How Does Social Security Disability Make its Decision?
My typical stock answer to this is to explain that a disability examiner will gather a claimant's medical records and then use this information to determine what the claimant's physical and/or mental limitations are.
However, cutting to the chase, the answer can be stated a bit more simply. How does social security makes it decision? By determining whether or not the claimant can still work. In fact, everything a disability claims examiner does is geared toward that end.
Disability examiners spend a fair amount of time gathering a claimant's medical records, meaning that they initially request them, and then often do multiple follow-ups with various medical treatment sources in order to obtain "enough" documentation to work with. The purpose of gathering medical evidence is to facilitate the rendering of an RFC (residual functional capacity) evaluation, an evaluation is one in which a claimant's specific functional limitations are rated and cited on a form.
However, rendering an RFC is only done for one purpose: to compare what the claimant is still currently capable of doing...versus what was required of them in their past jobs and versus what would be required of them in other work that they might possibly switch to (based on their medical vocational profile).
In a nutshell, if the disability claim decision-maker (an examiner at the disability application and reconsideration appeal level and a judge at the disability hearing level) finds that the claimant is not capable of going back to one of the jobs that they did in the past ("past" being sometime in the last 15 years), they have cleared one hurdle.
The second hurdle is something called other work. This includes jobs that a claimant might possibly be able to do based on a variety of factors including how functionally limited they currently are and what their skill levels are. Claimants who are found to be unable to do some type of other work, in addition to not being able to go back to their past work, are determined to be disabled. Not surprisingly, though, many claimants are denied on the basis of being able to perform some type of other work.
"Other work" is a very convenient method for the disability system to deny claims. And it is particularly easy to do so because, prior to the hearing level, the only viewpoint that counts is that of the decision-maker, i.e. the disability examiner. But other work is a hurdle that may be more easily cleared at a hearing where the claimant is actually present, hopefully with a qualified disability representative, in front of an administrative law judge. For this reason, among others, it is vitally important for claimants who have been denied to not give up, but, instead, follow the disability appeal process at least as far as getting a hearing requested.
Considerations of work and whether or not a claimant can return to their past work, or switch to some form of other work, are part of something called sequential evaluation, and cases that are approved this way are called medical vocational allowances.
However, there are cases that are approved for disability simply because a claimant's records indicate that they have a certain condition and that their record of treatment satisfies certain specific criteria in something known as "the listings". The listings are incorporated into the "Blue Book", titled "Disability Evaluation under Social Security".
There are adult claim listings and child claim listings and each contains certain conditions whose criteria, if met or equaled, will result in an approval for disability benefits.
Most claims are not approved on the basis of meeting or equaling the requirements of a listing because the criteria is very specific and, in many cases, are very difficult to satisfy. Which is why the other way of looking at a disability claim exists (reviewing the claimant's work history in conjunction with the records to see if they can or cannot work).
Return to the Social Security Disability SSI Benefits Blog
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