back Pay
Requirements for Disability
Applications for disability
Tips and Advice for Disability Claims
How long does Disability take?
Winning Disability Benefits
Common Mistakes after a Denial
Mental Disability Benefits
Denials for Disability
Appeals for denied claims
Disability Benefits from SSA
Child Disability Benefits
Qualifications and How to Qualify
Working and Disability
Disability Awards and Notices
Disability Lawyers, Hiring Attorneys
Social Security List of Conditions
What Social Security considers disabling
Medical Evidence and Disability
Filing for Disability Benefits
Eligibility for Disability Benefits
SSD SSI Definitions
SSDRC authored by Tim Moore
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How to Prove you are disabled and Win your Disability Benefits
Addressing this topic very often involves a discussion of the Social Security definition of disability, the SSA impairment listing manual, and the five-step Sequential disability evaluation process used by both disability examiners and administrative law judges. As a result of my own background as a former disability examiner, and my involvement in claimant representation, SSDRC gives significant coverage to these topics.
However, on this particular page, we will drill down to the core topic: How do you prove your disability case to the Social Security Administration? This is a fairly long page, but if you read it to the end, you will gain a strong understanding of how the disability process works and how cases can be successfully won.
There are just two ways of winning disability benefits under either the title II Social Security Disability program, or the title 16 SSI disability program (there is no difference in how either program is evaluated). The first way of winning is at step three of the sequential evaluation process. The second way of winning is at step five of the sequential evaluation process.
The first way - Satisfying a listing in the Impairment listing manual
Winning your disability claim this way means that your case has made it to step three of the evaluation process. This is where the question is asked "Is your condition found in the list of disabling conditions?" Note: Step 1 is where SSA asks if you are working and earning a substantial and gainful income. If the answer is no, your case moves to step 2 where the question becomes "Do you a severe impairment (versus an impairment that has only a negligble effect on you and, therefore, is non-severe). If you do have a severe impairment, your case moves to step 3.
The "list" is what disability examiners referred to as the blue book, because in printed form it was a desk reference that contains the approval criteria for a number of disabling conditions. The blue book, or list of impairments, addresses every major body system from musculoskeletal (arthritis, back conditions, amputations, soft tissue injuries) to mental.
It does not, however, address every diagnosed condition, meaning that very often a claimant's case cannot even receive consideration under a blue book listing, because it does not exist for that condition.
A relatively small percentage of disability cases are approved on the basis of a listing. The listing criteria tends to be very detailed and leaves no option for subjective analysis of a person's age, work history, or their ability or inability to transition to other types of work, assuming that they are unable to go back to their past work.
A person's claim either meets or equals the criteria of a listing, or it doesn't. In the great majority of instances, the case will not. However, most cases are approved via the second way, which, incidentally, is referred to as a "medical vocational allowance".
The second way - Proving you cannot do "other work"
As we said, most claims are approved through a medical vocational allowance. What does that mean?
That means that a disability case was not approved on the basis of a listing at step three of the sequential evaluation process. The case then moved to step 4 where the question becomes "Are you capable of doing your past work?". If the answer to that question is no, the case moves to step 5, the final question in the process.
This, of course, is the question that will decide whether or not you will win disability benefits: "Can you do any other work?"
Now, getting past the preceding step, step 4, is usually not so problematic. The truth is, most people file claims because they cannot do what they were previously doing. And so disability examiners and disability judges usually find that, even in a fifteen-year range of what Social Security refers to as "past relevant work", a claimant will not be able to return to one of those jobs. Other work, though, is more of a problem.
What does Social Security mean when they say use the term "other work"? They mean this: even if you have a severe impairment that is severe and limiting enough to prevent you from going back to your last job, or another job you may have had in the past 15 years, you can still be denied if Social Security finds that you can still do something else.
