What is (generally) needed to demonstrate adult disability to the Social Security Administration
There has been a lot of discussion of late on how easy it is to get disability benefits from Social Security's disability insurance program (including the disability-related auxiliary benefits programs) and Supplemental Security Income program. I would like to focus on the requirements for the adult programs only for a bit as the children's programs have some interesting requirements that are unrelated to the adult programs. It is important to clear about what the requirements are before generalizations about how “easy” or “hard” it is to get benefits are made.
In general, in order to obtain disability benefits, a claimant must prove that the claimant’s disability is expected, for a period of at least 12 months, to render the claimant unable to perform any job that exists in significant numbers in the national economy. 20 C.F.R. §§ 404.1505, 416.905. In order to make the analysis of a given claimant’s case understandable and efficient, the Social Security Administration (through the regulatory power granted by 42 U.S.C. §§ 405(a), 1383(a)(1)) devised a 5-Step Evaluation Process (which is sort of misleading as there are really 7 recognized steps: 5 whole steps and 2 half steps).
In determining eligibility for benefits due to a disabling medical condition, the Social Security Administration considers (1.) whether a claimant is presently working and whether the work activity is significant enough to be considered substantial gainful activity (thereby precluding eligibility to benefits); (2.) are each of the medical conditions (considered separately or collectively) severe enough to cause a more than minimal limitation in the ability to perform basic work activities; (2.5.) are the conditions that cause more than minimal limitations expected to last at least 12 months minimum; (3.) whether the diagnostic clinical and laboratory findings (as well as any required general functional findings) made through examining the claimant meet the criteria listed for the medical condition in 20 C.F.R. Part 404, Subpart P, Appendix 1 (or a diagnosed medical condition that is equivalent in severity to a closely analogous listed medical condition); (3.5) if the criteria of a listed medical condition (or combination of listed medical conditions) are not met or medically equaled, what the claimant is still capable of doing despite the limitations imposed by the medical conditions from which the claimant suffers; (4.) whether the claimant can do any of the past relevant work which that claimant performed over the 15 years prior to the determination or decision being then made (or prior to the date when the claimant was last insured for Social Security Disability Insurance benefits, which ever is earlier in time); and (5.) whether there exists a significant number of jobs other than jobs the claimant performed in that aforementioned prior 15-year period. 20 C.F.R. §§ 404.1520(a)(4), 416.920(a)(4).
If a claimant applies for Social Security Disability Insurance benefits (under Title II), there is an additional requirement beyond the 5-Step Evaluation Process that the claimant either be insured for disability benefits in the claimant’s own right or be an eligible auxiliary beneficiary of an insured individual who became disabled, has retired, or has died. If a claimant applies for Supplement Security Income benefits (under Title XVI), as an additional requirement beyond the 5-Step Evaluation Process, there are asset, income, and resource limitations that restrict eligibility (as Supplement Security Income benefits are directed to helping only the very poor of those medically unable to work).
A claimant can be awarded benefits without considering any vocational factors, if the medical records indicate that the diagnostic clinical and laboratory findings (as well as any required general functional findings) made through examining the claimant meet the criteria listed for the medical condition in 20 C.F.R. Part 404, Subpart P, Appendix 1. See also, 20 C.F.R. §§ 404.1525, 416.925. A claimant can also be awarded benefits without considering any vocational factors, if the medical records show the claimant suffers from a condition that is equivalent in severity to a closely analogous listed medical condition. 20 C.F.R. §§ 404.1526(a), 416.926(a).
