I speak to unrepresented disabled people every day who were just denied disability by the Social Security Administration. Talking to them, I realize that most do not have any understanding as to how Social Security makes a disability determination. For example, veterans are often stunned if they get a Social Security disability denial after the Veterans Administration has determined that they are 100% totally and permanently disabled. Similarly, municipal workers like firefighters and police officers don’t understand how they were denied after they have been found disabled by their departments or municipalities. The reason for this is that Social Security uses its own criteria to determine disability. Understanding the criteria will help you better prepare and prove your disability case. When I meet with clients, we discuss the criteria Social Security uses and we develop a plan of action to prove their case. I have laid out the process below in the hope that it will help you.
Social Security uses what is called the “Sequential Evaluation Process” for assessing disability. It is also called the “five step process”. The five steps are as follows:
Is the individual currently working? If so, is the work considered to be substantial gainful activity (SGA)? If the individual is working and their work is considered SGA, the claim will be denied.
The process starts with determining whether you are working and, if so, is the work considered to be substantial gainful activity (SGA). If you are not working or are working at a level below “SGA”, SSA will move on to step 2.
So what does Social Security mean by substantial gainful activity (SGA). This can get complicated. If you are not working at all and not earning any money from work activity, it is pretty simple, you’re not working at SGA. SGA is defined as work that is both substantial and gainful. “Substantial” means that the work involves significant physical or mental activities, and gainful means that the work is done for pay or profit. SSA considers work to be SGA if it pays more than a certain amount per month. The current SGA level is $1470 per month. If you are earning more than that amount in a month you will be considered to be working and will be denied at Step 1. The amount changes every year. For example, in 2020 it was $1260 a month. If an individual’s work activity generates income below these levels, Social Security will move on to the second step in the process. Note that the rules are different and more complicated if you are self-employed.
As an example, many of us remember Christopher Reeve, the actor who played Superman in the movies. Mr. Reeve had a tragic accident horseback riding that resulted in paralysis from the neck down. By almost anyone’s criteria he would be considered to be disabled after he was paralyzed. Even so, he directed, acted, and produced movies after his accident. If evaluated by the Social Security Administration at the time, he would have been evaluated unfavorably. His work during that period would’ve been considered substantial gainful activity and his case would be denied. The analysis of his disability would have ended there, and he would have been found not disabled at step one. His medical condition would not even be reviewed. Sometimes, people will tell me I stopped working in July 2022 but really, I have been disabled since 2017. I completely understand this. People often work for years after the onset of their symptoms in a heroic effort to try to support themselves and their family. But that is not the way Social Security looks at it. If you are working at “SGA” levels before you stopped working completely, Social Security will determine that you are not disabled at Step 1. To avoid a Step 1 denial, we need to pick an onset date of disability after you stopped working at SGA levels.
Does the person have a severe medical impairment? If the person does not have a severe medical impairment, the claim will be denied.
Social Security uses a test called the “severity test” to determine whether an individual’s impairment is severe enough to be considered a disability. To have a severe impairment you must have a condition or combination of conditions that significantly limits your ability to do basic work activities. Significant limits would include things like having problems walking, standing, sitting, lifting, carrying, pushing, pulling, reaching, handling, seeing, hearing, speaking, and understanding and carrying out simple instructions.
If you don’t have an impairment that significantly limits your ability to do these things your claim will be denied. If you do have an impairment that limits your ability to perform these basic work activities, Social Security will move onto the next step in the process. You do not have to have problems in all these areas. In fact, the bar is not set very high to meet the requirements of this step to move on to step three.
Does your medical condition meet or equal a listing in the Social Security Administration’s listing of impairments? If your conditions meets or equals a listing in the listing of impairments your claim will be approved.
Social Security has a list of impairments called the “listing of impairments“, which is used at this step of the disability process. The list can be found if you do a Google search for “SSD and listing of impairments”. The “listings” is a detailed set of medical criteria that describe conditions that are so severe they automatically qualify you for disability benefits. The “listings” is divided into different sections with each section covering a specific body system. For example, there is a section for cardiovascular disorders and another for psychiatric disorders, and so on. Each section includes a list of specific impairments and the medical criteria that must be met for an individual to be considered disabled. If your impairment meets or equals the criteria, SSA will approve the claim for disability benefits without considering your age education and work experience. If your impairment does not meet or equal a specific listing than Social Security will move on to the fourth step.