What is "something else"? Potentially, any one of hundreds or even thousands of other jobs you may be able to do based on these factors:
1) Your age;
2) Your education;
3) Your skill levels, and
4) The extent to which your impairment, or combination of impairments, limits your ability to do things (sit, stand, walk, lift, carry, push, pull, hear, see, smell, concentrate, remember, function among others, etc). This is what Social Security refers to as your RFC, or residual functional capacity.
Disability examiners and judges take all of these factors, which are your medical and vocational factors, and "plug them in" to a set of medical-vocational rules known as "the grid" to determine which particular rule you fall under.
Some rules will direct a decision of "not disabled", while others will direct a decision of "disabled" and will result in you winning your disability benefits. Obviously, you want your case to be directed by a med-voc rule that directs a decision of disabled, i.e. approval or allowance.
If certain rules guide decisions, how do you influence winning a case?
The rules are the rules. They are objective and they do not change. But the information that is most important about you and your case is not as concrete. It is subjective, it is open to interpretation, and it is the interpretive nature of this information that accounts for why a case can be denied if the facts are looked at one way, and yet approved if they are looked at another way. It is why cases that are denied at the disability application level are so often won later at a disability hearing.
If you recall, determining whether or not you can do some type of other work is based on finding the grid rule that applies to your case, and this is based on the factors of your age, your education, your skills, and your RFC, or residual functional capacity, assessment. The first two factors, your age and education, are not open to interpretation.
The last two factors, though, your work skills and RFC (the measurement of what you are still capable of doing, despite your impairment, or impairments) are open to interpretation. And so for this reason, a great deal of attention should be paid to the information you provide concerning your job history and medical history.
Each year, tens of thousands of Social Security cases are probably lost because:
A) The claimant's medical history was not developed sufficiently to point out to what extent and in what ways the claimant was functionally limited and
B) The claimant's work history was not properly analyzed, leading Social Security to believe the individual was more employable than they actually were.
Medical Records and the Opinion of your doctor
Because most disability claims will be denied at the disability application step and also denied at the reconsideration appeal level, most claimants will inevitably need to have a hearing before an ALJ or administrative law judge in order to be approved for disability benefits. One thing that most claimants will not be aware of regarding hearings is the fact that, at hearings, not only is the process different, some of the rules are different as well (for example, how your doctor's opinion may be regarded). And they can go a long way to the advantage of a claimant's case.
At the hearing, a great deal of attention will be paid to the claimant's work history. Very often, the focus will be on the claimant's work skills because a person's skill level (referred to as SVP, or specific vocational preparation, with jobs are rated at skill levels SVP 1 through 9) will allow the judge to gain an idea of how many other potentially suitable jobs might be available to the claimant.
Counter-balancing the claimant's skill levels will be the claimant's level of restrictions, or functional limitations, which we referred to as RFC. Simply put, the more limitations which can be cited in a case, the less likely it will be that a person will be considered to have the ability to do any other kind of work. And this is exactly why the following is true:
1. Recent medical records must be obtained. Social Security uses older records and these can help establish how far back a person's disability goes, i.e. their onset date. This by itself can have a profound impact on a) how much back pay they receive and b) when they can actually begin receiving benefits (there are waiting periods for disability benefits and for medicare and the earlier the onset date the more likely it will be that the waiting periods can be nullified). But only recent records will Social Security to determine an individual is disabled.
2. As much evidence should be obtained as possible because greater amounts of medical evidence can allow substantiating more functional limitations, either physical or mental.
Ideally, a supporting statement known as a medical source statement should be obtained from the claimant's treating physician (a doctor who has a longitudinal history of providing treatment versus an urgent care doctor who sees them once every winter for the flu).
While a statement from a treating physician can often have little effect at the disability application and reconsideration levels (because disability examiners usually have little to no training with regard to federal regulations and Social Security legal rulings), at the hearing level judges may give controlling weight to the opinion of a claimant's doctor as long as this opinion is in sync with, and substantiated by, the rest of the medical records.
