The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security disability insurance program (title II of the Social Security Act (the Act) and the supplemental security income (SSI) program (title XVI of the Act).
Title II provides for payment of disability benefits to individuals who are “insured” under the Act by virtue of their contributions to the Social Security trust fund through the Social Security tax on their earnings, as well as to certain disabled dependents of insured individuals. Title XVI provides for SSI payments to individuals (including children under age 18) who are disabled and have limited income and resources.
The Act and SSA’s implementing regulations prescribe rules for deciding if an individual is “disabled.” SSA’s criteria for deciding if someone is disabled are not necessarily the same as the criteria applied in other Government and private disability programs.
Definition of Disability
For all individuals applying for disability benefits under title II, and for adults applying under title XVI, 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.
Disability in Children
Under title XVI, a child under age 18 will be considered disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that 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 a network of local Social Security field offices and State agencies (usually called disability determination services or DDSs). Subsequent appeals of unfavorable determinations may be decided in the DDSs or by administrative law judges in SSA’s Office of Hearings and Appeals (OHA).
Social Security Field Offices
SSA representatives in the field offices usually obtain applications for disability benefits, either in person, by telephone, or by mail. 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 alleged disability. (The “claimant” is the person who is requesting disability benefits.)
The field office is responsible for verifying non-medical eligibility requirements, which may include age, employment, marital status, or Social Security coverage information. The field office sends the case to a DDS for evaluation of disability.
Disability Determination Services
The DDSs, which are fully funded by the Federal Government, are State agencies responsible for developing medical evidence and rendering 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 CE in order to obtain the additional information needed. The claimant’s treating source is the preferred source for the CE; however, the DDS may also obtain the CE from an independent source. (See Part III for more information about CEs.)
After completing its initial development, the DDS makes the disability determination. The determination is made by a two-person adjudicative team consisting of a medical or psychological consultant (who is a physician or psychologist) and a disability examiner. If the adjudicative team finds that additional evidence is still needed, the consultant or examiner may recontact a medical source (s) and ask for supplemental information.
The DDS also makes a determination whether the claimant is a candidate for vocational rehabilitation (VR). If so, the DDS makes a referral to the State VR agency.
After the DDS makes the disability determination, it returns the case to the field office for appropriate action depending on whether the claim is allowed or denied. If the DDS finds the claimant disabled, SSA will complete any outstanding non-disability development, compute the benefit amount, and begin paying benefits. If the claimant is found not disabled, the file is retained in the field office in case the claimant decides to appeal the determination.
If the claimant files an appeal of an initial unfavorable determination, 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 than the one that handled the original case.
Office of Hearings and Appeals
Claimants dissatisfied with the first appeal of a determination may file subsequent appeals. A hearing office within the Office of Hearings and Appeals (OHA) processes the second appeal. 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.