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Social Security Disability Insurance: How is disability determined?

SSDI is a federal benefit program for eligible claimants who are disabled from working.

Social Security benefits are not only designed to help you financially in retirement, but also to provide a safety net should you become disabled and unable to work before retirement age. Many do not know that when Social Security is taken out of their paychecks, they are also building eligibility for Social Security Disability Insurance, often referred to as SSDI.

Administered by the Social Security Administration, a federal agency, SSDI has its own unique provisions and procedures, similar to but also very different in some ways from private disability insurance or workers' compensation.

SSDI (and SSI its sister program for certain low income and asset beneficiaries) has its own definition of qualifying disability. To be disabled for purposes of SSDI, you must have a serious medical impairment (physical or mental) or combination of impairments expected to last at least one year or result in death that prevents you from working.

The other component of SSDI eligibility is that you must meet certain work history requirements; basically, you must have worked fairly regularly over time to have earned coverage and also fairly recently.

SSA uses a 5-step process to analyze whether you meet the definition of disability:

  • Are you currently working, meaning are you engaging in substantial gainful activity or SGA? In reality, you can earn a small amount that is not considered substantial enough to make you financially ineligible. In 2015, SGA is $1,090, so if you have average monthly earnings higher than that, you would be considered "working" and not eligible for SSDI. If you are not working (earning nothing or less than a monthly average of $1,090), go to step 2.
  • Is your impairment severe, meaning bad enough to interfere with basic work activities? If no, not eligible. If yes, go to step 3.
  • Does your medical diagnosis meet or equal one in SSA's Listing of Impairments? SSA has a list of impairments organized by body system that are so devastating that a diagnosis automatically means you meet the definition of disability. The listings are quite specific about the diagnoses requirements, including certain required symptoms, and testing or evaluation methods. Examples of listed impairments: cystic fibrosis; lung, liver or heart transplant; chronic heart failure; chronic kidney disease; sickle cell disease; multiple sclerosis; muscular dystrophy; lymphoma; leukemia; and many others. If yes, disabled and eligible. If no, go to step 4.
  • Can you do past work? If yes, not eligible. If no, go to step 5.
  • Can you do any other work? SSA looks at your residual functional capacity, or whether, considering your impairments, age, education, experience and transferable work skills, other work exists in significant enough numbers in the economy that you could do. If yes, not eligible. If no, disabled and eligible.

This process is extensive and detailed; unfortunately, the agency does make mistakes and people are pretty regularly wrongly denied benefits. Sometimes, the file is not developed enough to make an informed conclusion. It can be game changing to involve an experienced SSDI attorney to help develop the medical record and assess whether the agency may have made a legal error in analysis.

Do not let a claim denial stop you from appealing. Many claims are later approved on appeal.

Legal counsel can get involved at the initial application stage or at any subsequent step. There are three levels of review before the agency (in a few states, two levels), including a hearing before an administrative law judge or ALJ, and then the claim can be appealed to the federal court system. Many deadlines for review and appeal exist throughout the process, another reason a skilled disability lawyer can be invaluable.

From its office in Los Angeles, the Disability Rights Law Center provides legal advocacy and representation to SSDI applicants in California and across the country.

Keywords: SSDI, claimant, disability, disabled, work, Social Security Disability Insurance, Social Security Administration, SSA, serious, impairment, definition, five-step process, medical, substantial gainful activity, SGA, earnings. basic work activity, diagnosis, Listing of Impairment, residual functional capacity, RFC, benefits, medical record, appeal, application, review

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