How Does Social Security Decide If You Are Disabled Or Not?

Social Security uses medical records, work history, medical vocational rules, and a disability guidebook that contains a listing of impairments that affect the various body systems to decide if you are disabled or not.

Once you provide Social Security with your medical sources (names, addresses, treatment, medications and treatment dates) and work history (jobs you have performed in the past fifteen years that you worked at for three months or more, earned the substantial gainful activity amount or SGA, and had time to learn), your disability case is sent to a federally funded state disability agency for a decision. Once in the disability agency, your disability claim is assigned to a disability examiner who will make a decision as to whether or not you are disabled according to Social Security guidelines.

In order for the disability examiner to decide if you are disabled or not, they have to first gather medical records from the sources that you provided with your disability application. If they determine that you do not have enough current medical record information for them to make a medical disability decision, they will schedule you for a consultative examination with a doctor who is paid by Social Security to evaluate the current status of your physical and/or mental impairment.

You may be required to attend more than one consultative examination. This may occur, for example, because you have alleged both mental and physical disabling conditions but you have no current medical treatment (Social Security considers current medical treatment to be any treatment received within the past ninety days), or you have no medical records at all. Social Security rules require a disability examiner to have current medical information in order to make a decision.

While disability examiners like to have at least twelve months of medical history for their disability determination, it is not strictly required. From my experience as a disability examiner, a medical history that contains clear, concise medical treatment notes which address your treatment, prognosis, your response to prescribed treatment and the limitations caused by your condition or conditions usually help you to win your disability case. Conversely, consultative examinations alone rarely lead to an approval for disability benefits.

When the disability examiner has enough medical information to make their determination, they refer to the impairment listings contained in the Social Security Disability handbook, "Disability Evaluation Under Social Security". This is done to determine if your disabling condition meets or equals the severity requirement of the body system impairment listing that addresses your specific disabling condition or conditions.

For example, arthritis would be considered in the section of the listing book devoted to musculoskeletal impairments, while congestive heart failure would be considered in the section devoted to cardiovascular impairments.

If your disability condition is so severe that it meets or equals an impairment listing, you may be approved for disability benefits. If your specific limitations do not meet or equal the criteria of an impairment listing, you may still be approved for disability benefits provided that your disabling condition causes your residual functional capacity (what you are able to do in spite of the limitations of your disabling conditions) to be so restrictive as to prevent you from doing any of the jobs you have done in the past fifteen years, or any other kinds of work.

In other words, you may be approved for disability benefits through a sequential evaluation process that considers both medical and vocational factors.

About the Author: Tim Moore is a former Social Security Disability Examiner in North Carolina, has been interviewed by the NY Times and the LA Times on the disability system, and is an Accredited Disability Representative (ADR) in North Carolina. For assistance on a disability application or Appeal in NC, click here.

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