Are you able to perform any of your past relevant work? If you are able to perform any of your past relevant work your claim will be denied.
So what is past relevant work? Generally, past relevant work is any job that you have performed within the last 15 years before the onset of your disability. At this step, Social Security will look at your past job duties, the physical and mental demands of the job and the skills required to perform the job and compare those requirements to your residual functional capacity (RFC-explained briefly below). To determine what is required in those jobs, SSA will rely in part on what you tell them about the jobs that you performed, they will also consult a government publication called the “Dictionary of Occupational Titles (DOT)”. The “DOT” is supposed to document the mental and physical demands of all jobs in the United States. It does not do a great job of doing that and it hasn’t been updated in many years but that is what they use. SSA may also seek assistance from a vocational expert to determine the physical and mental demands of a job.
As noted above, the administration will compare your residual functional capacity (RFC) to the requirements of your past jobs. A residual functional capacity is an assessment that considers your maximum sustained work capability considering your ability to sit, stand, walk, lift, carry and understand and carry out simple instructions. There is a little more to it but that is the basic idea. To determine your residual functional capacity, the administration will get input from you and your doctors. They may also have you examined by one of their doctors and have your records reviewed by another doctor that will never see you in person. The most important consideration in this evaluation is often the opinions of your treating doctors. In recent years, Social Security has changed its rules and now affords less weight to the opinion of your doctors than it did in the past, but that opinion is still crucial. No one knows you and understands from a medical perspective what you can do better than the person who has seen you, examined you, and treated you. To win your Social Security case, it is almost imperative that we get an opinion from the medical expert that knows you the best. If after comparing your “RFC” to the requirements of your past work, the administration determines that you can do your past work they will deny you disability. If they determine that your residual functional capacity will not allow you to do your past work, they will move on to step five in the process.
Is the individual able to perform any other type of work? If the individual is unable to perform any other type of work considering their age, education, and skills, the claim will be approved, and disability benefits will be awarded.
If after comparing your residual functional capacity (RFC) to other jobs in the economy, the administration determines that there are other jobs you can perform it will find that you are not disabled. At this step in the process, it is the administration that must prove, usually by expert testimony that there are other jobs that you can perform. To establish this, they usually use a vocational expert to identify jobs that a person in the same situation as you could allegedly perform. At this step there are also allowances made based on a person’s age skill level and educational background. The guidelines that Social Security uses to make this assessment are called the “grid rules”. The grid rules as a general rule do not kick in until a person is age 50 or older. The rules are organized into tables and direct findings of disabled or not disabled depending on your residual functional capacity, age, education level and work experience. For example, if you are over 50, have a limited education, and always worked in an unskilled job, on your feet that requires heavy lifting, and now you are limited to only doing sit down work, the grid rules direct a finding of disability. The grid rules can get complicated, and a number of different factors are involved depending on your age, the type of work that you did in the past, and how skilled your work was.
Ultimately, in most cases the most crucial part of this process is determining your residual functional capacity. The best way to prove that your RFC prevents you from working is to get a good opinion from your doctor. The opinion should be clear as to your ability to do the basic work functions outlined above. A statement from the doctor that says, “my patient can’t work anymore” doesn’t go very far.
The above is an overview of the process the Social Security uses to evaluate a disability case. At each step there are regulations, procedures and case law that further clarify the process. It can get complicated but hopefully this helps.
Understand The Evaluation Process: Social Security goes thru a five-step process to evaluate your disability claim. Make sure that you understand each step of the process to best present your disability case.
Treating Opinions Are Crucial: It is very hard to win a disability case if your doctors are unwilling to provide an opinion on your “RFC”. Binder & Binder has been helping claimants with their disability cases for many years and we can help your doctor format their opinion to make sure that the doctor covers all the issues that Social Security needs to do the evaluation.
Representation Matters: Binder & Binder is experienced in handling the most complex cases, and we work to resolve them as early as we can for our clients. Social Security rules can be complicated, but we have successfully represented thousands of claimants over the years. Experience matters.