Who makes the Determination of a Social Security Disability Claim?

There are various decision-makers for Social Security Disability and SSI claims. Who decides whether or not a claim meets the SSA disability qualifications depends upon what level of the disability process the claim is at.

The disability application), the reconsideration appeal level (the appeal is known as a "request for reconsideration"), administrative law judge hearing level (the appeal is known as a "request for hearing before an administrative law judge), the Appeal Council review level, and finally the Federal district court level. Each level of the disability process has individuals who are responsible for making disability determinations.

The first two levels of the Social Security Disability, SSI system

At the initial disability claim and reconsideration appeal levels, the disability determination will be made by a team of sorts. Once a case has been transmitted from a local Social Security office to the state disability agency (see Disability Determination Services), the disability claim is assigned to a disability examiner. The examiner is a case processing specialist who will be responsible for gathering your medical evidence and making a disability determination.

Generally, after gathering the medical evidence, reviewing it, and also reviewing the claimant's work history (academic history if the claimant is a school-age minor child), the disability examiner writes up the determination for the case.

In some cases, the examiner will have complete authority as to whether her or she will issue a disability denial or an approval of the claim. Social Security does have SDN, or single-decision-maker disability examiners. These examiners have the freedom to make disability determinations without consultation and review (by medical consultants who are attached to their case-processing units) provided, of course, that the case is not complex and does involve significant mental health allegations.

Most claims, however, will not involve just a disability examiner, but a disability examiner who receives consultation from a medical doctor and a psychologist who both work in the disability examiner's unit.

Additionally, there are times at most state disability agencies when unit managers become involved in the disability determination process themselves. Often, managers have to worry about statistical information that may say they are approving or denying too many disability claims. And unfortunately, there seems to be more concentration on whether or not their unit make too many disability approvals.

If the disability claim is not approved at either of these levels (disability application and reconsideration appeal), it will move to the administrative law judge hearing appeal level.

The hearing level

At the disability hearing level, an administrative law judge will make the actual determination on the disability claim. Although the judge makes the final disability determination, they may use a medical or vocational expert to help them make their determination.

If the disability claim is not approved by the administrative law judge, it may move to the Appeals Council Review appeal level. The Appeals Council reviews disability determinations that are made by judges.

Most Appeals council reviews are denied without much of a "review" actually happening. If they are not denied, most are simply remanded back to the administrative law judge who made the original disability hearing decision for a second hearing, or "remand hearing". Appeals Council judges do approve a very small percentage of the appeals, but this is somewhat rare.

The last level of the Social Security Disability process is Federal district court. Of course, the disability determination at this level will be made by a federal judge. This level of the disability process is rarely used because of the time it takes and the expense of trying the case in federal court.

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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