How Social Security Determines if you are Disabled

June 27, 2014 By Sherrie

The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program.

SSDI provides for payment of disability benefits to individuals who are "insured" by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings. SSI provides for payments to individuals (including children under age 18) who are disabled and have limited income and resources.

SSA prescribes rules for deciding if an individual is "disabled."

Definition of Disability

For all individuals applying for SSDI benefits and for adults apply for SSI, the definition of disability is the same. The law defines disability as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

What is a Medically Determinable Impairment?

A medically determinable physical or mental impairment is an impairment that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. A physical or mental impairment must be established by medical evidence consisting of signs, symptoms, and laboratory findings-not only by the individual's statement of symptoms.

The Disability Determination Process

Most disability claims are initially processed through the local Social Security offices and State agencies (usually called Disability Determination Services, or DDS). Subsequent appeals of unfavorable determinations may be decided in the DDS or by administrative law judges in SSA Office of Disability Adjudication and Review (ODAR).

Local Social Security Offices

Applications for disability benefits are made to the local SSA office either in person, by telephone, by mail, or via an online application process. The application and related forms ask for a description of the claimant's impairment(s); names, addresses, and telephone numbers of treatment sources; and other information that relates to the disability. The local SSA office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status, citizenship/residency and Social Security coverage information, and additionally, for SSI eligibility, income, resources, and living arrangement information.

State Disability Determination Services

The SSA District office sends the case to the State Disability Determination Service (DDS) for evaluation of disability. The DDS is a State agency that is funded by the federal government. DDS is responsible for developing medical evidence and making the initial determination on whether the claimant is or is not disabled or blind under the law. Usually, the DDS tries to obtain evidence from the claimant's own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a Consultative Examination (CE) in order to obtain additional medical information. The claimant's source of medical treatment is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. After gathering the necessary information, the DDS makes the disability determination and returns the case to the local SSA office for appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the local office in case the claimant decides to appeal the determination. If the claimant files an appeal of an initial unfavorable determination, it is known as a reconsideration. The appeal is usually handled much the same as the initial claim, except that the disability determination is made by a different adjudicative team in the DDS rather than the one that handled the original case.

Office of Disability Adjudication and Review

Claimants who are dissatisfied with the first appeal of a determination may file subsequent appeals. The second appeal is processed by a hearing office within the Office of Disability Adjudication and Review (ODAR). An administrative law judge makes the second appeal decision, usually after conducting a hearing and receiving any additional evidence from the claimant's medical sources or other sources. ODAR frequently conducts medical development through the DDS. However, hearing offices may also contact medical sources directly.

Reference, SSA.gov

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