The Medical Requirements for Receiving Social Security Disability or SSI

Medical Eligibility Requirements for both Social Security Disability and SSI

To receive either SSD or SSI disability benefits, you must obviously be able to prove that your mental or physical condition is disabling. You prove this by the information contained in your medical records and potentially also by statements submitted by the physicians who have treated you.

Note: the social security administration does not attempt to obtain medical source statements, also known as RFC, or residual functional capacity statements from a claimant's treating physicians. However, if you go to a disability hearing before an administrative law judge and you are represented by a disability lawyer, there is a good chance that your lawyer will attempt to get such a statement to add to your case since it can often make the difference between winning or losing a claim at a hearing).

What does the social security administration mean by "disabling"?

Social security does not take the viewpoint that your condition must render you completely unable to function. It does take the position, though, that your condition must be severe enough that it prevents you from able to work at any job and earn the income limit for SGA, or substantial gainful activity, for a given year. This includes working at jobs you have held in the past, and other jobs that the social security administration may consider you capable of performing based on your medical and vocational profile.

Obviously, then, winning a claim for Social Security Disability or SSI will boil down to specific eligibility requirements, namely proving that you have certain physical and mental limitations that make it impossible for you to engage in work activity while earning SGA-level income.

Proving such limitations is based entirely on extrapolating from the information contained in your medical records, which can be a difficult task considering that most medical records and mental health records make little reference to how the condition actually affects one's ability to engage in and perform normal daily activities.

Winning a disability claim also means properly identifying a claimant's prior jobs and accumulated work skills so that it can be demonstrated that the claimant's functional limitations are not up to the task of going back to a former job or performing some type of other work for which those skills could come into play.

In either case (medical factors or vocational factors), the entire evaluation of a disability claim is largely beyond a claimant's control at the initial claim, or disability application, level. The same is true of the first appeal level, the request for reconsideration. This is because at both levels, the claim is decided by a disability examiner and neither the claimant nor the claimant's disability representative (who can be an attorney or a non-attorney) is significantly involved.

At the disability hearing level, however, the claimant, and the claimant's disability attorney if he or she has one, assume a much greater role. This is because, unlike the prior levels, the claimant will meet the decision-maker (an administrative law judge) at the hearing.

Also, the social security administration no longer gathers medical records on the claimant's behalf once the case moves beyond the first appeal, the request for reconsideration. So, at a hearing, whatever new records are presented, or whatever physician statements are presented, these will have been obtained and submitted by the claimant and/or their disability attorney.

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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