Social Security's Five Part Disability Test

Social Security's Five Part Disability Test
By Pitt Dickey

No one ever expects to become disabled.  We all tend to assume it will happen to the other guy.  But sometimes the other guy is you.  If you can't work how will you pay your bills?   The Social Security Administration's  Disability Insurance Benefits program provides  monthly income to qualified persons.  People come to my office and frequently say that they are embarrassed about having to apply for benefits.  The  Disability Insurance Benefits program is not a welfare. It is funded by the FICA taxes that are taken out of your paycheck. You don't have a choice whether to pay for Disability Insurance Benefits. Disabled people should not feel like they are on the dole if they apply for Disability benefits. You have paid for those benefits. If you haven't paid enough tax into the system, the SSA will turn you down because you haven't paid for your coverage. 

The SSA uses a five step evaluation to determine if a person qualifies for Disability Insurance Benefits.  If the claimant is denied at the initial and reconsideration level, she can have a  hearing before an Administrative Law Judge who will make a new decision independently of the earlier denials. The Judge's decision is based on the same five step evaluation used at the lower levels but the Judge can overrule the earlier denials and approve the person's claim.

The five steps used by the Judge will be discussed below. The Judge has to evaluate each claim using this five step framework in sequential order.

1. If the claimant is performing substantial gainful work, she is not disabled.

The first question the Judge must decide is whether the person is working and earning above a certain amount of income. No matter how sick or injured a person is, if she is still working and earning above the maximum amount allowed then the claim must be denied.  There is a complex formula for determining the monthly  income  can be earned and still qualify for Disability, but roughly, the amount is slightly above $740 per month for an employee.  For self employed claimants, the test is more complicated and depends not only on how much money the person earns each month but upon how much time she spends at her business each month.  If she is not earning above the maximum amount the judge goes to the next step.

2. If the claimant is not performing substantial gainful employment, her impairment must be severe before she can be found to be disabled.

A severe health impairment is one that "significantly limits an individual's physical or mental ability to do basic work activities."  The health problem must have a medical diagnosis that is supported by qualified medical opinion and laboratory tests in the case of physical health problems. If the claimant has a mental health impairment, it must be medically diagnosed by competent mental health professionals.  If the claimant meets this test then the judge goes to step three.
 
3.  If the claimant is not performing substantial gainful work and has a severe impairment that has lasted or is expected to last for a continuous period of 12 months , and her impairment meets or equals a listed impairment of the SSA, then the claimant is presumed disabled without further inquiry.  

The SSA has an elaborate series of "Listings" for various diseases and injuries which the Judge will use to evaluate if the person's claim either  meets or equals  the requirements for that particular health problem. The requirements of the Listings are very stringent and are intended to allow the SSA to approve the most serious disability claims early in the process. However in life there are many shades of gray and illnesses, and a person's health condition may not completely meet the requirements of a listing.  The Judge is expected to determine if close cases equal the various listings when  making the  decision to award disability benefits. If the claimant's condition doesn't meet a Listing, then the Judge moves to step four.

4.  If the claimant's impairment does not prevent her from doing her past relevant work, she is not disabled.  

The SSA looks at the jobs the person has held for the last fifteen years. Jobs before that time are not considered relevant in the disability process because they were performed in the distant past. If the Judge decides the person can go back and do her former job despite her health problems, then the claim will be denied. If the Judge decides the person can't do her former work, then he goes to step five.

5.  Even if the claimant's impairment prevent her from performing her past relevant work, if other work exists in significant numbers in the national economy that accommodates her residual functional capacity and vocational factors, she is not disabled.

If the person can't do any of her old jobs from the last 15 years, the Judge must decide if despite her current health problems there is other full time work she can do.  He considers her "residual functional capacity" in making this decision. This means what can she still do after considering the effects of physical and/or mental limitations that affect her ability to perform work related tasks.  Essentially, if the Judge decides there is other types of work that the person can do, then he has to deny her claim. The type of alternative job does not have to pay comparably to the person's last job.  It can pay much less, but if the person can do any type of job then the claim will be denied.  If the Judge  decides that due to her health problems, educational background, work experience that there is no other work she can do, he will approve her claim.

Copyright © Pitt Dickey 04/23/2004