In other words, a doctor's statement can, and often does win a case. But not just any statement. It cannot be a short note stating "Patient is disabled" (I have seen many of these). This type of statement will not influence a case.
A statement from a physician that wins a case will focus on the kinds of limitations that Social Security is concerned with. And since very few doctors have any earthly idea what Social Security is actually looking for in a medical source statement, this is why so many disability representatives (disability attorneys and non-attorney disability representatives, many of whom are former claims examiners -- I am the latter) will send to the doctor a check-off form that allows them to indicate the types of limitations the claimant has in the language that Social Security is looking for.
Building a Theory of the case - How do you win?
At this level of the system, you win by highlighting enough physical or mental limitations (which restrict the types of activities a person can engage in) so it becomes clear that the individual cannot do any other type of work. Sometimes, the limitations simply amount to a person being of a certain age, with a certain level of job skills, and not being able to lift more than a certain amount of weight. Sometimes the individual's condition will be purely mental and will result in an inability to work based on the limitations that arise from the condition.
Other times, however, the case will be more complex and will require a theory or argument for winning. For instance, there are certain nonexertional limitations that when proven to exist, can sufficiently lessen the number of potential jobs available to a claimant, and, thus, result in an approval, even when, without these limitations, the rules would ordinarily require that the person be denied.
Winning a disability case usually involves obtaining a medical-vocational allowance, a type of decision in which the information from your medical history and work history will be used to decide whether or not you can do some type of other work. In some instances, getting an approval of this type will be simple because the record will be plain: given the person's age, limitations, skills, and restrictions/limitations, they cannot do any work.
However, because many cases involve proving that the claimant has additional limitations (e.g. inability to bend in certain ways at the waist, inability to use the hands in certain ways, inability to sustain sitting for certain lengths of time, inability to endure certain environmental factors, inability to sustain attention or concentration) that effectively erode the occupational base of jobs that would ordinarily apply to them, they often require a solid theory or argument to effectively convince the adjudicator that benefits should be awarded.
The following page covers this topic also but fills in a few gaps in terms of how disability examiners process claims: How do you Win Benefits under Social Security Disability or SSI or SSI?
Return to: Social Security Disability Resource Center, or read answers to Questions
Proving a Social Security Disability Case Often Means Getting a Statement from Your Doctor
What Can I Do to Improve My Chances of Winning Disability Benefits?
Proving Functional Limitations and why this is Important on a Disability Case
What do you Need to Prove to Qualify for Disability Benefits?
Proving the requirements for disability in North Carolina
How do you Win Benefits under Social Security Disability or SSI?
How does age affect a Social Security Disability or SSI case?
Filing for disability with congestive heart failure and cardiomyopathy
Will I qualify for disability with back pain, a bone spur, and bulging disks?
Information on the following topics can be found here: Social Security Disability Questions and in these subsections:
Frequently asked questions about getting Denied for Disability Benefits | FAQ on Disability Claim Representation | Info about Social Security Disability Approvals and Being Approved | FAQ on Social Security Disability SSI decisions | The SSD SSI Decision Process and what gets taken into consideration | Disability hearings before Judges | Medical exams for disability claims | Applying for Disability in various states | Selecting and hiring Disability Lawyers | Applying for Disability in North Carolina | Recent articles and answers to questions about SSD and SSI
These pages answer some of the most basic questions for individuals who are considering filing a claim.
Filing for disability - How to file for SSD or SSI and the Information that is needed by Social Security
How to Apply for Disability - What medical conditions can you apply and qualify for?
Applying for Disability - How long does it take to get Social Security Disability or SSI benefits?
What happens if I file a disability application and it is denied by a disability examiner or Judge?
How to Prove you are disabled and qualify to win disability benefits
How do you prove your disability case if you have a mental condition or impairment?
Social Security Disability Back pay and How Long it Takes to Qualify for it and receive it
Social Security Disability SSI - Eligibility Requirements and Qualifications Criteria