How does the Disability determination process work in NC?
by Tim Moore. Free Case Evaluation here.
How does the actual disability determination process work in North Carolina to make decisions on claims? A disability examiner, or an administrative law judge if your case is at the hearing level, will apply a five-step sequential evaluation process to your case.
Here are the five steps:
1. Is the person working and earning more than the SGA limit? If the answer is yes, the claim will be denied. If the person is not working at all, or is working but earning less than the SGA limit, the case moves on step two.
Step one is usually resolved at the Social Security office–before the claim ever gets to North Carolina disability determination services where it is assigned to a disability examiner whose job is to review the medical evidence and make a decision on the case.
2. Step two: Does the person have a severe impairment? If the person does not have at least one severe impairment? The case will be denied.
If the person has at least one severe impairment, which could be mental or physical, the case will move on to step three.
Of course, step two is handled after the case has been assigned to a disability examiner, meaning the examiner will have requested and received the medical records.
3. Step three asks the question “does the person have a condition that meets or equals a listing“?
What do we mean by this? Social Security has a set of “listings”. These listings are essentially the approval criteria for a number of physical and mental impairments.
The listings are divided into adult and childhood listings. And they are further divided according to body system, such as Musculoskeletal conditions, cardiovascular conditions, respiratory conditions, Mental conditions, and so forth.
Satisfying the requirements of a listing, and being approved in this manner, is fairly difficult. This is why only a relatively small percentage of Social Security and SSI cases are approved on the basis of a listing.
Why is it so difficult to get approved this way? Probably because a listing-level approval is completely objective, meaning that if you are approved on the basis of a listing it is with regard to your medical evidence only, with no consideration to your age, education, work skills, or the type of work you may have done in the past.
Also, the level of specificity of medical record documentation required by a listing is very often more than what a claimant’s medical records can provide.
Most individuals will not be approved through a listing. If a person is not approved through a listing, the case moves on to step four.
4. Is the person capable of returning to their past work?
By past work, Social Security is referring potentially to any of the jobs you may have performed in the relevant period, which is the 15 year period prior to you becoming disabled.
However, not every job that you have held in the last 15 years may be considered as part of your “relevant past work”. For example, if you held a job but did not hold it long enough to learn the functions of the job, it will probably not be considered relevant.
Also, if you held a job but did not earn at least a substantial and gainful wage while doing the job, it will probably not be considered as relevant.
The jobs that will be considered at this step of the disability determination process will be those that are indicated by the claimant on their work activity questionnaire when they file a disability claim.
Obviously, it will be very important for the claimant to give specific information about the jobs they have held, including descriptions of the work performed for each job, the dates each job was held, and correct job titles.
But, here is why this information is so important: the disability examiner will use the information provided by the claimant to look up each job in something known as the DOT, or dictionary of occupational titles. Accurately identifying a person’s past jobs can have a tremendous bearing on the outcome of the case.
For example, identifying someone’s past job as a tractor-trailer truck driver will produce a different outcome versus identifying a person’s past job as a light truck driver.
If a disability examiner or a disability judge determines that a person is capable of going back to one of their past jobs, they will be denied at this step. How is this decision made? The disability examiner, or the disability judge, will look at the mental and physical requirements of the jobs held by the claimant. These requirements will then be compared to what ever functional capacity is currently possessed by the claimant (referred to as RFC, or residual functional capacity), which will be determined as a result of the information contained in the medical records.
It is probably safe to say that most individuals are found at step four to be incapable of going back to their past work. If this is so, the case then moves on to step five.
5. Is a person who is not capable of going back to their past work, also not capable of doing “other work”?
This is the point at which many claimants get denied for disability. Because while it is fairly easy for a disability examiner to conclude that an individual has enough functional limitations to rule out their ability to go back to one of their past jobs, it is often easy for an examiner to come to conclude that they have the skills and education, in combination with their age, and level of functional capacity, to switch to some type of other work.
If Social Security decides that an individual who cannot go back to their past work also lacks the ability to switch to some type of other work, they will be approved for benefits.
However, if Social Security determines that a person can do some type of other work, they will be denied for disability.
Step five of the sequential evaluation process is arguably the most subjective, because Social Security makes certain assumptions about the extent to which a person can transfer their prior work experience into a new type of work that they have never done.
The subjectivity of step five, unfortunately, means that quite a few disability cases are denied at this level. However, by the same token, it also means that once a claimant gets to the hearing level, where they can actually be seen, and speak with, the administrative law judge who reviews their claim, they have a chance of arguing that their vocational job base is actually more limited than previous disability examiners concluded it was.
Step five of the evaluation process may be where most of the work gets done on a disability claim at the hearing level. Step five is also where a disability attorney or nonattorney disability representative may be instrumental in assisting a case, particularly when the judge has chosen to have a vocational expert appear at the hearing to provide witness testimony.
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