Under 20 C.F.R. §§ 404.1526(b), 416.926(b), there are 4 ways to medically equal one or more of the medical conditions (termed “impairments”) in severity to a closely analogous medical condition that is listed in 20 C.F.R. Part 404, Subpart P, Appendix 1 (also referred to as the “Listing of Impairments”). The first way is where a claimant has a medical condition described in the Listing of Impairments, but does not exhibit one or more of the required findings in that particular listing, but that claimant has other findings (not mentioned in the Listing of Impairments, but related to that claimant’s impairment) that are at least of equal medical significance to the required criteria specified in the entry of the Listing of Impairments considered. The second way is where a claimant has an impairment described in the Listing of Impairments and exhibits all of the required findings, but one or more of the required findings is not a the specified severity level, but that claimant has other findings (not mentioned in the Listing of Impairments, but related to that claimant’s impairment) that are at least of equal medical significance to the required criteria specified in the entry of the Listing of Impairments considered. The third way is where a claimant has an impairment that is not described in the Listing of Impairments, but the diagnostic and functional findings are of a severity level of at least an equal medical significance to a closely analogous listing. The fourth way is where a claimant has a combination of impairments, not one of which meets an entry in the Listing of Impairments, but the diagnostic and functional findings (of the combination of impairments) are of a severity level of at least an equal medical significance to a closely analogous listing.
If the claimant’s medical condition is found to not meet or equal an impairment listing in the Listing of Impairments (20 C.F.R. Part 404, Subpart P, Appendix 1), then the claimant must be found incapable of performing the work which that claimant performed over the 15 years prior to the determination or decision being then made (or prior to the date when the claimant was last insured for Social Security Disability Insurance benefits, which ever is earlier in time) as well as any other job that exists in significant numbers in the national economy. What constitutes a significant number of jobs varies according to the claimant’s age, the presence of skills that are transferable from the claimant’s past work to other jobs, the claimant’s education level, and how recently the claimant obtained that level of education.
When a given claimant starts approaching what the Social Security Administration considers to be advanced age, such a claimant may be granted benefits by “gridding out.” When a claimant is closely approaching advanced age (50+), found limited to sedentary work, can no longer perform vocationally relevant past work, and has no transferable skills, a finding of disability is warranted under 20 C.F.R. Part 404, Subpart P, Appendix 2 (which is otherwise known as the “Medical-Vocational Guidelines” or the “grids”). Similarly, when a claimant is of advanced age (55+), found limited to light work, can no longer perform vocationally relevant past work, and has no transferable skills, a finding of disabled is warranted under 20 C.F.R. Part 404, Subpart P, Appendix 2. What constitutes a transferable skill changes at age 55 (and older) with respect to skills transferable to sedentary occupations and 60 (and older) with respect to skills transferable to light occupations (according to Medical-Vocational Guidelines sections 201.00(f) and 202.00(f)) - namely: “there must be very little, if any, vocational adjustment required in terms of tools, work processes, work settings, or the industry.” Also notable is that pursuant to Social Security ruling 83-10, the “age categories are not applied mechanically in borderline situations,” which is generally interpreted to mean that up to 6 months prior to a given age category change a claimant could be found to be within the given age category.
If a claimant does not “grid out” for some reason and neither meets nor medically equals a medical listing (or a combination thereof), there are 3 special medical-vocational profiles that, if the criteria of one of which is satisfied to the letter, may allow an individual to be found eligible for disability benefits. The Regulations at 20 C.F.R. §§ 404.1562, 416.962 provide for 2 of these profiles; the 3rd is derivable therefrom. The worn out worker rule provides that if a claimant has a sixth grade education level or less, has work experience of 35 years or more in only “arduous” unskilled physical labor, is no longer performing any work activities that would be considered substantial gainful activity, and is no longer able to do that claimant's past “arduous” unskilled work due that claimant's severe impairment(s), such a claimant is disabled and eligible for benefits. The house spouse rule provides that if a claimant is found to have at least one severe, medically determinable impairment (or a combination of medically determinable impairments that is severe), who is at least 55 years old, has no past relevant work, and neither has completed high school nor was awarded a general equivalency diploma (GED), such a claimant is disabled and eligible for benefits. The third profile may be found POMS § DI 25010.001.B.3, which is derived from the other 2 profiles, and is called the lifetime commitment rule, which provides that if a claimant (who is 60 years of age or older) has work experience of 30 years or more in a single field of work from which no transferable skills have been acquired, is no longer able to perform any of that claimant's past relevant work due that claimant's severe impairment(s), is no longer performing any work activities that would be considered substantial gainful activity, and neither has completed high school nor was awarded a general equivalency diploma (GED), such a claimant is disabled and eligible for benefits.
