Determining Social Security Disability and SSI eligibility
If you file a claim for benefits through Social Security Disability or SSI disability, your initial claim will be taken by a federal employee known as a claims rep. Typically, this will occur at a local social security office and the disability interview will be conducted in person, though the interview can be done over the phone for individuals who may find it difficult to visit a field office.
Once the claim has been taken, however, it is not actually processed to a decision point at the social security office. Instead, it is transmitted to a state disability claim processing agency (usually called DDS or disability determination services) and once there it is assigned to a disability examiner.
As a former disability examiner, I will discuss what elements go into the "pot" when it comes to determining Social Security Disability and SSI eligibility.
1. Medical Records - When claimants file for disability, there are two things that have to be determined by a claims examiner.
A) Is the claimant currently disabled?
B) Was the claimant previously disabled and, if so, when did the disability begin?
To determine each of these (basically, we are talking about a claimant's eligibility for past due benefits, or disability back pay, and ongoing, or continuing monthly, disability benefits), a disability examiner must have access to a claimant's medical records. And this, obviously, includes older records that go back as far back as possible (hopefully, at least as far back as when a claimant alleged that their disability began). And it also includes a claimant's medical most recent records since a disability approval typically cannot be made if the social security administration does not have access to medical record documentation that has been generated recently (within the last 90 days).
Medical records form the basis for disability decisions because they provide substantive proof as to what a claimant can functionally do and not do. In other words, what a claimant's RFC, or residual functional capacity, is and their RFC rating is. RFC, of course, is measured against the requirements of a claimant's past jobs to see if they can possibly return to one of their former jobs. Which brings us to number 2.
2. Work history - The Social Security Disability and SSI disability system uses a setup that is both medical and vocational in nature when it comes to determining disability claims. And the vocational aspect of the system is probably something that many claimants (who make the assumption that only their medical records will be used) do not consider when it comes to eligibility for benefits. However, work history plays a big role in deciding claims.
Some claimants who apply for disability will be approved because their records satisfy the criteria for a specific medical condition in the social security administration's impairment listing manual.
But for the majority of claimants an approval will only be made if a disability examiner can determine A) that their condition limits their functional capabilities to the extent that they no longer perform the duties of their past relevant work, and also B) that their condition limits them to the extent that they cannot be expected to transition to some form of other work for which they might be otherwise suited based on their work skills.
Work history, for adult disability claims, plays nearly as large a role in deciding the outcome of claims, as a claimant's medical history. And for this reason, it is vital that claimants supply to the social security administration as detailed as possible a list of their past jobs, along with the dates of their employment (how long the job was performed and whether or not it was performed in the last 15 years will determime if it is relevant to the disability claim that is under consideration).
In part 2 of this post, I'll discuss other elements that go into the mix as far as eligibility for disability benefits is concerned.
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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