If a claimant is under the age of 50 (or really 49½ depending on how Social Security ruling 83-10 is applied) or can't “grid out” for some other reason and neither satisfies the criteria for one of the special medical-vocational profiles nor meets or medically equals a medical listing (or equals a combination thereof), then the claimant must show that the claimant is medically precluding from performing even sedentary jobs such that there is an insignificant number of jobs in the national economy the claimant can perform. Typically, if the limitations opined by a claimant’s treating healthcare practitioner are found to satisfy the criteria outlined in Social Security rulings 85-15, 96-8p, and 96-9p, the claimant may be found disabled within the framework of the Medical-Vocational Guidelines sections 201.00(h) and 204.00 (or a closely analogous grid rule). Pursuant to Social Security ruling 85-15, “[t]he basic mental demands of competitive, remunerative, unskilled work include the abilities (on a sustained basis) to understand, carry out, and remember simple instructions; to respond appropriately to supervision, coworkers, and usual work situations; and to deal with changes in a routine work setting.” Social Security ruling 85-15 further states that a “substantial loss of ability to meet any of these basic work-related activities would severely limit the potential occupational base,” which, “in turn, would justify a finding of disability because even favorable age, education, or work experience will not offset such a severely limited occupational base.” Social Security rulings 96-8p and 96-9p both provide that either a claimant must be able to perform at the assessed residual functional capacity on a sustained basis (i.e., an 8-hours-a-day, 5-days-a-week schedule or the equivalent) or a finding of disability is warranted. Social Security ruling 96-9p states in pertinent part that a “complete inability to stoop would significantly erode the unskilled sedentary occupational base and a finding that the individual is disabled would usually apply.” Social Security ruling 96-9p also states in pertinent part that a “[a]ny significant manipulative limitation of an individual's ability to handle and work with small objects with both hands will result in a significant erosion of the unskilled sedentary occupational base.” Of course, if the vocational expert returns an answer of “no jobs” and the Administrative Law Judge finds the limitations used in the hypothetical question to the vocational expert accurately reflect the claimant's limitations, then a finding of disable will follow and the claimant will receive the granted benefits.
However, Social Security Ruling 00-4p states that “SSA adjudicators may not rely on evidence provided by a [vocational expert] or other reliable source of occupational information if that evidence is based on underlying assumptions or definitions that are inconsistent with our regulatory policies or definitions” meaning that policy statements trump vocational expert testimony.
If a claimant has not yet attained a high school diploma or a general equivalency diploma (G.E.D.), it is important to consult the tables in the Medical-Vocational Guidelines to see if the claimant can be found disabled under an exception to the general trend in the Medical-Vocational Guidelines (as the claimant may not need to be as physically limited as a high school graduate would be in order to be found disabled under the Medical-Vocational Guidelines). On the other hand, acquiring more education that one might learn in high school or completing either a vocational education program or an apprenticeship could represent the acquisition of skills applicable to other semi-skilled and skilled occupations in the national economy (and if earned “recently” enough may preclude a finding of disability).
As you can see, there is a significant variation in how one may qualify for disability benefits (even though you can simplify it to 5 particular ways to win benefits). Notice how it can get easier for the physically impaired to be found disabled (if the physical impairment leads to exertional limitations) as such a person ages. I hope you found this informative. If you would like me to expand on any of the topics discussed here, please leave a comment. I am also happy to provide citations for anything discussed here. However, please keep the discussion general as I have no interest in discussing particular cases.